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Informing patients is job one: West Penn Allegheny Health System did the right thing
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Patient safety should always be a health-care professional's top priority. Our goal is to heal people and, when we can, prevent illness entirely. We also want our patients to be engaged and actively involved in the decisions that impact their health. However, to what lengths should we go to ensure they are informed? And to what end should we be held accountable for sharing that information?
At the West Penn Allegheny Health System, we believe it is our duty to be fully transparent with our patients, always. How else can we earn their trust? This principle was never more tested than several years ago at our Forbes Regional Hospital.
In 2004, Forbes purchased new equipment -- "scopes" as they are called in the industry -- to be used during colonoscopies. Although it was the custom in the industry, the manufacturer didn't alert Forbes at the time of the purchase that the new scopes, while the same series as other Olympus models owned by Forbes, had a significant design change.
Believing that the scopes were the same design as previous models, our team used them and disinfected them in the exact same way they always had. However, we soon learned that these specific scopes had a new feature, an extra channel, which we had never seen nor used previously.
Once our team discovered this feature, we found the scopes were not being disinfected to the manufacturer's specifications. We learned other health-care institutions were unaware of these issues. In fact, we learned the very same scopes had been subject to a safety alert prior to our purchasing them. We had already conducted 200 procedures without knowledge of these issues.
We were alarmed and immediately stopped using the scopes. We quickly contacted the Centers for Disease Control and local health officials for guidance. We were relieved to learn that the risk of any blood-borne infections was remote. In fact, the risk was so minuscule that the regulators and experts felt it was unnecessary to notify our patients. Why concern them? We simply needed to update our cleaning procedures.
We knew we should do more. We not only reviewed our procedures, we also elected to inform our patients. We made free testing immediately available around their schedules. We set up a toll-free number to answer questions and ensured a professional was always available to answer any questions. As suspected by the CDC and local experts, not a single person was infected. Yet, WPAHS has been in litigation for the past several years (as reported in the July 22 Post-Gazette, "Forbes Hospital Found Negligent").
Keeping quiet might have enabled us to avoid a prolonged court case and negative publicity, but it was never a consideration. We believed then -- as we believe now -- that our patients have a right to all information related to their health care. We value both patient safety and transparency.
WPAHS has done and continues to do the right thing by improving our processes to maintain our patients' trust. WPAHS did more than update the cleaning procedure for these scopes. We revised our entire process for how we purchase all new medical devices.
We also know other hospitals around the country were similarly impacted by these Olympus scopes. If we had not been fully transparent, we would never have been able to share our experience or alert others regardless of how remote the risk.
WPAHS and Forbes Regional Hospital have continued to move forward since this incident. WPAHS was recently named as one of the country's top performing health-care systems based on patient care quality and efficiency for the third consecutive year. We are the only health-care provider in Western Pennsylvania to earn this distinction.
U.S. News & World Report also recently lauded four of our hospitals. Forbes Regional Hospital was noted as being "high performing" in gastroenterology among other medical specialties. We're proud of these accolades, because they reflect our tireless efforts to improve patient care.
Given the importance of high- quality care, there are never too many ways to improve performance. Talking about any incident can be beneficial, just as keeping patients informed can never be wrong. Soon, a second proceeding will be held to decide what damages should be awarded in this case, nearly a decade after the incident occurred. Fortunately, WPAHS and Forbes Regional Hospital put patients first, acted quickly and applied the lessons we learned to improve patient safety overall.
First Published August 1, 2012 12:00 am
