Cameras in the Operating Room? The Discussion Continues…

In response to recently introduced Wisconsin legislation, we penned a column this past video camerasummer about the use of cameras in the operating room or so-called “surgical black boxes.” We got a lot of feedback from healthcare, insurance, and legal professionals, and almost all of it good and supportive. One veteran risk manager wrote, “How do we fix problems if we don’t know what they are?” And several lawyers wrote the evidence is powerful, and usually FOR the doctors and nurses. Unfortunately, these folks don’t work for the hospital and medical lobbying groups. The Wisconsin hospital and medical associations — the state where this legislative proposal has first been proposed — think it’s a terrible idea that will “get in the way of the patient/doctor relationship.”


How does me the patient or the family knowing what is happening in the operating room get in the way of a relationship with my doctor? Anyone who understands or has experienced marriage counseling knows that secrets in a relationship are a ticket to trouble. Being open is the best policy with those you want to trust. Why do medical and hospital lobbyists think they are different? Nope, just more knee jerk reactions and fears that this idea will benefit the evil trial lawyers. This crowd said the same things about disclosure 10 years ago…..

Moreover, when you think about it, operating rooms are full of technology, computers, and other gadgets which if coaxed by a qualified technician can spill all of their secrets. Also, today’s patients and families come armed with smart phones that record every utterance and image— remember the surgical case from the summer? Indeed, we already have many “mini” black boxes in operating rooms as well as waiting rooms and everywhere else in the hospital or doctor’s office, so why not the full Monty?

Lastly, most hospitals claim they are supportive of disclosure (although the truth is the “support” comes in various shades and colors). So, if we all like disclosure, then let’s really be transparent! Videotape the operations, and, as many defense lawyers say, the tapes will usually show the complainant there really is no case. When, however, the tape shows a mistake, no worries, we were going to disclose anyway! Now we can show you the screw up in color on our I-PAD.

With this last point in mind, I think true disclosure hospitals will have to lead the way on this idea. It may too big a push legislatively, but a disclosure hospital can say (without legislative approval) to their surgeons, “Look, you know our disclosure policy, if you make a mistake we want to know about it, together we will go to the family, and together we will get everyone right, including you. So, the camera is just another tool to help us that do that.” When these disclosure hospitals start reporting their experiences using cameras and can show the roof didn’t fall in, well, then, the idea will get a lot less scary, including for the medical lobbyists.

Remember Sorry Works! is marketing the Disclosure Documentary developed and produced by Lawrence and Steve Kraman. This movie provides audiences with an in-depth look at disclosure from all stakeholders — including detractors! — and it is wonderful for Grand Rounds, staff retreats, medical and nursing students, and other audiences. The documentary helps healthcare professionals understand this very important issue. To order your copy, click here. Officials considering the purchase of this film for their organization can view the complete film in advance by sending an e-mail to Please include 1. the name of the organization, 2. your title/role and 3. Your e-mail address. There is no obligation to purchase.

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Hospital Continues to Send Mail to Grieving Family – Then Apologizes!

wadeOn several occasions Sorry Works! has shared the story of Wade and Jennifer who lost their daughter to medical errors at Children’s Hospital Oakland (CHO) – now named UCSF Benioff Children’s Hospital Oakland after a recent merger. We even shared the Westhoff’s experience in the new Sorry Works! Tool Kit Book. There are many angles to this tragic story, but one facet is painfully simple and incredibly galling: This hospital continued to send mail to the Westhoff family! Despite in-person pleas from the family, media coverage, and a mutual understanding when the case was settled, the family continued to be assaulted at the mail box.

The latest piece hit recently….it was one of those “read about our latest miracle and send money!” solicitations that hospitals routinely use. Wade said it was another punch in the gut. Part of Wade would like to re-write the fundraising pitch: “Read about how our daughter died at this hospital due to medical errors and the hospital treated us horribly afterwards…including repeatedly sending mail to us. Don’t send money to this hospital!”

