Barbara Heartwell, a surgeon at Hôtel-Dieu Grace Hospital in Windsor, Ont., mistakenly performed mastectomies on two women.
When this information came to light, she voluntarily stopped performing surgery. Then she had second thoughts, so the hospital suspended her privileges.
Dr. Heartwell appealed and was reinstated earlier this month.
On the surface, the decision by the hospital's board of directors seems outrageous. How could they possibly allow a doctor who cut off the healthy breasts of two women to continue to perform surgery?
But Hôtel-Dieu Grace made the right decision.
About 7.5 per cent of the 2.5 million patients admitted to hospital in Canada each year suffer an adverse event - a medical error in common parlance.
According to a groundbreaking 2004 study by Peter Norton of the University of Calgary and Ross Baker of the University of Toronto, between 9,250 and 23,750 of those patients died in 2000 after a doctor, nurse or other health-care professional made an avoidable mistake in their treatment.
There is some evidence that the rate of medical errors has dropped in the past decade. There have been all kinds of promising initiatives, chief among them the creation of health quality councils in several provinces (better safety means better quality, and vice versa), the Canadian Patient Safety Institute and the emergence of several grassroots patient groups. (The impetus for these groups is invariably a terrible mistake.)
But we still have a long way to go on patient safety in this country.
So how do we make health care safer?
First and foremost, we need to change health care culture, particularly in hospitals. Safety has to matter at every level, from the chief executive officer to the janitors. The primacy of patient safety has to be imbued into teaching from day one and into the daily provision of care.
Safety not only has to be encouraged, it has to be rewarded, and, when errors do occur, the problems have to be discussed openly and corrective measures taken.
We are not going to build a safer system by blaming and shaming health care professionals.
Dr. Heartwell is a case in point. She is an experienced surgeon. According to the public record, she made two mistakes - one in 2009 and one in 2001 - that had horrific consequences.
Dr. Heartwell disclosed the errors, admitted she had misread pathology reports, offered credible explanations of why the errors occurred, apologized to the patients and paid the price in the courts (one lawsuit was settled and the other will be) and in the court of public opinion.
A review of Dr. Heartwell's work revealed that she has performed 692 other mastectomies and 4,249 other surgical procedures about which there are no concerns.
Rare is the individual who has a perfect record, particularly in a volatile field such as medicine, in which virtually every intervention has potentially harmful consequences.
When errors do occur - particular monstrous ones such as the removal of a healthy breast - they are rarely, if ever, the fault of one individual.
There were, for example, severe problems with pathology at Hôtel-Dieu Grace. Like most hospitals, it lacks procedures and systems that would have prevented these two tragic cases (and no doubt many others) from occurring.
Surgery will not become magically safer by making Dr. Heartwell a scapegoat. On the contrary.
We need an environment where lessons are learned. And, of course, efforts need to be made to prevent errors in the first place.
There is good news afoot.
Beginning April 1, Ontario law will require hospitals to report on their use of a 32-point surgical checklist. The cheap, effective tool, borrowed from the airline industry, sees the surgical team systematically go through a list of basic questions such as "are the instruments sterile?" and answer aloud.
The approach, outlined in The Checklist Manifesto, a wonderful book by Atul Gawande, has many applications beyond surgery. The research on the benefits of this approach is extensive but we have been slow to adopt it.
Canada has also largely failed to recognize the importance of health quality councils. These groups, the first of which was formed in Saskatchewan, are fonts of knowledge and have blazed a trail on patient safety.
In some provinces, however, these councils have moved beyond research into the investigation of medical errors. This kind of independent review is welcome but there is a danger that these exercises become adversarial and almost prosecutorial.
This happened recently in Alberta where the investigation of four unrelated, non-fatal errors at Alberta Children's Hospital led to a damning report and calls for heads to roll.
We have to, at all costs, avoid going down that path.
Let's be clear: Doctors, nurses and other professionals who are incompetent or grossly negligent need to be weeded out, and quickly. But they are a tiny minority.
Medical errors are, by and large, just that: errors, unintended and sometimes unavoidable.
If we suspend, fire or otherwise persecute every health care professional who makes an error, we risk having no one to deliver care. At best, we will have a work force that is cowed and on the defensive, and every patient viewed as a potential litigant.
If, on the other hand, we give them the tools to practise safer health care, from checklists through to electronic health records, we will have better health care.
As the definition from the Agency for Healthcare Research and Quality states so eloquently: "Quality health care means doing the right thing at the right time in the right way for the right person and having the best possible results."
And even when we don't get the best possible results, we still need to do the right thing.
So welcome back to surgery, Dr. Heartwell.
We hope your experience was humbling, not only on an individual level, but for the health care system as a whole.