On the Wrong Side of a Wrong Sided Surgery

Written by David Mayer, MD, Executive Director, MIQS

Many of us know medical errors are the third leading cause of death in the United States. We are also aware that healthcare is a high-risk industry like aviation and nuclear energy. But unlike other high risk-industries, healthcare has been slow to adopt tools, techniques and behaviors proven to lower risk. As a result, errors made by well-intentioned caregivers continue to cause unintentional harm and even death to patients at alarming rates. 

What comes next however, after a preventable medical error is discovered to be just as alarming. Largely driven out of fear, many times medical mistakes are “buried” by the hospital system. An approach, known as “delay, deny, and defend” has become common place in the healthcare industry.  When hospital leaders begin to hide or even lie about medical errors a second set of harm is occurring – to the afflicted patient, family and even caregivers. During my anesthesia residency, I was involved in a medical error…

As the anesthesiologist, my job was to bring our patient into the operating room, put the required monitors on him, and then administer the general anesthetic that would keep him unconscious during his right-sided hernia surgery. Focused on my job, like others in the operating room, I didn’t notice that the senior surgical resident had taken the scalpel and made the surgical incision on the patient’s left-side by mistake. Two minutes later the attending surgeon, who had been detained with a question from another surgeon, came into the operating room, looked at the patient on the operating table and asked, “I thought this was a right-side hernia repair?” When the surgical resident realized the mistake, she passed out.

Covering Up More than Incisions

The surgeon closed the incision on the left side and then proceeded to fix the hernia on the right side. The patient now had two surgical bandages on their abdomen: one to cover the hernia repair, the other to cover our mistake. I dreaded having to discharge the patient from the recovery room after they fully woke up and explain my part in the medical error that harmed him. I had never been involved in a medical error before, and was very nervous about the anger he might feel towards me and our team. When I went to see the patient about an hour later, I noticed he had a big smile on his face as I approached his bed. Before I could say anything, he looked at me and said, “Today is my lucky day.” I was dumbstruck. He continued, “Yes, today is my lucky day because under anesthesia my surgeon told me he discovered I had two hernias, one on each side, and was able to repair both at one time so I don’t have to miss another day of work to get the second one repaired. It then hit me. The plan was to lie to the patient and cover up our mistake. I didn’t know what to say or how to react. After a very long pause, I responded, “Yes, today is your lucky day,” and I discharged the patient.

Courage and Transparency: The Path Forward

In defining professionalism in healthcare, we use words like altruism, honor, integrity, respect, caring, compassion, and accountability to name a few. In telling my patient “Yes, today is your lucky day”, I violated every one of those principles we take an oath to honor when becoming a caregiver. Not only was my lie morally and ethically wrong, our lack of honesty and transparency kept us from learning from our mistake and finding ways to prevent others from suffering similar harm. As a result, wrong-sided surgeries continued to occur far too frequently.

It is said healthcare “buries” our medical mistakes. Fear of malpractice claims and multimillion dollar settlements, fear of losing our license, fear of admitting we are fallible and can make a mistake are just a few of the reasons caregivers and hospital leaders try to hide or even downright lie when medical errors cause patient harm. This approach, known as “delay, deny and defend”, is a common legal and malpractice insurance strategy, not only in healthcare but in other insurance-based industries.

Historically, the role of hospital risk managers has been to protect the hospital at all cost, even if it meant lying to patients and families. Refusing to answer questions, denying patients access to their medical records, not returning phone calls, or referring patients to hospital lawyers has been routine practice for many health systems. Many patients and families wait years to have their calls returned, and still fail to receive truthful answers on what really happened when there is a conversation. As many plaintiff attorneys have shared through the years, “There’s a lot of lying going on out there.” The only option patients and families often have to get their questions answered, is to hire their own lawyer and file a lawsuit against the hospital and the physician. Once both sides “lawyer up”, the only thing that matters is to win the lawsuit, regardless of the financial cost or additional suffering incurred by all stakeholders. No one wins in a medical malpractice trial.