Wade also confided to me that he simply thought about throwing the letter in the recycling bin and forgetting about it. His family will be moving shortly, so CHO’s mail will come to a complete stop eventually due to the move. However, Wade feels a duty to his daughter and other families to share what is happening. Perhaps CHO will never change — even after local media in the Bay area reported this problem – but perhaps other hospitals will learn from CHO’s continued insensitivity.

On a chance, Wade wrote the attorney who represented the hospital during his daughter’s lawsuit. Wade laid it out in an e-mail just like it is presented here…and the attorney let the hospital know! To their credit, the hospital contacted Wade, scheduled a conference call with Wade and several hospital executives, said they were “mortified,” apologized several times, and promised to never let it happen again. The conference call was not without pitfalls…one CHO/UCSF executive who had a sick child said she “understood” Wade’s feelings. Wade quickly rebutted: “So, did your child die due to preventable errors?” The hospital executive quickly retreated. The call ended with a CHO/UCSF executive confiding to Wade that his daughter’s case identified several problems and shortcomings in the hospital, and they are working to improve in these areas. We can certainly hope. In looking back at the conference call, Wade and his family felt this was the first time that CHO/UCSF actually heard them and actually “got it” as far as the need to improve their communications program. For the first time since his daughter’s death, Wade feels some optimism about the ability of CHO/UCSF to improve their care and communications efforts with families.

Earlier this year, I was conducting a Sorry Works! training for a large hospital system, and I shared the Westhoff’s story as part of the seminar. When I finished describing the Westhoff’s experience, the hospital’s General Counsel raised her hand and I called on her, but instead of addressing me she turned instead to the hospital marketing chief and stated, “Don’t let this happen at our hospital. We cannot do this to our patients and families.” I shared this experience with Wade and it made him feel good…his family’s story is already making a difference.

Moral of the story: Patients and families need communication from hospitals, practices, and clinicians post-event, but that communication must be empathetic and delivered in an intelligent fashion. Bills, marketing magazines, surveys, and fundraising solicitations are insensitive and cruel to any family, and make the hospital/practice look stupid and incompetent. Moreover, people should not have to move away to stop the assault at the mail box. With a few key strokes, good disclosure hospitals can suspend all mail, including bills, marketing magazines, surveys, fundraising letters, etc, to families who have experienced adverse medical events. All communication attempts need to go through the disclosure team and clinicians involved in the event – period.

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Another British Hospital Apologizes for Baby’s Death

In late September we reported that a British Hospital apologized and admitted liability for mistakes that led to the death of a baby. We also reported in October that an American hospital (State of Idaho) had apologized for medication errors that caused the death of an infant. Well, it was reported yesterday that another British Hospital — lghLeicester General Hospital — apologized and admitted liability in the death of a baby. Baby Delilah Hubbard died two days after birth, the victim of medical malpractice. In their admission of liability, the hospital said staff did not treat the high risks pregnancy in an appropriate manner and was slow to order a C-section, among other items.

The news article included the statement of apology from the hospital — no weasel words here:

In a statement, Joan Morrissey, Midwifery Matron at Leicester’s Hospitals said: ‘In light of the mistakes that were made in the way Delilah’s birth was managed we know that an apology can never undo what happened and may bring little comfort to Mr Hubbard and Ms Bassford. Nevertheless we are deeply sorry for the mistakes that were made and we would like to send our condolences to them both. We let them, and Delilah down. We have written to Mr Hubbard and Ms Bassford offering our sincerest apologies for what happened and to provide them with a copy of the detailed investigation report we carried out following Delilah’s death. Senior members of staff also met with Mr Hubbard and Ms Bassford to discuss their concerns and talk them through the findings of our investigation.” We have taken this tragedy incredibly seriously and will be attending the inquest in April to explain to the Coroner exactly what went wrong and what we have done and will be doing to ensure as far as possible that this does not happen again.’

