Windsor Hospital CEO Takes Responsibility For Surgery Mistake

CBC  |  Posted: 05/04/2012 4:09 pm Updated: 05/06/2012 4:37 pm


The CEO of Windsor Regional Hospital says he failed a healthy patient who underwent a lumpectomy and had her lymph nodes removed.


David Musyj said he is ultimately responsible for the mistake in Windsor Regional Hospital's pathology department that led to the unnecessary procedures performed at Hotel-Dieu Grace by Dr. Barbara Heartwell, who in 2009 unnecessarily removed a healthy breast from a woman.


That mistaken mastectomy led to a $2.2-million lawsuit and a health ministry review.


In the latest error, the pathology department mixed up the test results of the healthy woman with those of a woman diagnosed with advanced stage breast cancer.


Hospital staff notified the patient of the mistake Wednesday.


“As CEO, I’m the one responsible if policies and procedures are not followed. This occurred under my watch. I’m responsible, this is not on the surgeon,” said CEO David Musyj. “What we are dealing with here is an unfortunate administrative error made in our pathology department where existing practices and procedures were not followed.


“If they were followed, this would not have happened.”


Musyj said the pathologist who made the administrative error has voluntarily taken paid time off. He called the pathologist "a good worker with no history" and said the pathologist is "remorseful and distraught."


The hospital is investigating exactly what went wrong and how, Musyj said.


Windsor Regional's chief of pathology, Dr. David Shum, said more than one case was open at a time and that is how the mix-up occurred.


Shum said the checks and balances in place focus on the correct diagnosis and not the correct patients. He said 10 or 11 pathologists at Windsor Regional handle 30,000 surgical cases each year.


Musyj said the hospital is helping the patient with medical treatment. He said he is not sure whether the woman is taking legal action.


Windsor Regional's chief of staff, Dr. Gary Ing, said the generally accepted universal standard for minor discordance in pathology overall is 10 per cent. He added that pathology "is not exact."


"We have one and it is not acceptable," Ing said. "People expect the best from us ... we have to have high standards. But we are human."


Not the first mistaken surgery


In 2009, Heartwell misread a pre-surgery pathology report that ruled a lump in a woman's breast was benign.


Hospital officials said the woman was initially told she had breast cancer and underwent a single mastectomy in the fall of 2009.


A release issued by the hospital said that after misreading the report, Heartwell, a surgeon with 28 years' experience, "unfortunately proceeded with the surgery."


While investigating that incident, the hospital learned that Heartwell performed a mastectomy in 2001 on a patient who also did not have cancer.


In late 2009, Heartwell voluntarily stopped operating. She later asked to have her operating privileges restored, but the hospital put her on suspension instead.


The board of directors at Hôtel-Dieu Grace Hospital reinstated Heartwell's operating privileges in March 2011.


Veteran pathologist Dr. Olive Williams resigned after the provincial health ministry reviewed thousands of files and accused her of making numerous errors.


The Heartwell cases and investigations led to the health ministry making several recommendations to change procedures to ensure mistakes would never happened again.


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02:35 PM on 05/07/2012
The fact that mistakes are repeated is a problem. The Pathologist's comment that there are procedures in place that focus on making the correct diagnosis but not for the correct patient is disturbing.
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gantt4life
Seen or heard on TV/internet don't = fact.
09:59 PM on 05/05/2012
This is called human error, it happens in every single aspect of life. There is no rationale for it but a review of the processes to be sure it never happens again. HOWEVER, with human nature another error will occur in some other aspect, for once if man can admit that indeed perfection is impossible regardless of all the mechanisms put in place. It is disappointing that life is impacted by the mistake---hell by any mistake but it is possible to get past it without throwing everyone under the bus.
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therealjezzie
Gay or straight - it gets better, kids.
04:06 PM on 05/05/2012
There seem to be quite a few "a breast isn't worth $2.2 million" comments. I'm very curious to know if the word breast was replaced by penis what the value would be appraised at by these same commenters?
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therealjezzie
Gay or straight - it gets better, kids.
04:02 PM on 05/05/2012
While I feel terrible for this woman undergoing unnecessary surgery, I can't even begin to imagine the other woman who has lost so much valuable treatment time because of her false-negative diagnosis.
Although it will be difficult to deal with an unnecessary disfigurement & I believe she deserves the settlement she was given, at least this will not adversely impact her physical health. She can't die from a needless mastectomy. Unfortunately, the other patient might not be so lucky - dependant upon what stage she's in. I think a second, much bigger settlement will be coming.
03:15 PM on 05/05/2012
Musyj said the pathologist who made the administrative error has voluntarily taken paid time off. He called the pathologist "a good worker with no history" and said the pathologist is "remorseful and distraught."
03:24 PM on 05/05/2012
shouldn't the pathologist be off work with out pay as the good Dr. is? The Dr. only did what the pathologist gave a indeed good knowledge so the Dr could operate. With this being said the patologist is the one at fault not the dr or the hospital.
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elizlucinda
a mind is a terrible thing to waste
03:38 PM on 05/05/2012
Elly...It is the pathologist who is off work..not the surgeon.
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elizlucinda
a mind is a terrible thing to waste
09:47 AM on 05/05/2012
People are mixing up two stories here. i would suggest you read the article before you start to comment.
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07:14 AM on 05/05/2012
I wonder, where this doctor did her undergraduate science in chemistry, to compare pathology?
DISASTER, for the her victim.
JUST SLOPPINESS!
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froidytoidy
Be alert, stay smart - Underwhelmed Independent
12:47 AM on 05/05/2012
Doesn't matter if the percentage rate for this mistake is .00000000001% - - when it happens to you it's 100%.

this woman deserves every penny she got. Think of the heartache, the family turmoil, the emotional anguish, all she went through....and the fear she must have had.
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swsmith45
Keep calm and carry on.
11:55 PM on 05/04/2012
Sometimes "oops" just doesn't cover it.
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Tragedy Of The Comments
07:44 PM on 05/04/2012
I feel really awful for this woman.
I really, really, really do.