Fortunately, some courageous health systems, hospitals and medical malpractice carriers are discovering there is a better way. They are embracing CANDOR – being fully open and honest when preventable harm occurs. We will talk more about this disruptive new approach to preventable harm in my next post.


The Telluride Experience – Not Your Typical Patient Safety Training – Part Two

By Stacey Gonzalez

In my previous blog post, I described the unique immersive experience The Telluride Experience (TTE) program delivers and the profound impact it has had on over 1,000 resident physicians and health science students that have gone through the workshop.  But the immersive environment and varied teaching modalities is only half the story.  

During my time with TTE, I have repeatedly witnessed how deeply personal patient stories and engagement of patient and family advisors throughout the 4-day workshops are essential to truly changing learners’ attitudes and actions. 

Patient stories are incredibly powerful in an industry where patients are often seen as a set of ailments rather than a person.  And while impactful stories have been central to the curriculum since its inception, TTE goes even further.  Imagine hearing a life-altering medical story, and then discussing the event directly with the patient or family member who was (and is) living it every day. 

Patient and family advisors are an invaluable part of our TTE family, and it’s hard to forget after attending that every patient and family member is a valuable part of your healthcare team.

Students learn about leading-edge patient safety topics from internationally renowned leaders at TTE, but (again) it goes even further.  Daily social activities and group outings afford learners additional opportunities with faculty to continue discussions or ask questions.  We often hear how some of the most meaningful lessons occurred one night around a fire pit, or while over a drink at happy hour, which is hard to find at typical programs.

And finally, Telluride Experience alumni are embraced by a community of like-minded colleagues for ongoing support or collaboration long after departing.  But (once more) it goes even further, and that partnership is formed not just among the learners themselves, but with the faculty and patient advocates who remain an email or phone call away. 

We hear from alumni, years later, how TTE helped them improve care and safety at their own institutions or how it changed the way they engage with and care for their patients.  We are proudly entering an era where TTE alumni are returning – this time as faculty members or small group leaders.

Whether you’re reading this as a prospective student, alumni, Dean, administrator, or anyone looking for an exceptional patient safety program, we hope you’ll consider learning more, applying, or supporting our program.  We rely on your word of mouth, referrals, and financial support to continue our mission. 

Additionally, please check out our new book, Shattering the Wall: Imagine Health Care without Preventable Harm, which tells the TTE story through the voices of our faculty and learner reflections.  All book sale profits go directly to supporting scholarships for future students and residents.

The Telluride Experience – Not Your Typical Patient Safety Training – Part One

By Stacey Gonzalez

Anyone reading a blog post for the MedStar Institute for Quality and Safety probably already knows the importance of improving quality and safety.  You know healthcare has struggled for decades since first becoming truly aware of this issue’s magnitude and pervasiveness.  I’d also bet you’re already actively engaged (or seriously interested) in solutions.  For those reasons, I’ll jump right in to The Telluride Experience

The Telluride Experience (TTE) is a 4-day, intensive workshop that convenes resident physicians and health science students to focus on patient safety concepts and the application of quality and safety improvement strategies and tools. Over 1,000 alumni across the United States and internationally have taken part in the Telluride Experience.

However, the real story is what makes The Telluride Experience so unique and transformative for its learners. 

There’s a quote with unclear origins that speaks well to the TTE approach.   

Tell me and I forget.  Teach me and I remember.  Involve me and I learn. (unk.)

Whether originally said by Xunzi, Confucius, or Benjamin Franklin, the message is relevant.  Some lessons aren’t best taught by a lecture or textbook.  You need to be involved and immersed in the lesson to really “get” something in a way that will effect change in your daily life. 

TTE utilizes various teaching modalities to help all students learn profoundly for sustained impact.  Small groups, engaging discussions, games, and case studies are all critical pieces of our unique formula.  Learners receive functional tools to share these lessons with colleagues after returning to their institutions. 