This appears to be a powerful example of apology and how healthcare organizations can use disclosure to learn from events and provide closure for all stakeholders. Moreover, it is good to see hospitals publicly owning mistakes in potentially high value cases, as opposed to seemingly low value cases as we have discussed in this forum recently.

Disclosure starts with teaching your directors, managers, and front-line staff how to say “sorry.” The Little Book of Empathy is a terrific teaching tool for healthcare, insurance, and legal professionals. We’ve sold thousands of copies….to receive your copy, click here.

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How to Preview the Disclosure Documentary

flyerOver the last month, we’ve told you all about the new Disclosure Documentary produced by Lawrence and Steve Kraman, and marketed by Sorry Works! A lot of buzz has been generated, and many people are interested in purchasing the film for their organization.

Officials considering the purchase of this film for their organization can view the complete film in advance by sending an e-mail to Please include 1. the name of the organization, 2. your title/role and 3. Your e-mail address. There is no obligation to purchase.

*The $500 price is for one hospital, group practice, or nursing home…..organizations with multiple hospitals or multiple nursing homes or multiple insureds (such as a PIAA carrier) or organizations with multiple members should call 618-559-8168 or e-mail for a quote. The license agreement for the film is as follows: Upon payment of the sum of five hundred dollars ($500.00), Newport Classic hereby grants to Licensee the non-exclusive right, for the life of the relevant DVD copy, to: (a) include the Film in Licensee’s public library to its authorized users and/or card-holders for the purposes of research, education, or other non-commercial or non-performance use for student, staff and faculty or any additional authorized users; and/or (b) exhibit the Film in a public or private setting, provided that such screening is in a non-theatrical and non-broadcast setting. The Film may not be exhibited to an admission-paying audience.

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Hospital Shares Errors, Apologies with the Public

bwhRecently, I was alerted by a reporter that Brigham and Women’s Hospital in Boston is now sharing stories of errors and apologies with the public. The hospital is publishing stories and posting them on the Internet for the whole world to see.

We applaud this move. For years at Sorry Works, we have told hospitals, long-term care facilities, and the insurance, claims, and legal professionals who serve them that disclosure should NOT be contained within the four walls of their buildings. We routinely instruct people to share the details of their disclosure programs with the public, the media, and the trial bar, and, when appropriate, share stories of specific cases. We need to educate the public and — moreover — CHANGE the public’s perception that doctors and nurses will run away post-event and the only way to get answers is to file a lawsuit, file a complaint with the state or the media, rant on social media, etc. Following an event, consumers need to know they can go back to their hospital/doctor with questions and will be treated fairly . Trial lawyers also need to know the door is open and phone calls/e-mails are welcomed.

The two disclosure stories shared so far by Brigham and Women’s Hospital involved a delayed diagnosis of cancer in an 85-year old woman (which was viewed not to have impacted her chances of survival), and a mistake in an infant leading to a scar on the wrist (which was viewed not to warrant plastic surgery). It will be interesting to see if Brigham and Women’s — and other hospitals — will begin publishing disclosure/apology stories of truly compensable errors. There is still an unwarranted fear among some claims and legal professionals that by telling the public the hospital or nursing home paid money on a case that the flood gates will open, families and their lawyers will be lined up around the corner looking for handouts, etc. The claims record of the University of Illinois Medical Center (in Cook County!), University of Michigan Health System, and other systems who have been public about compensable errors do NOT validate these fears. In fact, the public and the trial bar view these healthcare organizations as having integrity and seem to be more willing to treat them fairly. It’s all about restoring trust!

On Thursday, November 12, Sorry Works! will be hosting a webinar on how to start and sustain your disclosure program. Sorry Works! Founder Doug Wojcieszak will be teaching from the new Sorry Works! Tool Kit — and every registrant will receive a copy of the Tool Kit. Click here to register.

