Fragmentation

If you haven’t seen the remarkable management of a medical “never” error that was displayed by Paul Levy, President and CEO of Beth Israel Deaconess Hospital over at Running A Hospital, I’d encourage you to read it. This post should be a “must read” for any hospital risk management personnel or hospital administrator.

In short, this is what happened:

It was a hectic day, as many are. Just beforehand, the physician was distracted by thoughts of how best to approach the case, and the team was busily addressing last-minute details. In the midst of all this, two things happened: First, no one noticed that the wrong side was being prepared for the procedure. Second, the procedure began without performing a "time out," that last-minute check when the whole team confirms "right patient, right procedure, right side." The procedure went ahead. The error was not detected until after the procedure was completed.

Mr. Levy described the doctor’s, hospital’s and hospital board’s response to the error, which, considering the proverbial cat-was-out-of-the-bag, was commendable. Readers were awestruck by the “openness” and “humanness” of the moment. I confess, I too, was impressed at the handling of a disaster that no one should have to endure. Of course the natural question that arises in such a circumstance is “How could that happen?”

So off went the “physician safety division” to interview all involved while the details regarding the incident were fresh in everyone’s mind. The doctor (appropriately) notified the patient’s family and made a full apology. And the board member chimed in:

"Protocols are meant to make procedures insensitive to distraction and busy days. These are inadequate and embarrassing excuses. The 'culture of safety' has not permeated the front lines. Culture of safety training, and application of advances in safety science, I believe, are critical to preventing the type of complex harm that occurs in hospitals. Not just for new staff. For everyone who wears a BIDMC badge, or is affiliated as a physician to the hospital. I know that this is a new science, and a new way of doing business, but this event might just give that leverage needed for change."

There it was. Corporate speak: “culture of safety,” “culture of safety training,” that “hasn’t permeated the front lines”, the era of “new science, and a way of doing business.”

I read through the more than 45 responses to Mr. Levy’s remarkable post, and there, at the very bottom, was the one response that stopped the entire thread in it’s tracks, as one brave Noah Zark stepped forward and said:

”I have an idea. Perhaps the surgeon (as opposed to a PA, NP, intern, or Family Doc) should perform and record the complete pre-op history and physical exam requisite for surgery. This ancient protocol ensures that the surgeon knows the patient for the sake of both...; but it is not followed any more.

Don't waste your time with high tech digital video that can be played from your state of the art computers...just be sure the surgeon examines the patient before he/she is in the OR...the old fashioned way.”

We all know Mr. Zark is right. We also know that it is unlikely, in today’s day and age of the “business” of medicine, that real change in how care is delivered by physician’s stretched to do more in less time than ever before, will occur. We have become fragmented as a profession – too specialized – too procedurally based - too frenetic to stop and really speak and examine patients like we all learned in medical school. Those values lose their cache in the business world of medicine and is exactly the reason that wrong site surgery exists today. That’s why this error was so sad...

... we realize what we’ve lost.

-Wes