Dr. Rachel Nash attended the Telluride Experience in 2012 as a rising 3rd year medical student, and in 2018 she reached back out to us.  Finding herself interviewing for her first attending job, she shared the following reflection on her career so far, attesting to the program’s long-standing impact. 

“I keep coming back to the Telluride Roundtable and how meaningful that experience was for me. It was truly life changing. Being immersed in that environment with passionate people was incredibly powerful. I think that experience gave me the confidence to plan quality and safety events in medical school, and to be a successful resident.” 

Whether you’re reading this as a prospective student, alumni, Dean, administrator, or anyone looking for an exceptional patient safety program, we hope you’ll consider learning more, applying, or supporting our program.  We rely on your word of mouth, referrals, and financial support to continue our mission. 

Additionally, please check out our new book, Shattering the Wall: Imagine Health Care without Preventable Harm, which tells the TTE story through the voices of our faculty and learner reflections.  All book sale profits go directly to supporting scholarships for future students and residents.

If you’re interested in learning more about how TTE consistently changes learners’ attitudes and actions, read on to Part Two of The Telluride Experience – Not Your Typical Patient Safety Training.

Shattering the Wall: Imagine Healthcare without Preventable Medical Harm

By Anne Gunderson Ed.D, MS, GNP

Since the official creation of The Academy for Emerging Leaders in Patient Safety: The Telluride Experience in 2009, over 800 health science students and residents have attended one of our immersive sessions.  The program is intended to fill gaps in health sciences education where formal, systematic patient safety and quality curriculum is lacking. Learners leave with the tools, knowledge, support, and enthusiasm to make a difference at their institution or school, and a commitment to make patient safety a focus of their medical careers.  While in attendance, each learner is asked to blog nightly to provide an outlet for their reflections and the impact of its curriculum in their own words.  These powerful glimpses into their thoughts and experiences formed the inspiration for our new book, Shattering the Wall: Imagine Healthcare without Preventable Medical Harm.

Shattering the Wall is a collection of works created by these young healthcare learners and the faculty members who taught them.  Each chapter is deeply rooted in the healthcare domains of safety, quality, and leadership. No matter what type of reader you may be—healthcare professional, health science educator, or a patient who uses health services—this book will hopefully open your eyes to many of the intricacies of our current healthcare system, as well as the challenges faced by all of us in delivering safe, high-quality care. In this book, you will be exposed to first-hand accounts of real-life situations involving learners, professionals, patients, and their families, which reflect the historical background, current state, and lessons learned of each prevalent topic in healthcare practice.  The chapters do not have to be read in order. Feel free to pick a chapter on a topic that intrigues you, or start from the beginning and immerse yourself in a learning experience similar to what our learners experience while attending The Telluride Experience.

The future is limitless for these young leaders. The leaders of tomorrow have the opportunity to create a culture that is safe, and, most importantly, patient-focused. By stretching the boundaries of traditional thinking and acting, learners and professionals can deliver higher-quality care to patients and their families, thus transforming and improving healthcare culture and practices for future generations.

We hope you will accept this work in the spirit in which it was intended: to give a larger platform to the voices of our future healthcare leaders—voices that will carry the much-needed healthcare culture change forward. Our faculty strongly believes in the “Educate the Young” premise – providing the future generation of health care leaders the knowledge, tools, techniques, and behaviors associated with high-quality, safe care.

Whether you are a healthcare learner, a healthcare professional, or a patient or family member interested in learning more about our current healthcare culture, you will appreciate Shattering because we all have one thing in common - we are all affected by the health of our current healthcare system, and we will all, one day be patients.

Please note: Any and all proceeds from book sales will go directly to support future Telluride Scholars in their quest to become the safest, most patient-centered caregivers they can be. We are, in turn, grateful for your support.

Purchase book here: amazon.com

Council of the Safety and Quality Jedi

By Anne Gunderson MS; Ed.D.