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Sorry Works! at ASHRM – Booth 409 – with The Sullivan Group

ashrmSorry Works! Founder Doug Wojcieszak will be at ASHRM this Monday — Booth 409 — with our partners The Sullivan Group.   Sorry Works! and The Sullivan Group will be showcasing our new online course entitled, “Communication and Resolution: Empathy Post-Event.”  Wojcieszak will also be providing mini-presentations at 8:15am and 1pm on Monday at the booth — please stop by and see us.

If you are having any trouble finding us or would like to schedule a private meeting to discuss the new online course, call Doug’s cell at 618-559-8168 or e-mail

See you at ASHRM!

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Idaho Hospital Transparent, Apologetic After Child’s Death Due To Medication Errors

STLAccording to media reports, seven-month old August Dean Elliott died at St. Luke’s Magic Valley Medical Center due to a medication error.  The hospital held a press conference about the death, is investigating the event with the family and their attorney, and has apologized.  It looks like the hospital is handling the situation in an empathetic and intelligent manner.

Though this a tragic situation, it is good to see the hospital acting in this manner….in the not-so-recent past this behavior would have been unthinkable for a hospital.  The trick now is how to do we get every event (big or small, apparent or not-so-apparent) in every healthcare and insurance organization to be handled in this manner every time.  That day will come when every hospital and insurer has a disclosure program.

At Sorry Works! we are committed to helping organizations develop and sustain successful disclosure programs.  We recently launched the Sorry Works! Tool Kit to show organizations how to make disclosure work on a consistent and ethical basis  by developing successful and sustainable disclosure programs.  We are holding a November 12th webinar to teach from our new Tool Kit, and every participant will receive a copy of the Tool Kit.  To register for the November 12th webinar, click on this link.

Click on this link and this link to see media reports about the death of August Dean Elliott.

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Disclosure Documentary: Informed Consent Trailer & Pricing

dan hallThe Disclosure Documentary produced by Newport Classic Films and Dr. Steve Kraman and marketed through Sorry Works! is generating A LOT of interest. It’s a terrific movie that really gets people thinking about all of the issues surrounding medical errors and disclosure. And at 47 minutes in length, the documentary is perfect for Grand Rounds and other staff meetings.

Many experts from around the country provided interviews for the movie, including Dr. Dan Hall from the University of Pittsburgh Medical Center. A surgeon and ordained priest in the Episcopal Church, Dr. Hall offered an in-depth interview on informed consent. To see the trailer from Dr. Hall’s interview click here. To see Dr. Hall’s biography, click here.

INFORMATION ON PRICING FOR MOVIE: We are charging $500 for the movie for one hospital, practice, or nursing home. Organizations with multiple facilities (a chain of hospital or nursing homes, for example) or an insurer or association with many members should call 618-559-8168 or e-mail for a quote. To order the documentary, click on this link.

To see a trailer for the movie, click on this link.

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Sorry Works! Webinar: Starting and Sustaining Your Disclosure Program – Nov 12th, 1pm ET

We all want clinicians to say “sorry” after something goes wrong, and most of us know that webinar“running to the problem” is the best approach ethically and economically. But how do you actually start a disclosure program so that every adverse event is handled in an ethical and expedited fashion? And how do you sustain your disclosure program….how do you keep it from becoming the flavor of the month?

Sorry Works! recently released the Sorry Works! Tool Kit to teach healthcare organizations how to start and sustain a successful disclosure program. Sorry Works! Founder Doug Wojcieszak will be teaching from the Tool Kit in this exciting and interactive webinar. Wojcieszak will walk you through how to build your disclosure program including the development of your disclosure policy, how to teach disclosure to your front-line staff as well as claims, legal, etc, and then discuss cases and answer your questions. The registration fee includes a copy of the Sorry Works! Tool Kit.

When? Thursday, November 12th at 1pm ET/10am PT

Who Should Attend?

  • Risk managers
  • Claims managers
  • General counsel and defense lawyers
  • C-suite personnel
  • Chief Medical Officers
  • Physicians, nurses, and other front-line staff

To Register, Click on this Link.

