In a letter to the editor of the New York Times this week, former Beth Israel Deaconess Medical Center CEO Paul Levy stressed the need for a balanced approach to medical mistakes that encourages providers to modify their behaviors and protects patients from egregious errors.
Levy offers an example from his former hospital, describing how one patient awoke from orthopedic surgery and asked her surgeon, "Why is the bandage on my left ankle instead of my right ankle?" The doctor realized he had operated on the wrong foot, immediately reported the error, and offered a thorough apology to the patient, Levy notes.
Over subsequent weeks, clinical leaders worked to strengthen Beth Israel's care delivery processes in order to minimize the chances of a similar error in the future, Levy adds.
Hospitals lead the way
Boston Hospital cuts medical errors by 40% in three months
Mich. system uses barcodes, x-rays to curb never events
How the VA cut medical errors by 25%
One hospital trustee asked Levy what he intended to do to punish the doctor in the case. Levy recalls answering, "Nothing. He already feels terrible about this mistake. Further punishment does not act as a deterrent in these kind of inadvertent errors." A senior physician added that punishing doctors would discourage error reporting.
Levy writes, "People in the medical field are well intentioned and feel great distress when they harm patients." While punishment should be reserved for "clear cases of negligence," other errors should be used to "reinforce a learning environment in which we are hard on the problems rather than hard on the people," he concludes (Levy, Times, 10/15).