Over a decade ago, our nation’s healthcare sector was in upheaval following the disclosure of the Institute of Medicines report on deaths due to medical errors (IOM, 2000).  In response, a Jedi warrior with a passion for patient safety education determined that someone needed to bring like-minded warriors together to discuss the plight of healthcare in America. Contemplating the vast need to join forces with other patient safety Jedi masters, the warrior identified and invited select masters to the table. In 2004, select Jedi made their way to a remote mountain in Colorado. Over five long days and nights, each member of the Jedi council shared their knowledge and experience at the Roundtable. As the council members engaged in open conversation and consensus building, the initial plans for the rebellion against medical error became a reality.  As each member shook hands and agreed to meet again the following year, the rebellion was born.

In 2008, two medical students and two residents with strong interest in safety and quality were invited to the Jedi roundtable. The four Padawan learners added their voices to the discussions while learning from the Jedi masters.  The success of this model provided the inspiration for a new training academy for health science learners. The Council determined that a constantly expanding interdisciplinary educational program was needed to better prepare health sciences students and medical residents to understand, appreciate, demonstrate proficiency, and assume a leadership role in patient safety and quality outcomes initiatives. The learning opportunities would provide young Padawan’s with the knowledge and experiences that promote discipline competence and a sense of personal and societal responsibility for the delivery of safe, highly reliable patient care.

Padawan to Jedi Warrior: A New Hope for Healthcare

Despite our progress, we are facing a dark future unless we embrace the Force. By that, it means we must focus on what is happening around us, to be mindful, and commit fully to the rebellion on preventable medical error and or harm. Recent reports estimate deaths due to medical error are not improving, and in fact, are now thought to be four times the number revealed in the 2000 IOM report (James, 2013). Although we have trained almost 1,000 Padawan learners over the past 8 years, our Jedi army cannot withstand the siege. Patient safety practices’ resulting in quality outcomes is the number one requirement for the provision of safe patient care. To meet this requirement, education and training in safety and quality must be the very foundation of every training academy. Instead of teaching to the content of national examinations, academic institutions should focus on creating effective learning that meets the needs of the health care system and the patients that are dependent on their care.

I wrote this reflection on my last run to the rebel base. As I sit in the back of the training room, wearing my Yoda shirt and observing the newest team of Jedi warriors, I have to believe that the Force is strong in them. A Jedi must have the deepest commitment. We have coached them to focus on the present, to fully embrace and commit completely to providing safe healthcare practice. They have learned, and they have been tested. They are aware of the dark side and have acknowledged that we must beat the enemy all around us; medical error. As Yoda said, “Try not. Do. Or do not. There is no try” (The Empire Strikes Back, 1980)

A Jolly Good Fellowship

By Melanie Powell, MD, Fellow for Quality & Safety
MedStar Institute for Quality & Safety

Imagine starting a new job. You immediately feel slightly stressed, right? Regardless of how adequately you’ve researched the company, or whether you’ve worked at the company for 15 years and are simply starting a new position, there is a feeling of uncertainty associated with a job change. What will the challenges be? Will I get to do what I love? Will I have support when I feel like things aren’t going as planned?

Now imagine starting a job that’s never existed in your company. Would you feel something more than stress?

While there exist other Fellows in Quality and Safety around the country (albeit a small number), there has never been an administrative Fellow in Quality and Safety at MedStar Health. It was the distinct vision of a select few at the MedStar Institute for Quality and Safety who created my position and continue to support my efforts and our collective vision.

This distinction affords me two things:

  1. Freedom
  2. Pressure

On any given day, I have the freedom to participate in activities that further my education, and to collaborate in real time with quality and safety leaders in the organization (at least once weekly I have one-on-one time with the Assistance Vice President of Quality and/or the Assistant Vice President of Safety at MedStar Health – invaluable mentorship that I cherish). This is important for several reasons: obviously the education, but also because safety events happen at 2am; event reviews are arranged within 48 hours of an event; disclosure happens within minutes; CANDOR and Patient Communication Consult training sessions and Clinical Quality and Safety meetings are scheduled throughout the week at widely varying times. There needs to be flexibility in the schedule of an administrative fellow.

