QUALITY: Lend Me Your -- Which Ear Was That Again?

No sooner had we posted our previous item about how we experienced the emergence of a hospital "culture of safety" when we picked up the Health Section of today's Washington Post, and read about a 12-year-old boy who nearly had surgery on the wrong ear. His mom, Tracy Grant, a Washington Post editor, told the medical team over and over and over again in the days, hours, and minutes before the operation that they were about to slice into the wrong ear, that the paperwork was wrong. They treated her like she was the problem. The story has a happy ending—they operated on the right ear. Or rather, the correct, left, ear.

Grant learned through subsequent research that for 15 percent of the population, telling left from right is not automatic. John R. Clarke, a professor of surgery at Drexel University and the clinical director of the Pennsylvania Patient Safety Reporting System, has found that surgical mistakes involving the wrong side of the patient occur three times a day in the United States. That doesn't count the near misses—when someone, in this case a mom, spoke up.

I walk to the waiting room shaking, knowing that if my training as a journalist hadn't taught me to question authority, if I were just a little more intimidated by people in surgical scrubs, if I didn't speak English fluently, my son would have had a perfectly normal ear operated on...

It's understandable that so many of us fall into Lazarus syndrome: the belief that doctors are godlike miracle workers who should never be questioned. It's certainly easier to believe that than to worry that they're making mistakes. But heck, we question the checker at the Giant [supermarket] if we think we're being overcharged. Why wouldn't you question the doctor who is about to cut into your child?

One solution Grant put forth, besides more involved patients and family members, is to make sure that doctors check a patient's whole file, not just the recent piece of paper on top. (Don't get us started on the whole topic of paper records versus computerized ones.) In Grant's son's case, the error had appeared in the paperwork after one recent appointment but there was a thick two-year file documenting the problem in the correct ear. A more thorough review of his paperwork would have highlighted the mistake earlier.

Boston's Beth Israel Deaconess hospital has gotten a ton of publicity for its openness about a recent wrong-side surgery. Here's our recent post on it, and the hospital CEO Paul Levy's Running a Hospital blog has been reporting on the error and the aftermath for a few weeks.