Sunday, March 29, 2009

When Things Go Awry: Making Sense of Medical Errors

Per the prompt for next week’s Grand Rounds, I’ve been thinking a lot about medical errors and what they do to the relationship between patients and healthcare providers.

Fortunately, I’ve never been involved in the type of medical errors that make the news, like wrong-side surgeries, items left in body cavities after surgery, lethal doses of the wrong medicine, etc. Thankfully, no one in my life has ever experienced anything of this magnitude either. But for every major crack in the system that makes the news, there are many tiny fissures that chip away at its integrity.

In my 28 years of patienthood, I’ve collected my fair share of mishaps and errors: The time I was forgotten about for 20 minutes after a barium swallow test, suspended in the air with my oxygen out of reach several feet away. The time that I was transported to radiology for someone else’s head CT scan, despite repeated protests that my lungs were the problem. The time I woke up during lung surgery (in the recovery unit I’d hoped that horrifying feeling had been a dream. It wasn’t), or the time a loved one was woken up and ordered to take pain medicine that wasn’t hers. I’ll leave delayed diagnoses and altogether wrong diagnoses for another day, because they are more nuanced, less obviously categorized, and especially in the case of delayed diagnoses, less split along lines of culpability.

(And of course there are the minor infringements and indignities: The blood draws that take 3 different techs and leave 8-10 bruises. The CT scans that aren’t where they are supposed to be for pick-up, or the mix-up with test results. Vials of blood dropped on the floor, cultures whose results get lost somewhere in translation, paperwork that is not filled out correctly, bills that belong to other patients that end up on my account…)

Though it relies so heavily on science, medicine is a profoundly human institution, never more so than in those moments when things go wrong. And like most human interactions when things go awry, the reasons usually include pure unintentional accident (who hasn’t pressed the wrong button, misplaced a slip of paper, etc), basic incompetence (there is a learning curve to everything), and what I think are definitely more damaging to the relationship, indifference and pride.

Personally, I am less interested in dissecting what can go wrong than focusing on what to do when it happens. In the macro sense, this could include improved safety protocols (like the checklist before surgeries) and other institutional safeguards. But I’m coming at this from the patient perspective, so I will leave those discussions to others.

No, what I am talking about are the more immediate reactions, how we treat each other when things don’t go as planned. Mistakes will happen but the mistakes themselves are not usually what bother me or stick with me, it’s the way they were handled.

(I recognize, of course, that it is because I have never experienced a major, life-threatening medical error that I can focus on this aspect of things.)

For example, in the wrong CT scan scenario I mentioned earlier, I received two very different responses. The person doing the scan became angry when I repeatedly told her I did not need a brain scan (as forcefully as someone in respiratory distress could), and became angrier when the same thing was told to her from someone higher up in authority. A vulnerable situation—not being able to breathe has a way of making you feel powerless—was made even more so by the fact that my voice was repeatedly ignored.

But moments later, the attending doctor apologized, told me he’d make sure the “patient has altered mental status” comment would be erased from my medical record, and checked in with me later to confirm with me the correction had been made and to apologize again. That’s what I needed—a simple apology and more than that, assurance that the mess had been cleaned up. In the exchange itself, what I needed was a few seconds of listening, an extra minute to confirm my patient ID, or basic recognition that someone who is visibly not breathing well might be onto something when she says it’s her lungs that need checking. I needed to be treated as a person, not a nuisance and not as someone who has absolutely no knowledge or insight into my own body.

If the mix-up had ended when I first got to the room (the transport orderly stared at my ID bracelet for a long time and somehow declared I was the right patient and that the number matched the brain scan patient’s) I would not have cared. After all, mistakes happen, especially in a busy ER. My ID would have been confirmed, I would have gone to get the imaging I needed for my own care, and the patient with the brain tumor would not be wandering around the hospital. It could have been cleared up in a couple of minutes.

But that’s the difference between accidents (reading the wrong number) and events that are the result of indifference or pride. Generally I try to laugh off some of these mishaps; after all, they make a good story and after all, everyone makes mistakes. However, what makes me angry or makes me resentful are the times when the errors are somehow shifted back to me. Whether it’s a doctor, nurse or lab tech doing that to a patient, a teacher doing that to a student, or a boss doing that to an employee (notice the trend here that skews towards issues of balance of power and authority?), it doesn’t make it right and it always damages the relationship.