But no boob is worth 2.2 million dollars.
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08:20 PM on 05/04/2012
it is if there is no reason for removing it beside the incompetence of the person operating on you. These errors should never happen - the people operating should know what they are doing.
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Tragedy Of The Comments
08:50 PM on 05/04/2012
What is your profession?
I would like to meet someone who has never ever made a mistake a work.

Again it's tragic.
But nothing is 100% perfect all the time always.
I just think 2.2 million is excessive.
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MJinCanada
Safe from zombies until my 2nd cup of coffee
11:16 PM on 05/04/2012
That's what the Occupy Movement has been trying to say about CEO salaries for months now. :-/

I feel bad for all the women who suffered unnecessary surgery. When I was diagnosed (correctly), I was furious at my breast for betraying me and had no trouble saying goodbye to it. Losing one for a mistake -- yikes! That's turmoil that's worth $2 million, I'd say.
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07:45 PM on 05/07/2012
More.
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07:36 PM on 05/04/2012
"As CEO, I’m the one responsible if policies and procedures are not followed..."

This is not helpful. It deflects the blame and focus away from the actual event(s) that need to be corrected. It sounds more like a Hollywood movie were the captain is always to blame and takes his lumps with heroic stoicism. Not helpful at all.

No settlement can restore this woman's health. And the CEO's "responsibility" caper is not going to help correct the events that led to this terrible misfortune.
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10:53 AM on 05/05/2012
Unfortunately your understanding of what responsibility means with respect to employees, supervisors, managers, bosses, CEOs is incorrect.

It is not deflecting the blame from the actual event. There are procedures in place to prevent this sort of thing. They weren't followed. The employee is responsible for missing steps/skipping steps which caused the error. The supervisor is responsible for allowing the error to slip through (I work in a hospital, there are several opportunities to catch this type of mistake) and not ensuring the employee has done their due diligence. The manager is responsible for having a supervisor that couldn't catch the error. The boss had a manager overseeing a department where one of the main responsibilities is due diligence and allowed numerous people to miss a fairly important part of a standard policy. The CEO has department bosses who are not ensuring that procedures are followed to ensure the health and well being of the patients seeking help in the facility they are overseeing.

So yes, it is helpful because it implies there are problems throughout the chain. It's a very, very terrible situation for everyone involved, but would you prefer that the hospital didn't even own up to the error? With each increase in role within the company comes increased responsibility. This includes being responsible for the ones under you (which is the point of that position...)
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12:49 PM on 05/05/2012
If the CEO is going to claim responsibility, by your analogy, the CEO must be everywhere at all times. This is unreasonable. Once the procedures are in place, hopefully the best practices will be followed.

But the CEO claiming responsibility is a wave in the air and will nor serve the final outcome.
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SeeTheFnords
Look out - there's one behind you!
07:34 PM on 05/04/2012
So, what happened to the woman who was given a clean bill of health in error?
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elizlucinda
a mind is a terrible thing to waste
09:37 AM on 05/05/2012
Read the story.....
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SeeTheFnords
Look out - there's one behind you!
03:34 PM on 05/05/2012
I did. It's poorly written and unclear which woman they are talking about... since both women could have "treatment" resulting from this horrendous mix-up.

I hope that the woman with the cancer did not lose time prior to treatment that would make a life-or-death difference to her.
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06:11 PM on 05/04/2012
Mistakes are made in every hospital, at least 99.9% of us in Canada have comprehensive, accessible healthcare. It's a crime that people go bankrupt or worse don't get proper treatment at all because they can't pay, in your good ol' America!
08:48 PM on 05/04/2012
Really?! I am a doctor in good ol' America and I have a ton of patients from Canada who come down here for surgery because the wait is SO long in Canada (over 18 months according to some). Socialized medicine does not bring everyone "up" to the best care....rather, it brings us all down to the worst care. Yes, we would all have care. Just not care worth having. We need a concerted effort by the American people to take good care of themselves with exercise, diet and social habits that prevent disease. Only that can keep health care costs down.
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arkymorgan
Nobody knows the trouble I've been...
09:38 PM on 05/04/2012
You ever think that maybe your sources are biased?

Perhaps you could tour a Canadian hospital or three, and talk to some doctors and patients. And then canvass around some of the millions of uninsured Americans and compare these situations and consider your words more carefully.

We don't have the ''worst care''. And wait times in Canada vary geographically as well as being longer for those ops for less urgent needs.

Our real problem is that like politicians everywhere, our government representatives have been starving the health care system for two decades, largely because they know that pretending that it is too expensive garners votes, leaving the money to be spent on fighter jets that won't work as well as planned and pork-barrel projects to enrich their corporate friends.

But I still have never worried a day in my life that if I got sick, I would go bankrupt.
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10:03 PM on 05/04/2012
Socialized medicine? It's called single payer! My Canadian health care is care worth having.........all my family has been well taken care of from my children through their university years in sport, my husband and I in middle age, me with my epilepsy and my eighty six year old Mom with COPD, a former nurse may I add. We have all been very happy and satisfied with our care.
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Kittykui
05:40 PM on 05/04/2012
This is what we will face if Obamacare passes by the Supreme Court!!!1
05:45 PM on 05/04/2012
Don't believe what you hear on FOX news.
06:01 PM on 05/04/2012
You haven't clue with a stement like that....not one