Legal Insight from Thomas Jones of Davis, Bethune and Jones.
Operating on the wrong body part or on the wrong site of a patient should never happen at a hospital.
What this article doesn’t mention is the hospital’s integral part in patient safety issues like wrong-site surgery. The article details how the surgeon broke patient safety rules but completely ignores the hospital’s responsibility and complicity in wrong-site surgery.
Doctors will operate on the wrong patient, wrong site and wrong side. Hospitals know this. The hospital industry has known this for decades. Hospital must be institutionally accountable for making sure that these “should never happen” events do not happen.
How do hospitals know this? Several sources: experience and common knowledge but also the industry’s regulators. The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) knows how important the hospital’s role is in making sure that these “never events” do not happen.
The 2004 Universal Protocol poster is required to be prominently displayed and taught in all hospitals with the intention of stopping wrong-site, wrong procedure and wrong person surgeries from ever happening.
Why doesn’t the article focus on why this hospital didn’t force this doctor to document exactly what happened in a timely fashion? Patient safety must be an institutional commitment from the hospital’s administration, nurses, risk management and leadership. Everyone must be on the same page, committed to making sure a surgeon is never allowed to make this kind of mistake. For this hospital to allow one of it’s physicians to wait four years before documenting what happened in the operating room breaks multiple patient safety rules. Full documentation of what happens during a patient’s stay in a hospital is taught in medical and nursing school basic courses. Ironically, this hospital has now put the physician who was allowed to do this to be the one in charge of making sure other doctors and health care providers document patient treatment properly.
Many hospital rules must have been broken for this surgeon to operate on the wrong lung. The surgical team did not identify the correct lung during the “time out” procedure (or there was no “time out”) and the support team said nothing to protect this patient. Any patient is totally vulnerable under anesthesia and needs the hospital team to step up and advocate for them when they can’t speak for themselves.
This article illustrates the same old “let’s blame it all on the surgeon” defense that most hospitals and their lawyers typically do. Choosing this doctor to be the head administrator is remarkable given what’s happened in the past. This is poor decision making and cannot be viewed as the best available decision for the safety of the patients who’ve chosen to be treated at this hospital.