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Report Points Out OR Staff Lapse in Hub Surgical Error

August 30, 2008

By JESSICA FARGEN

A state investigation into a surgery on the wrong part of a patient’s body at Beth Israel Deaconess Medical Center found that the operating room staff failed to perform a routine and crucial verbal safety check before the operation.

The 12-page report on the June 30 incident, which was released yesterday, also found that the simple system of marking the location of an incision failed.

Investigators found that there were no “associated deficiencies” on the hospital’s behalf because Beth Israel had taken immediate action to fix the lapses that led to the horrifying mistake.

“Our goal is to have hospitals fix these events and change their systems so they don’t reoccur,” said Paul Dreyer, director of the Bureau of Health Care Safety and Quality at the Department of Public Health.

“We didn’t cite deficiencies and that’s because by the time we arrived on scene the hospital had developed and entirely implemented a corrective action plan on their own,” Dreyer said.

A spokesman for Beth Israel declined comment on the report.

The hospital did not divulge the surgery the female patient was undergoing.

The 18-day probe found that:

** The surgeon and operating room staff did not have a “time out,” immediately prior to the two-hour surgery, during which the staff verbally confirm the incision site, verify the patient’s identity and the procedure to be performed.

The hospital has since put in place a “time out” compliance monitoring process and enhanced safety procedures, including a requirement that blades are not to be placed on scalpels until after the “time out” is completed.

** Marks indicating the correct incision site were apparently washed off or not visible during the surgery. The hospital has since required the use of an FDA-compliant marker to mark incision locations.

The attending surgeon also told investigators that he performs the specific surgery only three to five times a year, adding to the confusion.

– jfargen@bostonherald.com

Originally published by By JESSICA FARGEN.

(c) 2008 Boston Herald. Provided by ProQuest LLC. All rights Reserved.




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