A Better Way to Manage Medical Errors

Many of us in healthcare know medical errors are the third leading cause of death in the United States.

We are also aware that healthcare is a high-risk industry. But unlike other high risk-industries however, such as aviation and nuclear energy, healthcare has been too slow to adopt tools, techniques and behaviors proven to lower risk to patients. As a result, errors made by well-intentioned caregivers continue to cause unintentional harm and even death to patients.

In my last ETY blog post, I shared a medical error I was involved in that led to patient harm. I also shared how we hid that error from the patient, as well as other caregivers who worked in our hospital. It is said healthcare “buries” our medical mistakes. Fear of malpractice claims, fear of losing our license, fear of admitting we are fallible and can make a mistake; doctors are expected to be perfect, and this behavior is an unintended consequence of those unrealistic expectations. These are just a few of the reasons caregivers and hospital leaders try to hide or even downright lie when medical errors cause patient harm.

This approach, known as “deny and defend”, is a common legal and malpractice insurance strategy, not only in healthcare but in other insurance-based industries. Not only is “deny and defend” morally and ethically wrong, but in healthcare it also keeps us from learning and improving our care systems when these very unfortunate events occur. If we don’t openly talk about, and learn from our mistakes, we will never fix healthcare so that future patients don’t suffer similar harm. In our wrong-sided surgery error, no one wanted to discuss how we could have prevented that harm from happening again. All we wanted to do was bury it, hoping no one found out. And then what happened? Wrong-sided surgeries continued to occur over and over again for years afterwards.

Historically, the role of hospital risk managers has been to protect the hospital at all cost, even if it meant lying to patients and families. Refusing to answer questions, denying patients access to their medical records, not returning phone calls, or referring patients to hospital lawyers has been routine practice for many health systems. Many patients and families wait years to have their calls returned, and still fail to receive truthful answers on what really happened when there is a conversation. As many plaintiff attorneys have shared through the years, “There’s a lot of lying going on out there”. The only option patients and families often have to get their questions answered, is to hire their own lawyer and file a lawsuit against the hospital and the physician. Once both sides “lawyer up”, the only thing that matters is to win the lawsuit, regardless of the financial cost or additional suffering incurred by all stakeholders. No one wins in a medical malpractice trial.

Fortunately, some courageous health systems, hospitals and medical malpractice carriers are discovering there is a better way…


“Yes, Today is Your Lucky Day”

As we at the Academy for Emerging Leaders in Patient Safety (AELPS) prepare for our 13th year of Patient Safety Summer Camps for future healthcare leaders, I always reflect on a personal story I share the first day of each session to kick-off our week of work together. The story captures many of the reasons we have a preventable medical harm crisis today, such as: fear, devastation, lack of transparency, refusing to learn and improve from mistakes, lack of embedded human factors. The story also serves to show our young learners that we all are human and we all make mistakes, and helps set up a learning environment where they feel safe in sharing their own personal stories. Those who have only worked in healthcare a short time will have seen, or been involved in, an event that harmed a patient. For those that have followed our blog through the years, you have read some of these personal stories…mistakes that even harmed our own family members. I thought I would share my story with all of you.

Many years ago, I was involved in a medical error as a resident – a wrong-sided hernia repair that unfortunately harmed one of our patients. As the anesthesiologist, my job was to bring the patient into the operating room, put the required monitors on so I could make sure he was safe during the procedure, and then administer the general anesthetic that would keep him unconscious during his right-sided hernia surgery. I did that successfully and was focused on my job but, like others in the operating room, I didn’t notice that the senior surgical resident had taken the scalpel and made the surgical incision on the patient’s left side by mistake. Two minutes later the attending surgeon who had been detained with a question from another surgeon, came into the operating room, looked at the patient on the operating table and asked, “I thought this was a right-side hernia repair?” When the surgical resident realized her mistake, she passed out…the impact making a medical error can have on us as caregivers.