For instance, this month (all with minimal notice) I attended an event review for a serious safety event, volunteered to interview providers in operating rooms at two separate hospitals as part of a project to reduce the incidence of retained foreign objects, scheduled a lecture to educate residents about just culture and high reliability, rounded with surgical residents to observe safety events and unsafe conditions, attended a conference to improve the diagnostic process and reduce diagnostic error, became the team lead on a project to develop measures to reduce diagnostic error with the Institute for Healthcare Improvement, joined a committee to develop educational interventions to improve the diagnostic process with the Society to Improve Diagnosis in Medicine, and on and on and on…

Now to the pressure. This particular fellowship is not accredited by the ACGME…yet. If I succeed in attaining my educational objectives it will further the case for ACGME accreditation; if not, we will have lost a huge opportunity to contribute to a formal Quality and Safety Curriculum in Graduate Medical Education. To maximize the likelihood of success, I spent a great deal of time researching other fellowships and looking at the credentials of leaders in quality and safety to create a robust list of goals and objectives. I will also complete a certificate program in Executive Leadership in Quality and Safety in the spring at Georgetown University, a passion project of quality, safety, and education leaders at the MedStar Institute for Quality and Safety. This Masters level certification will provide critical didactic knowledge to round out my practical experience.

So, while I do feel stressed, I also feel incredibly privileged. Every day I get to do exactly what I love. I also have the privilege and the pressure (as Billie Jean King likes to say, pressure is a privilege) of setting the tone for all future fellows who work at the MedStar Institute for Quality and Safety. It’s a huge responsibility. I think to myself, in 15 years what will the fellow(s) be working on? Will there be a fellow in Resident Quality and Safety education? A Fellow in High Reliability? A Fellow in Practice Improvement? The possibilities are endless…if this experiment succeeds.

What I do know is…when I go to residency programs and tell current trainees that they can complete a Fellowship in Quality and Safety, they sit up straighter and at least one set of eyes sparkles. I remember that feeling, and I know that any future Fellow in Quality and Safety at MedStar, because of the flexibility to seize all educational opportunities and develop projects with system-wide support, will make a huge difference at MedStar Health and beyond.

Join the Revolution to Change the Culture of Healthcare

By Anne Gunderson, Ed.D, MS, GNP

In 1999, the Institute of Medicine (IOM) released a report that estimated 44,000 to 98,000 people were dying each year in hospitals as a result of medical errors. Even the lower estimate suggested that medical errors were the eighth leading cause of death, higher than motor vehicle accidents or breast cancer. A little over a decade later, medical errors are now the third leading cause of death and account for more than 400,000 deaths per year.

Recent studies have reported that as many as one-third of hospitalized patients may experience harm or an adverse event, often from preventable errors. For more than a decade, reports of the IOM have focused attention on a persistent set of problems within the American health care system, including: poor quality, lax safety, high cost, and questionable value. The traditional systems for dissemination of new knowledge can no longer keep pace with scientific and quality improvement advances. According to the IOM, if unaddressed, the current shortfalls in the performance of the nation’s health care system will deepen on both quality and cost dimensions, challenging the well-being of Americans now and potentially far into the future.

According to the IOM, the culture of health care is central to promoting learning at every level. The need for a new culture of care is common to all types of health care organizations. Continuous improvement requires understanding of the scientific method, systematic problem solving, the application of systems engineering techniques, operational models that encourage and reward sustained quality and improved patient outcomes, transparency on cost and outcomes, strong leadership with a vision devoted to improving health care processes. The goal is to create continuously-learning organizations that generate and transfer knowledge from every patient interaction to yield greater performance predictability and reliability.

The absence of such training leads to medical errors – a serious problem that affects not just patients, but also the health care workers involved.  Many good physicians, nurses, pharmacists and other health care professionals have left the field due to depression and lack of support from their colleagues. Even more unfortunate, a growing number of health care professionals take their own lives each year when involved in a preventable medical error. If we cannot take care of our own, how could we possibly administer care for our patients?

