QUALITY: Fessing Up to Serious Medical Errors

A prominent Boston hospital made a big mistake (operating on the wrong side of the patient—who luckily should be fine) and then told the whole world—including the Boston Globe—about it in an email and a blog post from the hospital CEO in which he describes the circumstances and the hospital's response.

We like Beth Israel Deaconess CEO Paul Levy's "Running a Hospital" blog, and we link to it now and then. Beth Israel has a reputation for being a leader in both quality improvement and transparency, and Levy often writes about how even people on the lower rungs of the hospital hierarchy are encouraged to pipe up when they see something potentially unsafe or just inefficient. What really bothered us about this case was the hospital does have a "time out" policy—before the surgery, the team is suppose to call out, "Right patient, right procedure, right side." No one did, and no one spoke up. It bothered Levy too. As he said, the "culture of safety" hasn't permeated everywhere it needs to go.

Not only did Levy tell the Globe about it (yes, it's textbook PR crisis management, coming clean, as some of the more cynical commenters on his blog pointed out, but it's still the right thing to do), he then even provided a handy list of blogs that have been examining his actions. We liked this comment from the "New York Personal injury Law Blog," which we hadn't come across before, that said

This type of conduct is simply unheard of from my view in the medical malpractice world. I've taken testimony from hundreds of doctors. Exactly one has acknowledged that he made a mistake. .... If more hospitals and doctors acknowledged mistakes and sought to learn from them—as Beth Israel Deaconess is doing—it would probably go a long way to putting medical malpractice attorneys out of business.

Medicare, several states, and some health plans are moving toward a system where they don't pay for care stemming from preventable errors. That may be a powerful incentive in reducing them. But we like Levy's approach too. Develop safety systems. Talk about them. Address their failures. And fix them.