The surgeon closed the incision on the left side and then proceeded to fix the hernia on the right side. The patient now had two surgical bandages on their abdomen: one to cover the hernia repair, the other to cover our mistake. I dreaded having to see the patient in an hour and explain my part in the medical error that harmed him. I had never been involved in a medical error before, and was very nervous about the anger he might feel towards me and our team. When I went to meet the patient in the recovery room, I noticed he had a big smile on his face. This struck me as very odd. Before I could say anything, he looked at me and said, “Today is my lucky day”. I was dumbstruck. He continued, “Yes, today is my lucky day because under anesthesia my surgeon told me he discovered I had two hernias, one on each side, and was able to repair both at one time so I don’t have to miss another day of work to get the second one repaired”. It then hit me. The plan was to lie to the patient and cover up our mistake. I didn’t know what to say or how to react. After a very long pause, I responded, “Yes, today is your lucky day,” and I signed the patient out.

Not only were my six words to the patient “Yes, today is your lucky day” morally and ethically wrong, our lack of honesty and transparency kept us from learning how to prevent others from suffering similar harm. As a result, wrong-sided surgeries continued to occur far too frequently.

In defining professionalism in healthcare we use words like altruism, honor, integrity, respect, caring, compassion, and accountability to name a few. In telling my patient “Yes, today is your lucky day”, I violated every one of those principles we take an oath on when becoming a caregiver.


Some Thoughts for New Graduates from Dr. Kim Oates

Finishing medical school is about looking back to your time as students and looking to the future as new graduates.

It’s the future I want to focus on. Medical school is just part of the continuum of medical education. You’ll keep learning new facts and new techniques. You’ll even find that as years pass and knowledge increases some things you learned in medical school have become obsolete or outdated, overtaken by new information.

But some things never change. One of these is the need to always put the patient first. It sounds so simple, but there will be many temptations to put the patient’s need lower on your list of priorities.

Many events and people will influence you. Some of these events will be errors you or others will be involved in. Most errors are not the fault of an individual, although the individual may be the last factor in a string of contributing causes. Most errors are the fault of a system where the safety of the patient is not always paramount. And when they do occur, they should always be seen as opportunities to learn and improve.

The people you meet and work with can influence you. Not all will be good influences. Some will be arrogant, some will cut corners, some will ignore protocols, some will not show respect for their patients or for other health professionals. Some will not put the patient first.

You’ll meet others who treat staff and patients with respect, who aren’t self-promoting, who sit at the bedside to talk with patients, who listen, who understand the value of other members of the care team, who want to learn as well as to teach and who put the patient at the centre of every decision.

Both groups have the potential to be role models, particularly if they have strong personalities or are much more senior than you. So pick you role models with care. Decide who you want to be like and who you don’t want to be like.

Here are my 10 tips for new graduates, tips that will help you right through your career, but more importantly, tips that will help your patients, giving them good care and keeping them safe.

  1. Never forget that patients are vulnerable.
  2. Remember that you are the guest in your patient’s illness.
  3. Listen to your patients. “What’s the matter with you?” is a good question but your care will be better if you also ask “What matters to you?”
  4. Use simple, clear language with your patients, remembering that good communication involves listening.
  5. Work collaboratively with and learn from nurses and allied health professionals.
  6. Admit your mistakes and use them as opportunities for improvement.
  7. Don’t accept standards and behaviours that aren’t in the best interests of the patient. The standard you walk past is the standard you accept.
  8. Keep learning, stay up to date.
  9. Never let people put you on a pedestal. Stay humble.
  10. Always put your patient first, never forgetting that “It’s all about the patient”.

Have a wonderful and fulfilling career.

