Beth Israel is likely to be held responsible

Accreditation, Medicare/Medicaid are at risk

Pending investigations are likely to find that Beth Israel Medical Center in New York City is responsible for the incident in which a doctor carved his initials on a patient’s abdomen, says one risk manager, even though the doctor clearly was acting in an unreasonable and unexpected manner. Another says the case should be a lesson in the importance of explicitly reporting problems to licensing authorities.

Like New York State Department of Health officials, investigators from the Joint Commission on Accreditation of Healthcare Organizations are likely to conclude that hospital officials should have foreseen the incident due to other disturbing behavior, says Margaret Douglass, MPH, RN, director of risk management at FPIC, a physicians’ insurance company based in Jacksonville, FL. The investigation by the health department concluded that the hospital had ample warning that something was seriously wrong with Zarkin but did not respond appropriately.

"They will get dragged in hook, line, and sinker," Douglass says. "If this was so egregious, there must have been some behavior patterns that they should have picked up on before. It doesn’t sound like it would be an isolated event. You would think that if a practitioner did something as egregious as this, there would be other signals."

They are as exposed as they can get’

Douglass was a nurse before she became a risk manager, and she says she occasionally saw "pro-viders outside of the norm, with some quirky behaviors, but nothing even close to this. It’s hard to believe anybody could do something this strange and you wouldn’t see warning signs."

Another question regards the action, or apparent inaction, of the hospital staff and possibly other physicians nearby when the doctor was carving his initials on the patient. It is not clear who was around and who might have been close enough to see exactly what the doctor was doing, and it also is not clear whether anyone tried to intervene. But the doctor’s attorney says the carving took place in the delivery room, immediately after the doctor closed the Cesarean incision, so that suggests that hospital staff may have been nearby.

"This is not just about the doctor and the actual moment he did the carving," Douglass says. "What were the people around the room thinking? How could they let him do this and nobody said anything? They are as exposed as they can get."

Clinic failed to check credentials

The doctor’s immediate hiring at a women’s clinic after leaving Beth Israel points to significant problems with the licensing system, says Steve Johnson, director of risk management for Wellstar Health System in Marietta, GA.

Johnson says the hospital may have erred by reporting "gross misconduct" to the state health department as the reason for Zarkin’s departure, rather than explicitly saying what he had done. With something as egregious as mutilating a patient, an explicit report would prompt an investigation, whereas a more general comment might not.

"When we’ve had bad situations with professionals, we try to give more details for the reason they were suspended than just a generic description," Johnson says. "I can think of one case where we had a physician who changed a medical record after the fact, and we reported it to the state in that manner, not just as a violation of policy. We gave them enough information to make a judgment."

Johnson notes that hospital officials often must walk a fine line between explicit disclosure and protecting a professional’s right to due process and privacy, but he says the Zarkin case is one in which the hospital should have just told state authorities what happened as clearly as possible. The wrongdoing was so extreme and so clearly unacceptable that any sugarcoating would be a disservice to patient safety, he says.

"This should be a learning opportunity for all of us that we’ve got to work more closely with our licensing folks in certain situations we consider egregious to give them the infor mation they really need," he says. "Give them enough information to know whether this is something they need to move on quickly or not so quickly."

As for the clinic that apparently hired Zarkin without checking his credentials, Johnson says that failing tempts any administrator who is personally familiar with a candidate, but it nevertheless is a failing.

"It happens all the time that we get referrals from close friends swearing this guy is a great doctor and would be an asset to our organization," he says. "That’s great, but we do all the normal checks, go through the normal credentialing process, because we have a responsibility to due diligence."


o Steve Johnson, Director of Risk Management, Wellstar Health Systems, 805 Sandy Plains Road, Marietta, GA 30066. Telephone: (770) 792-7536.