There is finally a solution for practitioners and their patients. The Executive Master’s in Clinical Quality, Safety and Leadership at Georgetown University and MedStar Health provides an opportunity to change the world with a Patient-First Education. The Executive CQSL degree program unleashes a systematic, evidence-based education that will achieve striking results in safety, quality, reliability, and healthcare value. A fundamental tenet of the program is that all health care professionals must work in concert toward the wellbeing and safety of each patient. The Executive CQSL will allow learners across the world to access the safety science and quality learning opportunity provided by our Executive program.

Healthcare practitioners and leaders need new skills and attitudes to meet the changing needs of patients in a medical environment that has complex, multi-layered systems, informatics, assessment, outcomes, and quality indicators. Secondary to these changes, health care has become a high-risk industry. With a learner-focused environment, the CQSL program will equip learners to become leaders in the advancement of safety science and quality healthcare, and leadership. The curriculum includes online, asynchronous coursework, simulations, team training, and one onsite residency. The future is yours…and your patients’.

Change the World with a Patient-First Education

Clinician Education, Mentorship, and Teamwork: Building Tomorrow’s Leaders

By Melanie Powell, MD, MPH

Hello! I am the inaugural fellow in Quality and Safety at the MedStar Institute for Quality and Safety. Over the next year, I’ll provide monthly insights and document my transition from Family Medicine chief resident at one of MedStar’s community-based hospitals to the administrative fellow at MIQS, an institute housed within one of the largest hospital systems in the Northeast United States.

As residents settle into the new academic year, the most common question upper levels face is: “What’s next?” My former co-residents, having figured this out and starting their new positions, now ask, “How did that go by so fast?”

Times of transition are both challenging and incredibly exciting. Trainees across the healthcare spectrum transitioning to independent practice may feel high levels of anxiety, stress, and concerns about inadequacy, isolation, confusion, and fear. This can lead to underperformance, burnout and ultimately compromise the delivery of safe, high-quality care. In response, organizations such as the American College of Surgeons and residency programs like University of Iowa Health Care Anesthesiology developed Transition to Independent Practice Programs to help fill perceived gaps in training. The National Council of State Boards of Nursing recently completed a national study to transition new nursing graduates into clinical practice. Initial results show that nursing clinical competence significantly increased after 9-12 months of participation.

What these programs have in common is mentorship. Mentorship is critical to the development of confident and clinically competent healthcare providers. Typically, it is implied and assumed by residency programs but actualized with varying degrees of value to residents and faculty. Reviewing the ACGME Milestones for Family Medicine Residents, mentorship is mentioned only once (within the description of a Level 5 achievement for professionalism) and in the context of a resident becoming a successful mentor herself. While it’s expected and vital that residents become effective mentors so they may train the next generation of leaders and support their colleagues, all health care providers require guidance to do so.

I am excited to be part of a health system that recognizes the value of mentorship and feel privileged to have been mentored by two very strong women during my Family Medicine residency at MedStar Franklin Square Medical Center. In addition to the research mentorship provided through the MedStar Health Research Institute, the MedStar Institute for Quality and Safety is generating a network of quality and safety mentors to pair with young trainees. Further, the Academy for Emerging Leaders in Patient Safety (AELPS) continues to educate an interdisciplinary group of young trainees in the US and abroad that includes medical and nursing students, connected with each other through a shared love of patient safety and dedication to culture change.

The question we must always ask ourselves going forward is: “How can we improve?” There are abundant opportunities to add to the curricula of nursing/medical schools and residency programs so that future clinicians can start building their skills as early as possible. To do this, we must identify ways to make mentorship, quality improvement, patient safety, and leadership a part of trainees’ everyday experiences. I think this includes encouraging interdisciplinary collaboration whenever possible. We grow professionally and make our patients safer when each front-line voice is heard and connected.

I hope those of you reading this post reply with your insights and share the innovative changes happening at your medical schools, nursing schools, hospitals, and elsewhere.