IHI: Getting Surgeons to Embrace Safety

Cheryl Clark, for HealthLeaders Media , December 15, 2011

This weekend, I was reading the gory details of 14 immediate jeopardy penalties totaling $850,000 against California hospitals that put patients in harms way.  Seven were retained surgical items, but one incident at UCSF illustrates the greater problem:

A surgeon operated on a patient's left eye instead of the right one because the operating table was turned 180 degrees and the surgeon said he "got confused."

"No time out was done prior to the beginning of Patient 1's surgery," reads the state report. The coordinator "stated the surgeon was not sure who should initiate the time out and the circulating nurse did not remind him a time out had to be done prior to beginning the procedure."

When a state investigator asked if a time out was done prior to the beginning of the procedure, the surgeon replied there wasn't. "Usually the circulating nurse initiates it," he said.

No healthcare provider gets up in the morning and says, "Today I'm going to do something to hurt a patient." But as long as immediate jeopardies still occur, maybe more surgeons need to get off their high horses. And stop being cowboys.

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