Disclosure and Surgical Fire Case: Ms. Kouko Bonney Story
Recently I gave a series of disclosure presentations for Allegiance Health in Michigan over two days. After my first day of presentations I went to dinner with Ken Empey, Allegiance General Counsel, and Dr. Mohan Kulkarni, who is a surgeon and Medical Director of Quality and Safety for Allegiance. Over dinner Dr. Kulkarni told me the story of a surgical fire that happened to one of his patients – Ms. Kouko Bonney - and how the incident was disclosed and resolved. Dr. Kulkarni and Ms. Bonney’s family have given permission for me to share their story with the Sorry Works! audience.
Dr. Kulkarni and Allegiance provided a Power Point Presentation about the Ms. Bonney’s story with me, and I will summarize the slides here:
Ms. Kuoko Bonney was a 78-year old Asian immigrant with a large, tight knit family. Ms. Bonney was suffering from metastatic lung cancer, and presented to the OR for an excision/biopsy of a deep cervical lymph node and implantable port insertion for chemotherapy. The surgical prep was normal….oxygen by mask…neck prepped with alcohol-based skin prep…standard tent draping over patient’s torso and face….port implanted without incident….and the surgeon proceeded to excise node using cautery when technician yelled “Fire!”
The fire was immediately extinguished, but not before Ms. Bonney suffered 1st and 2nd degree burns to her face, neck, and shoulder, but no injury to her airway.
The entire surgical team met with the General Counsel and Chief Operating Officer to discuss the case and how to disclose. They then quickly met with the family to empathize – “sorry this happened” - and promise a review to learn how this happened. Naturally, the family was upset and shocked, but Dr. Kulkarni and Allegiance stayed connected with the family.
The results of the review were shared with the family, but some family members were still very upset with the hospital. Ms. Bonney died within several months of the incident due to her cancer, and family members believed the fire reduced her quality of life and perhaps hastened her death. Nevertheless, the surgeon and hospital worked stay connected with the family and involved them in quality improvement efforts.
Over dinner, Dr. Kulkarni told me that they simply asked the family what they needed and wanted, and the most prominent response from the family was they wanted to make sure their loved one’s legacy was to improve the hospital and make sure this never happened to anyone else. The family requested that their mother’s story be shared throughout the organization so that staff would not forget the danger of a surgical field fire.
At the recommendation of the family, the fire risk assessment has been named “The Kouko Bonney Fire Risk Assessment” as a legacy for their mother. Ms. Bonney’s story has been shared with the Allegiance leadership team and is being cascaded throughout the organization.
Dr. Kulkarni told me that now before every surgery at Allegiance the surgical team reviews the “The Kuoko Bonney Fire Risk Assessment.” Dr. Kulkarni said Ms. Bonney’s name has literally been said thousands of times in Allegiance operating rooms…she will never be forgotten. As further testament to the power of transparency and apology, Mr. Bonney, the widow husband of Kouko Bonney, continues to receive his medical and surgical care at Allegiance, demonstrating his trust of the Hospital and his caregivers.
What an incredible story and powerful example for other healthcare organizations. Here are Dr. Kulkarni’s PPT slides. He has used these slides to not only tell the story within Allegiance but also at professional meetings and conferences. And now the story has been shared with Sorry Works!
Thank you, Allegiance, and thank you to Ms. Bonney’s family. Many hospitals, healthcare professionals, and patients and families will greatly benefit from your story. Thank you!