"He's otherwise a good physician": A surgical error

In June, a Massachusetts surgeon set out to remove an 84-year-old woman's gallbladder with a fiber-optic instrument called a laparoscope. Unexpectedly, he found a significant amount of organ inflammation and bleeding during the procedure, so he switched to open surgery to address the problem. However, he misinterpreted the results of a medical test during the procedure, so he operated in the wrong anatomical area. He dissected and removed the woman’s right kidney instead of her gallbladder. The error was only discovered when a pathologist tested the removed organ three days later. The patient was transferred to an academic medical center, where her condition improved. In fact, she has not since needed her gallbladder removed.

The state Board of Registration in Medicine has now finished its investigation. It noted that the award-winning surgeon had no other action against him in the past. The Board’s spokesman commented that while the incident warrants close observation, "oftentimes, it doesn't do anybody any good to remove a physician from practice if he is otherwise a good physician." I agree.

Advice to patients: When a surgeon advises surgery, get a second opinion from a doctor who is not a surgeon. This woman did not need her gallbladder--or her kidney--removed.

Read another kidney story, or read the full newspaper article by David Riley.

Dis-Infecting Hospitals: A Role for Citizens

State Senator Richard T. Moore, the chairman of the Massachusetts legislature’ Health Care Financing Committee, filed legislation yesterday that eventually would require health officials to make public the infection rates for individual hospitals. State health officials said public disclosure probably would be part of any new reporting requirements placed on hospitals. Sen. Moore said public reporting will give hospitals added incentive to improve their infection rates.

Hospitals can indeed greatly cut their infection rates. Last month, Beth Israel Deaconess Medical Center president Paul Levy posted his hospital's rates for central line-related infections, in part to spur other hospitals to be more transparent about their quality of care. Bacteria on the tubing can flow quickly through the bloodstream and to major organs, making these infections of particular concern. BIDMC staff have cut the central line infection rate in half from its rate of 3 central line infections per 1,000 patient days a year and a half ago.

Advice: Tell your friends in Massachusetts to support this bill.

Read a patient's story, or read more on this from Liz Kowalczyk's article in today's Boston Globe.