Kim Oates

 

 

 

 

 


A Breast Cancer Survivor Tells Her Story of Healing Through Faith and Good Care

One increasingly important realization by healthcare professionals is the need to both engage and encourage patients to participate in their care. The following story of recovery and healing from double mastectomy surgery is told by Ev, a grandmother of nine, mother of three and wife to husband Will of 44 years. I asked Ev and Will to share their story because, I was fortunate to be included in Will’s weekly updates during and after Ev’s surgery. Each message not only gave reassurance to family members near and far that she was doing well, but ended with an inspirational blessing for all; the family’s faith first and foremost in Ev’s healing process. Their faith was a silent but strong part of the care team, and their strength as a couple was a beautiful testament of what teamwork and love can do for a marriage and the trials that life presents.

I include Ev’s words unedited, as she hopes they will help another breast cancer patient facing a similar surgery–to find answers to questions, insight to questions they may not know they have, and to find the same peace be it through faith, a loving caregiver or a skilled care team. Ev had all three–the trifecta of healing for her, and as a result, many, many happy people including her nine happy grandchildren, Ev’s daughters, and her partner in life, Will.

What do I do now? I was growing quiet impatient with follow-up doctor visits regarding questionable mammograms, ultra sound screenings, MRIs and biopsies during the 4 years since I was first diagnosed and treated for breast cancer. My husband, Will, and I were also seeing physical changes (dimpling and caving in of the skin) which was now occurring in the breast where lymphedema was prominent and seemed impossible to alleviate. I had gone to physical therapy and done exercises at home for two years. It didn’t work. The lymphatic system in the breast barely worked. The left breast tissue was ruined by radiation and very angry. My practical problem was regarding bras—being size E and weighing 148, I could barely tolerate wearing any bra I tried.

Dr. Moline, my original breast surgeon, said she could do nothing to fix the angry tissue except a mastectomy. She explained that it would be completely paid for by my existing insurance “to make the situation right” after cancer had struck. This was a big factor in my deciding whether or not to have a mastectomy. My oncologist advised me to have a double mastectomy to alleviate further testing of both breasts– “Nothing there, nothing to test.”

Dr. Moline gave me the names of three plastic surgeons. I choose the first and only one I visited. Dr. Williams was very clear, gave us several options, and sold my husband and me on the benefits of a double mastectomy with Tram Flap reconstruction of both breasts; this would all be done in one day during 10 hours of surgery. Dr. Moline would do the double mastectomy and Dr. Williams would do the Tram Flap with the help of her team.

Will was in total agreement. He was positive and started plotting what I might need for this huge surgery. We purchased a leather electric recliner not only for sitting but for sleeping the first week home. The electric mechanism was very helpful. Will purchased a hand-held shower hose with nozzle to fit in our shower and found a folding chair I could sit on for the first showers.

Our faith is very important to both of us so we relied on the Promises of God to make decisions, to live each day and not worry or loose the feeling of peace. Our family, neighbors, and church friends prayed, brought food, sent cards and flowers, (even new PJs), called and visited. Their sense was not of dismay or, “What are you doing?” Attitudes were positive and they seemed to believe and say, “You’ll get through this!” Three pastors visited us and read Psalms and assured us God was with us.

The day of surgery was a breeze for me. A hospital chaplain said a prayer for us before I went to surgery. Will was sent home and the hospital nurses and doctors called him every 2 hours with good updates. Our house is only 10 minutes away from the hospital so he was close. I remember seeing him about 8:30 pm. I was certain no surgery had been performed on me because I felt no pain or nausea. All I really felt was quite a bit of stiffness. I was checked every hour to make sure the blood vessels that had been moved were successfully reconnected and working to nourish the tissue that had been moved from my belly area to the breast area. I had nine drains. I was down to five drains when I left the hospital 5 days later. I lived on ice chips the first couple days, moved on to clear liquids, and ate a salad later on. I was able to get up and sit in a chair the third day. I remember moving myself that very short distance by myself; Will remembers it differently (he assisted). The nurse helped my attitude about getting up by saying, “The first time is the hardest, and after that it gets easier every time.” She was right. It did get easier. I walked slowly into the hospital bathroom and had a shower on day four. The nursing staff and doctors could not have been more professional. I tried to follow all the rules. I was a little bent forward for a couple days.