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Hospital Admits Failings, Apologizes for Baby’s Death

ROBelow is an article that recently appeared in a British newspaper. The story pretty much speaks for itself. A baby died unexpectedly, the hospital’s review shows errors and mistakes, and then the hospital admitted their failings and apologized. The hospital appears to be extremely candid in their remarks — very powerful example of transparency.

Now, this event happened in a NHS hospital and, according to the news report, the family is pursuing a civil action against the hospital’s trust. Obviously, British healthcare is a little different than American healthcare…not sure how the British handle claims. If this event had happened in an American hospital, the hospital or their insurer could negotiate and settle with the family without going through civil litigation. After all, if you’ve determined fault and apologized, what is the point of a lawsuit? Just have some conversations, figure out what people need (financially and emotionally), and come to a reasonable agreement without the fighting. Perhaps the British can learn from how we are starting to handle claims with disclosure.

Hospital bosses admit that baby died after ‘failings in care’ at Royal Oldham Hospital

By Beth Abbit, Greater Manchester News, September 23, 2015

Baby Spencer Butler may have survived if doctors had carried out a Cesarian section at an earlier stage, an inquest has heard.

Medical and midwifery neglect was a ‘major factor’ in the death of a newborn baby who was delivered tragically late, an inquest has heard.

Baby Spencer Butler may have survived if doctors at Royal Oldham Hospital had carried out a Caesarian section at an earlier stage, coroner Lisa Hashmi said.

She found a causal link between errors and omissions made and the ‘unprecedented level of activity’ on the maternity unit when Natasha Butler was in labour.

Pennine Acute Hospitals NHS Trust has since revised its Induction of Labour Guidelines and apologised to the family for the failings in care.

Heywood Coroners’ Court heard there was a ‘gross failure’ in care and a ‘catalogue of errors’ and missed opportunities had contributed to Spencer’s death.

She said leadership on the unit was ‘almost nonexistent’ and added: “Apathy prevailed when it came to practical thinking.”

Mrs Butler was admitted to the maternity unit on May 14 for induction of labour and was induced four times over three days. When her baby became unwell she was transferred to the labour ward for an emergency Caesarean.

Spencer died of acute intrauterine asphyxia just 33 minutes after his birth on May 17, 2014.

Speaking after the inquest, Mrs Butler and husband Sean, from Oldham, said: “To come home without Spencer was heartbreaking and the hardest thing is knowing that his death could have been avoided. There was nothing wrong with him, he was a healthy baby and there isn’t a day goes by that we don’t get upset about that and wish he was still here.

“Nothing will ever bring Spencer back and we can’t help but be angry about everything the hospital has put us through.

“We put our precious baby in the hands of the professionals, but looking back we don’t feel that he ever stood a chance.”

Pennine Acute Hospitals NHS Trust said an external review into a small number of maternity cases at the trust’s hospitals was commissioned last year and the findings shared with the family.

Chief nurse Gill Harris said: “This is a terribly tragic case. Without question The Pennine Acute Hospitals NHS Trust let down Spencer and his parents, Natasha and Sean Butler, in aspects of the care provided. For this, we are truly sorry.

“We have apologised to Natasha and Sean for the failings in the care afforded to them and we wish to reiterate that apology today. Our staff will continue to support the family at this difficult time.

“It is important we ensure that we learn from their experiences and use this feedback and learning to help us achieve the highest standards of maternity care. As part of our maternity improvement plan across our two maternity units, we have learnt significant lessons from the detailed internal investigation we carried out.”

Following Spencer’s death his family has raised more than £5,000 in his name for the Make A Wish Foundation.

Jenny Urwin, a clinical negligence specialist at law firm Slater and Gordon, is representing the family in a civil action against Pennine Acute Hospitals NHS Trust.

She said: “The facts of this case are truly harrowing. The Trust failed in its duty and an otherwise healthy baby’s life was lost.

“This family is devastated, but determined that lessons are learned so that no one else suffers the same tragedy.”

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