It’s the same with smaller things like not getting my test results because my blood vials were dropped on the floor, or my name was entered in wrong, or the person who needed to submit form X did not do so. Just let me know and take steps to fix it and I’m on board with you; don’t get irritated with me that you now need to do more work, don’t act like I am an inconvenience to you when I am the one who needs to re-schedule work to come back in for the same tests I just had the day before because of your mistake.

Like every interaction, there are two sides and two avenues for conduct. The way I respond inevitably impacts how the situation resolves itself, too. I can accept the apology or not; I can be calm and reasonable or not; I can differentiate between an unintentional mistake and arrogance or indifference or not. These are distinctions I hope to receive when I make mistakes and errors that impact those around me (students, clients, etc).

Every profession, every interaction between people presents an opportunity for errors. Obviously the stakes are usually much greater when it comes to medical errors, but the basic rules apply nonetheless: Treat people with dignity and respect. Focus on fixing the problem appropriately and moving forward. Be forthright. Sometimes the hardest thing to do is simply say “I’m sorry.” Yet for (non life-threatening) errors, those two words can mean the difference between a blip on the proverbial radar screen and an event that damages trust and fosters resentment.


britta said...

Oddly, I just had this happen to me this week. Had a blood test on Tuesday and was contacted on Friday night about how I am suppose to come in next week to have the same test done again....umm, duh clinic, I just had the test done at YOUR LAB last week!!!!! Maybe it's the fact that the test is controversial for Lyme Disease and has to be sent out...but still annoying! Going to call tomorrow to see what the heck is going on! Great post Laurie!

Unknown said...

I had the pleasure of going in for a series of MRIs. The tech, once I was on the table, pulled a chart and said "OK so do you know why you're here?"
I said yes- for a series of QRS MRI's. the tech's face changed...and said "well what are your symptoms?" and I went into my schpiel....the tech then said "hold on one moment please..." and went back to the room behind the glass, and came back with a wholly different chart. WOOPS. While my first thought was "why are they asking me questions they already know the answer to?" the process was a simple, no-offense way to make sure everyone there was on the same page about me, the procedure, etc. A nice way of doing this, I think.

Kairol Rosenthal said...

I've had many medical errors occur, some of which could have been life threatening. My advice it two fold:

1. Keep your eyes, ears, and mouth open and always react. My motto is think, question, and shout when you need to.

2. Sometimes mistakes are made that are not life threatening and it is easy to not say anything about them. I try to bring every medical error, no matter how small, to the attention of a staff member. I do it politely, with the intention to improve the quality of care for those who come after me.

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Heather L said...

Yeah I unfortunately can vouch that it happens whether you are the patient or the parent of the patient. My daughter has Celiac disease. The first hospitalization she had was not under the GI of choices care. The GI on call assured us that a weekend of gluten wouldn't harm her. When my daughter(bless her heart) refused to eat after the first few bits he got terribly mad at her a 2 year old! Pride.. We got her a new GI and she is much better.

God bless
Heather L

Becca said...

I think that what we have to remember is that Dr.s are human although we do not want them to be. They make mistakes just as we do.


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Laurie said...

Thanks for the feedback, everyone. Kairol, I agree--you always need to be alert and proactive and ask questions. We are our own best advocates.

And Becca, yes I totally agree. That's the larger point of my post, in essence--they are human, everyone involved in healthcare is, and of course mistakes will happen. What's important to me here isn't the expectation that mistakes shouldn't happen but that they should be handled appropriately and professionally, just as they should be in any other setting.

Joel said...

may think back to the purposes .. our present career is our past choice, and to be a Dr. is great opportunity

Miss Waxie aka A Comic Life, Indeed said...

Hi Laurie,

You have an amazing resource here and truly enjoyed this article. It's amazing how many things CAN go wrong without them being fully news worthy, but the true challenge for us as a patient is how to cope.

I'm in the process of documenting my trials and triumphs with the medical systems in a comic-strip type photo blog - - and I thought you might like to check it out.

I think it's really important for us with chronic, autoimmune illness to form a community, not just for support, but to really stand up and say "Hey I'm HERE!"

Anyway, great site, I plan on link over to it.

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