At home, Will removed all the smaller rugs on hardwood floors from the recliner to the bathroom. He had learned at the hospital from the nurses, how to empty, measure, and clean the drains. I had completely cleared my schedule and did nothing but rest, eat a bit, and sleep. Will was a remarkable nurse once again. He was willing and able to help me and brought his sense of “get it done” with a cheerful attitude. I was unable to keep track of my meds: Oxycodone for a few days, Ibuprofen 600 MG, and Acetaminophen, so Will took care of dosages and times. That was so helpful. Our closest friends and our family were updated daily with a quick sentence or two by email of my progress. Will was able to keep them informed and they appreciated a quick update. All the drains were removed by the end of the second week after surgery. The metal lanyard that held the drain bulbs against my belly was one of my only irritations. Metal is pretty hard. Do they make a plastic one?

I’m back doing most things except lifting much. I can’t lift my grandchildren but I can hold my 3 month old granddaughter. I can reach most things in my kitchen but found weeding last week a bit of a challenge. I have started taking my walks in the park where it is flat.    

I am so delighted I had this big surgery. The chance for breast cancer is gone. A reduction in my breast size is also a huge blessing.  A caring support group and husband not afraid to help with the recovery process make it all that much easier. I know for sure a top team of doctors can do successful surgery and make you comfortable, but God is the One who heals.


Patient Advocate and Telluride Faculty Dan Ford Describes TE: CO Class of 2016

Sunlight_over_mtnsOver the last five days in Telluride, I have gotten to know an awesome group of 26 medical and nursing students. You clearly will play key roles in changing patient safety in constructive ways. As Dr John Toussaint (ThedaCare Center for HealthCare Value, Appleton, WI) suggests: “How can we provide high quality care unless we provide a base of safe care.”

Various descriptors come to mind. Compassionate. Caring. Thoughtful. Very smart. Respectful. Self-reflective. Genuine listeners. Open to learning and sharing new ideas. Passionate. Willing to live your values in speaking up, decision making and problem solving. Mindful. Inclusive. Thirsting to know more about patient safety….and you did.

You became good friends, bonding, getting to know and care about each other as human beings without labels or titles or tribes. It is clear you are patient and team focused and became even more so during our indoor and outdoor classroom work, social times and the big hike.

Telluride and the mountains are beautiful. Y’all have an inner beauty that will continue to serve you very well in all you do.

I didn’t want our time together to end, especially when several commented that this experience has been life-changing. I am desirious of staying in touch as you take your individual learnings and feelings forward and to helping you in any way I can.

I continue to encourage you to always live and to role model your True North. You will be seriously tested.

I wish each of you many blessings! I am honored to call you friends….


Resident Physicians Share Their Stories at Telluride Experience 2016

Ah_Haa_School_Trees_on_CreekFollowing are leads from Resident Physician reflections after attending the first 2016 session of the Telluride Experience. Links are included back to the original posting on the Telluride Experience blog. Thanks to all who so courageously offered their stories from the front lines of care so that others can learn through them. It is by sharing our stories that we free another to tell theirs as well.

The Magic In Transparency

This phrase struck me as the perfect way to describe an experience I had my intern year. My first continuity ob patient had a fetal demise at 34 weeks.  She was the first patient I had followed from the beginning of her pregnancy.  I performed her dating ultrasound at 9 weeks.  Unlike many of my patients, she and her husband faithfully came to every prenatal visit.  She did not smoke, use drugs and followed the dietary guidelines.  Her husband was the chatter one of the duo, while she would calmly take everything in at our visits.  They both teared up when I told them they were having a girl at the 20 week ultrasound.  They told me her name was Emma. More…

Important Conversations

I was not going to share this but have been inspired by the courage of others around me. So thank you!

