Hospital errors strike again (and again and again and again!)


By Mike Thelen:

Having spent the last 10 years working within Lean disciplines, it is second nature to identify shortcomings in any business model from a Lean perspective. Since I also have two individuals in my immediate family who work in healthcare, I tend to *find* many opportunities for Lean simply by listening to dinner conversation. Thus, when articles like the following cross my homepage, they seem to demand my attention.

RI hospital group says doc operated on wrong knee

Sep 19, 8:18 PM (ET)

PROVIDENCE, R.I. (AP) – State health officials were investigating how a surgeon operated on the wrong knee of a patient Friday at the Miriam Hospital, part of a medical network that was reprimanded and fined $50,000 last year for three mistaken surgeries at another of its facilities.

The medical network had reprimands and fines, but no mention of problem solving by root cause evaluation. Did reprimands and fines do anything useful? The results are obvious, repeated errors mean no benefit from paying a fine and a severe lack of problem-solving techniques to avoid repeatable errors.

The latest mistake happened while a surgeon performed a knee arthroscopy, a procedure in which doctors insert a pencil-sized camera into the knee so they can diagnose a malady. In some cases, surgeons will repair or remove damaged tissue.

After the operation was complete, the surgeon realized the mistake and operated on the correct knee, hospital officials said.

What about the added expenses to the hospital: time, delays, supplies, lawsuits, etc? How will the patient react and how long will his recovery now take? Healthcare coverage is a constant election-season topic. How about the added costs that will be driven back into insurance coverage (we all know this will happen, either directly or indirectly)?

Miriam spokeswoman Linda Shelton would not identify the doctor or patient, whom the hospital said was “doing well.” Lifespan, the not-for-profit corporation that operates the hospital, has started an investigation into the accident.

Will the investigation utilize the scientific method of problem solving or the traditional management method of assigning blame and reprimanding? By their own admission, past experience indicates the latter, not the former. So, can we expect to see the same repeatable and completely avoidable error again in a few months?

“We deeply regret that such a mistake occurred,” Lifespan said in a written statement. “We have apologized to, and are working closely with, the patient and the family.”

The state Department of Health was alerted to the mistake Friday and sent a team to investigate, department spokeswoman Helen Drew said.

The jury's still out on the benefits of sending a State team to investigate. I have a relative who works in a State department with a similar function. Usually, those situations are just like industrial inspections. Everyone knows “who's coming for dinner” and all employees are prepped for the appropriate responses to questions. This is often best described as pre-tour 5S activity, as opposed to everyday clean to inspection that 5S truly desires.

“We're obviously greatly concerned about the incident and the patient,” she said.

Lifespan revised its policies following a string of wrong-side surgeries at Rhode Island Hospital, a teaching facility for Brown University's medical school.

Revising policies. I guess that should make us all feel warm and fuzzy. How about solving problems? Take a team approach. Honestly, seek out opinions from all areas of the organization. Ask the 5 why's to get the true cause out in the open. More so with the evidence of repeated and continued mistakes with “a string of wrong-side surgeries”. Should we as the paying public be even more terrified that these completely avoidable mistakes are occurring at a teaching facility?

In November, the chief resident started operating on the wrong side of an 82-year-old patient's brain, health officials said. A different doctor performed neurosurgery on the wrong side of another patient's head in February.

In August, a patient died several weeks after a third doctor operated on the wrong side of his brain. Afterward, state health authorities ordered the hospital to take steps to avoid similar accidents in the future, including an independent review of its neurosurgery practices and better verification from doctors of surgery plans.

Verification? Sounds more like quality inspection. How can you remove the inspection process by building in quality? That should be the true goal. Does it really benefit anyone when an agency, or a person in a leadership position (not necessarily a ‘leader'), orders action to take place? How about working together without fear of reprimand to resolve an issue that, in this case, can honestly be life or death?

We (both members of the Lean community and hospital patients) should be outraged. How many times can the same mistake be repeated? Someone died from the same, avoidable error. The cost of healthcare (not to belittle a death) also gets driven up in an environment that is already cost-heavy. How much trust can, or should, patients have in this hospital system?

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. I’m not usually one to come to the defense of health care organisations BUT lets examine some of your thoughts on the matter.

    Certainly in the UK, RC problem solving has been used for years and I am sure that this is true in the US. Culturally there have been and are issues with assigning blame and we could all, if we dig hard enough, find articles to support our respective positions but the use of RC problem solving, FMEA and HAZOP assessments to evaluate processes have been in place for years.

    The reality is that these incidents do not occur as the result of any one particular cause (read Lawrence Gonzalez Who Live, Who Dies and Why) but as a result of compounded changes in the process and deviations from the norm.

    This is highlighted by Gawande and Regenboum (spelling?) paper on the counting of instruments in to and out of theatre. If I recall they found that a mistake occured for every 8 or 18 minutes of counting but the mistakes were more likely to occur under pressure in emergency rather than elective surgery.

    Its a little like leaving sponges in patients, it happens more often in emergency than elective surgery.

    If you want a good example of a wrong site operation and subsequent investigation look at Paul Levys blog as he has recently dealt with this very issue.

    As to a string of wrong side surgeries in a teaching hospital, was it the same surgeon, same team, same theatre, same procedure. My guess is that it was not as the likelyhood is low in the extreme but without further information it is rather difficult to understand what went wrong.

    However verification perioperatively seems very much the right thing to do. Surely a perioperative time out is exactly what needs to happen and that time out is in one sense a stage of the process that is purely inspection. Check out BIDMC’s solution to this problem, without a time out you have a surgeon cutting open a patient when they may not even know the name of the people in the room on their team.

    There is NO WAY I would want to enter a operating theater without verification at admission, ward, reception, anaesthetic room and in to the theatre to ensure that the right procedure will be carried out.

    Eliminating this step / steps by claiming that verification is inspection and that you’d rather “build in quality” is in this particular environment the fastest way to more wrong site surgeries.

    Verification is no different from a pre-flight check list and I don’t suppose we are advocating eliminating that even though it provides little value add?

    As to how much trust one should have in a hospital. I’ve worked in them every day now for years, some of my closest friends and acquaintances are MD’s, surgeons and physicians and I trust them implicitly that they want to do the right thing, I have little to no faith that the system allows them to so I have very little trust in any health care system and treat it all with the greatest degree of skepticism possible.



  2. Hi,
    I follow you blog, I read a lot praising lean. (because i like it ! ) I just received the book “Physics factory” which seemes to be a reference for manufacturing… In this books they are not so talking about it. I amwondering if there is some blogs/websites you know where they are against Lean and have some good reasons. It is always good to listen from both side.
    Thanks for your blog. and haven’t started to read the booh lean hospitals yet.


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