It's that "America's Best Hospitals" time of year again. Shortly after midnight tonight, the new rankings will blink into existence. You'll also find feature articles, a photo essay that follows an ER nurse through her 12-hour shift, and a video with Health Editor Bernadine Healy of the grueling rehabilitation process after a Tiger Woods-type ACL knee repair.
The big change this year is that we've swung the door wide open. Rather than providing information only on the 170 hospitals ranked in one or more specialties, we have posted the same data and scores online for more than 1,500 hospitals (out of a total of 5,453 analyzed) that were good enough to meet our basic standards for qualification but came up short of being ranked. It's a group that probably takes in most hospitals with at least a couple of hundred beds (small by big-city standards), so most readers will be able to find information of interest about a few centers that might someday, or sooner, be a medical destination for them or someone close to them.
As the project was finishing up a couple of days ago, I was thinking about a patient who had surgery on the wrong part of her body last week. It didn't involve loss of an organ or a limb, and she is reportedly recovering at home. The incident occurred at Beth Israel Deaconess Medical Center in Boston, a hospital that always does well in the rankings. Accounts of such "wrong-site surgeries" generally surface because of a leak or lawsuit.
Not this time. Instead, the top doctors and administrators sent a lengthy E-mail to the thousands of hospital employees, describing the event and calling it "a horrifying story." The E-mail was also sent to the media; the Boston Globe ran a prominent piece. The surgeon responsible for the mistake had already met with the patient and apologized.
It is extraordinary for a hospital to pull back the covers like this, let alone the same week. Never before has anything similar crossed my desk. "By publicizing the incident internally and externally," wrote Beth Israel CEO Paul Levy on his blog site, in response to a critical comment from a reader charging that the act was a mere feel-good stunt to draw approving applause, "we hope to make it less likely for mistakes like this to happen in the future—certainly at our hospital, but perhaps also at others." Levy has been agitating for more transparency for some time, but it's one thing to disclose hand-washing and infection statistics and another to offer a detailed mea culpa after your hospital has seriously screwed up. Others should emulate this. I doubt that many will.
I was also struck by the cause of the error. Since mid-2004, all hospitals accredited by the Joint Commission have been required to include a "timeout" before starting surgery, when activity stops and there is a verbal check of the patient's identity, condition, and type of surgery, and confirmation that the correct side and site are marked (preferably with the surgeon's initials). No timeout was called for this operation. The surgeon didn't do it. Someone else in the OR should have stepped in: The protocol at Beth Israel, and at most hospitals, makes it clear that it can be a nurse, a surgical technician, a fellow in training—a medical student. "You have to make it comfortable for the nurse or the scrub tech to say, 'Dr. So-and-So, I don't mean to interrupt, but we're supposed to do a timeout,' " Levy told me this morning. "And the surgeon is supposed to say, 'Thank you.' It should be second nature."
Why, then, didn't it happen? The entire OR team had worked often and well together. The surgeon wasn't authoritarian and impatient, says Levy. The circulating nurse had stepped out of the room for a moment; when he returned, the operation was in progress. The anesthesiologist was distracted by another matter. "We're obviously piecing together the whole thing," says Levy.
But here's the part that is alarming: The number of wrong-site surgeries since the timeout requirement was instituted in 2004 has steadily risen, not dropped; the Joint Commission gets reports of five to eight a month. Last year, one hospital in Rhode Island initiated surgery three times on the wrong side of patients' heads.
Nobody is sure what's going on. The literature suggests that the timeout ritual can become a ritualistic formula that literally gets lip service but not the OR team's full attention. Some surgeons see it as a bureaucratic intrusion. But does anyone have a better way to stop what arguably is the most preventable of all medical errors—cutting into a patient in the wrong place?