…In the first few days of Residency, we had a mandatory “Emotional Harm” meeting. I thought it was nice of them to do and always a good reminder. It focused on the empathy towards the patient and not losing our empathy when getting in the rhythm of dealing with similar situations and cases over and over again. I loved that they did this. This is something that is so important to remember and necessary to address.

Looking back however, I just wonder what about my emotional harm? Where are my resources? In this first 7 months of my residency experience two Senior Attendings committed suicide. I did not know the first, but I certainly knew the second. While there was heartfelt sadness and memorials to honor both, there was nothing else. No counseling offered to employees, no conversations, no checking in after some days, nothing at all. More…

Humility and Humanity

Humility and Humanity. This phrase stuck with me from Dan Ford’s talk. From medical school through residency it is drilled into us to be confident, un-phased, unemotional , these qualities are attributed to professionalism and success. Doctors are supposed to be infallible , so when we face an adverse outcome thats what we do instinctively. We become distant, listening to Helen, Sorrel and Dan thats the exact opposite of what patients need. Alienation only leads to prolongation of suffering for the patients family as well as the caregiver. Moving forward I hope to make these values a foundation of my practice.

Reading all the stories from my peers encouraged me to share as well, this was an amazing group of people and faculty. My first ICU night rotation as a PGY-2 I admitted a patient  in DKA and septic shock. More…


12 Years and 1400 Patient Safety Leaders Later…

Sunlight_over_mtnsTwelve years…that is how long it has been since we first traveled to Telluride, CO to kick-off our inaugural Patient Safety Educational Roundtable and Summer Camp. As we headed west again this weekend to meet with the 36 graduate resident physicians and future health care leaders who were selected from a large group of applicants, it is hard not to think back about all that has happened in those twelve years and the many who have contributed to make it happen.

Twelve years ago, those who came to Telluride believing in our Educate the Young mission consisted of patient safety leaders Tim McDonald, Anne Gunderson, Kelly Smith, Deb Klamen, Julie Johnson, Paul Barash, Gwen Sherwood, Bob Galbraith, Ingrid Philibert, and Shelly Dierking to name just a few. However, the smartest thing we ever did was invite patient advocates to the Patient Safety Educational Roundtable. People like Helen Haskell, Carole Hemmelgarn, Patty and David Skolnik, and Rosemary Gibson were active partners in our work from that first year and made our discussions more productive and our outcomes better.

Over the years, many new faculty joined us in our Educate the Young journey. Some of these additional patient safety faculty included Lucian Leape, Richard Corder, John Nance, Paul Levy, David Classen, Kathy Pischke-Winn, Joan Lowery, Roger Leonard, and Tracy Granzyk. We were also fortunate to have international safety leaders join our faculty, including Kim Oates and Cliff Hughes from Australia, who became regular attendees and popular “mentors” to the future healthcare leaders even though they had to travel almost 10,000 miles to join us each year.

Through all these years, two things remained constant – our commitment to Educating the Young and our partnership with patients. Helen, Carole, Patty, David, and Rosemary continue to be active participants each year but additional patient advocates have joined us including national advocacy leaders Dan Ford and Lisa Freeman.

Through the vision and support of Carolyn Clancy and the AHRQ, what began as a small educational immersion for twenty health science students has now exploded. We continue to grow because of the generous support of The Doctor’s Company Foundation (who provides full scholarships to close to 100 medical and nursing students each year), the Committee of Interns and Residents, COPIC and MedStar Health. This year, over 700 residents, medical students and nursing students will go though one of the Telluride Experience Patient Safety Summer Camps. Out Telluride Scholars Alumni network continues to grow – our future health care leaders staying connected through the years, sharing quality and safety project successes and learning from each other.  And, for the first time, the Telluride Experience went International this past spring as we ran patient safety camps in Doha, Qatar and Sydney, Australia.

Thanks go out to the many passionate and committed faculty and others who have given so much to make our Educate the Young journey so very special. It has been an amazing twelve-year run…