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Even a ‘saint’ can make mistake

By Carol Gentry
12/8/2009 © Health News Florida

An embarrassing goof like wrong-side surgery or the wrong procedure can happen to absolutely anyone. Anyone at all.

The latest icon to fall into the error trap is Dr. Alexander Brickler, the long-time director of Tallahassee Memorial's Family Medicine Residency Program and a past U.S. “Family Doctor of the Year.”

After performing an emergency Caesarean section on a 20-year-old patient last year, Brickler cut her left Fallopian tube in the incorrect belief she was scheduled for sterilization. The nurse-anesthetist stopped Brickler before he clipped the right tube – a lucky intervention that preserved the patient’s fertility.

“He’s a perfect example that accidents can happen to anyone,” said Allen Grossman, a Tallahassee defense attorney who wasn’t involved in the case.

Brickler came before the Board of Medicine in Orlando on Friday, two days before thousands of health-care professionals gathered there for the Institute for Healthcare Improvement's 21st Annual National Forum on Quality Improvement.

One of the central tenets of the organization is that it’s counterproductive to blame individuals for errors that are actually a result of safety gaps in institutions. IHI encourages hospitals and health-care systems to study errors and near-misses so they can identify danger zones and build in prevention.

Brickler, who’s around 80 years old, has delivered more than 30,000 babies and repeatedly been named favorite teacher of a whole generation of family physicians. Last year he was given the Florida Hospital Association's Lifetime Heroic Achievement Award.

Brickler told the Board of Medicine that the day of the mistake, the labor and delivery suite at Tallahassee Memorial was busy and stressed. While in the operating room doing the emergency Caesarean, Brickler was tracking the situation on the floor through video monitors.

“We were trying to decide who should be in the operating room and who shouldn’t,” Brickler said. “It was an emergency situation. But that’s no excuse.”

Tallahassee Memorial’s risk manager, Judy Davis, filed the report admitting the error, as required under state law.

Brickler said he and the hospital took several steps to reduce the chance of a repeat. One was to remove the clamps used in sterilizations off the C-section tray so that the surgeon would have to make a point of requesting them. Another was to post a board in the operating room with the patients listed with the procedures for which they’re scheduled.

The board clearly felt sorry for Brickler, who is well-known in the field for taking care of low-income women -- including the risky ones who show up in labor after having little or no prenatal care.

"He made a mistake, but Dr. Brickler’s a saint for what he’s done through the years,” said medical board member Elizabeth Tucker, a Pensacola OB-GYN.

The board agreed to accept a negotiated agreement between the Department of Health and Brickler. He received a “Letter of Concern,” $5,000 fine, and five hours’ training in “risk management.”