mistake mastectomies spark new protocol

A surgical safety checklist for all Ontario hospitals will become mandatory on April 1, and Ministry of Health officials predict it will significantly reduce mistakes made in the operating room.

“I see this as a crucially important step forward for patient safety,” the ministry’s Dr. Michael Baker said of the 32-item list. Following the format, he added, “saves lives and reduces the error rate.”

The introduction of a standardized guide is welcome news, especially in light of the recent tragedies at Hotel-Dieu Grace Hospital. Had there been a system in place to verify procedures done before, during and after surgery, Dr. Barbara Heartwell might not have performed mastectomies on two women who did not have breast cancer.

And the seven cases of “serious concern” that led to the January suspension of a female pathologist might have been caught before any patients were harmed.

There was great fanfare surrounding the announcement of the new rules, but many people — those of us not involved in the world of medicine — were shocked to discover such an important safeguard didn’t already exist.

Running a hospital is a high-risk business, where life-and-death situations are an everyday occurrence. As patients, we expect everyone involved to scrupulously check and double check our reports, leaving nothing to chance. We understand our surgeons are busy, but we also assume more than one set of eyes will see our charts. We have faith that our fate is based on several “second opinions,” and that the surgeons and hospitals work in tandem.

Not so. The more we learn about the events that have unfolded at Hotel-Dieu, the more obvious it becomes that we actually know very little about how the system works.

Officials have told us that surgeons essentially “rent” operating rooms, equipment and support staff. Physicians are given privileges, but they have sole ownership of their patients’ records, surgical procedures, pathology reports and followups. They are, for lack of a better term, independent operators, and they are often the only member of the surgical team to see a pathology report before they make that first cut.

We understand that this practice is not exclusive to Windsor hospitals, and we appreciate that Hotel-Dieu officials acted promptly when they became aware of the two recent situations. But the local incidents have accentuated the need for a consistent, universal set of rules that cover any and all contingencies. If hospitals want to expand that list to include more precautions, all the better.

The outstanding issue for the Ministry of Health now is developing a compulsory provincewide protocol for reporting cases of physician error, and for promptly revoking the privileges of those who do not. Dr. Heartwell did not report the mistaken mastectomy performed on Leamington’s Laurie Johnston last year, even though the hospital’s own rules required her to do so.

The changes in Ontario will be implemented because of a worldwide study seeking strategies to reduce the “unintended events or mistakes” that happen every year in hospitals. Baker says the checklist can lower those incidents by about 30 per cent globally.

That will come as a relief to patients everywhere, but it will be no greater felt than right here in Windsor and Essex County.

The Windsor Star
Fri Feb 26 2010
Page: A8
Section: Editorial/Opinion
Source: The Windsor Star