In the award-winning patient safety educational film “The Faces of Medical Error from Tears to Transparency…The Story of Lewis Blackman,” Robert Galbraith Director of the Center for Innovation at the National Board of Medical Examiners (NBME), says:
If we don’t talk about our mistakes, we are doomed to repeat them…over and over and over again. So we have to have transparency and admit we made a mistake in order to try and prevent that mistake from happening again…and if we don’t do that, shame upon us.
As caregivers, there are certain cases that stay with us throughout our lives. The following is one of those cases for me, as it was my own failure to be honest with a patient many years ago that has remained with me throughout my professional career. I share this story when teaching health science students and resident physicians about medical errors and transparency as an example of a situation I hope they can avoid during their own careers.
When I was a senior anesthesia resident in Chicago a number of years ago, my first case of the day was a forty-two year old gentleman scheduled for a right-sided inguinal hernia repair. The day started as it always did – My patient was asleep under general anesthesia and I was preoccupied with monitoring and charting my patient’s vital signs as the surgery resident was busy prepping and draping the patient for the procedure. Once completed, the senior surgery resident picked up a scalpel and made the first surgical incision…in the left groin area, instead of the right. No one noticed this mistake, or was really paying attention – we all were doing “our jobs” and working as individuals instead of a team. After two minutes or so of surgical dissection, the surgery attending (having been detained at the scrub sink) approached the surgical table and patient, looked at the surgery resident and said, “I thought this was a right hernia repair?” The room went silent… if it weren’t for the monitor beeping out each heartbeat, you would have heard a pin drop in the operating room. The attending surgeon proceeded to close the left incision made by the resident and then went to work on repairing the right-sided hernia, leaving the patient with two surgical incisions and dressings at the end of the case.
Upon awakening from the general anesthetic, my “newly harmed” patient was groggy and unaware of his two new surgical wounds. I dropped him off in the recovery room and went back to the operating room to prepare for my next case…still thinking about the harm that had just occurred. This was the first time I was involved in a medical error. I had never heard of wrong-sided surgery. Was this the first time it had happened at our hospital? In Chicago? How would I face my peers? Could I be sued? Would I lose my residency spot? Personally, I was feeling horrible. All I could think about during the first hour of my second case was how my first patient was doing, how he reacted when the attending surgeon shared what happened, and how angry he must be for having an unnecessary wound.
To this day, I still remember dreading going back to the recovery room to discharge my patient so he could go home. I had not been trained on discussions related to medical errors with patients, or how to deliver this type of bad news. What should I expect? What should I say…or not say? I could only think of how angry my patient must be. I was shaking as I approached his bed…but instead of being greeted with anger, he had a big smile on his face–a reaction I was not expecting. Before I was able to say a word, he begins, “Today is my lucky day!” I am dumbfounded but say nothing. He continues, “I am so fortunate to be in such an excellent hospital where under general anesthesia, my surgeon discovers I really have two hernias – one on each side – and is able to repair both at the same time, under one anesthetic so I do not have to miss a second day of work. Today is my lucky day.” I was shocked and remained silent for what seemed like an eternity. And then I spoke: “Yes, today is your lucky day.” I signed the gentleman out and wished him well.
In those six words, “Yes, today is your lucky day,” I had violated every professional standard I had vowed to uphold as a caregiver. For years, we have buried our mistakes…sometimes literally. Not only was what I did ethically and morally wrong, the secrecy of the event among the care team kept us and others from learning how the mistake occurred, and how to find ways to improve our systems so additional patients did not suffer similar harm.
Why did I keep silent? What was it that kept me from speaking up and doing the right thing? What is it that keeps many of us from doing what we know is right when unintentional harm does occur to our patients?
More on this issue of non-disclosure to follow.
Last week’s class at the Telluride Student Summer Camp proved to be very prolific, sharing their experience through metaphor and analogies found in everyday life to bring home the educational concepts shared during the week. Eva Luo, University of Michigan-Class of 2013, shared an excellent post–Health Care Assemble!–on the Transparent Health blog using the latest blockbuster movie, The Avengers, as an analogy for teamwork in healthcare. She writes:
As a fan of superhero movies, our deep confusion about how doctors and nurses work together to safely take care of patients reminded me of the movie, The Avengers. In the first half of the movie, a rag tag team of super heroes is brought together with the mission to save the world from alien domination. Each hero has his or her own superhuman talents (intelligence, strength, lightning generating hammer, etc.), not to mention movie franchise. However, the villain’s first attack quickly demonstrates that even superheroes are not effective alone and are at risk of causing unintentional harm…
The transformation in the second half of the movie was remarkable. Captain America rose to the challenge of leading the team. Each of the members communicated effectively removing any ambiguity about each member’s role. Most importantly, the superheroes played to each other’s strengths and supported each other. If my memory serves me correctly, I don’t believe any human lives were lost despite impressive damage to much of Midtown. Is similar effective teamwork possible in health care? I think so. But, we need to invest in building teams while we are still in school.
As an educator, Eva’s message is a reflection of how we are failing to properly prepare health science students and resident physicians to successfully address the complex needs of a team-based, patient-centered healthcare system. Patient care is now a team sport, not an individual sport as in years past. Health science curricula needs to be changed so students and resident physicians understand interprofessional roles, train in teams, and fully appreciate the powerful role patients can play when included on that care team. All too often, we continue to throw traditional curricular “roadblocks” into their educational schedules, those which only superheroes could overcome at times. Yet the young warriors attending this year’s summer camp remain eager to learn not only the science, but also the team-based, patient-centered, systems approach to making healthcare delivery safer.
The development of cohesive, multidisciplinary teams that include the patient’s voice can be instrumental in making care safer. Training around this important theme needs to be incorporated into all health science school curricula…not just at the few sites that have started moving towards this educational model. One nice example of interprofessional training is the work being done by Gwen Sherwood (a Telluride Patient Safety Summer Camp faculty member) and others, at the University of North Carolina. For more information go to: http://www.ncbi.nlm.nih.gov/pubmed/20427311
While more and more efforts are being focused on “educating the young” about transparency, patient safety and high quality healthcare, it is also evident educational efforts need to be focused on the media – both TV and press. An excellent post by Bob Wachter MD highlights how a TV program like House can undermine the importance of professionalism, leadership and team-based care – elements critical to the achievement of safe, high-quality patient care.
Along similar lines, on June 1st the California Department of Health announced that 13 California hospitals had been “assessed administrative penalties and fines totaling $825,000 after a determination that the facilities’ noncompliance with licensing requirements caused, or was likely to cause, serious injury or death to patients.”
For six of the hospitals cited this was their first administrative penalty. For four of the hospitals, it was their second. But for one health system, it was their eighth such offense. What was occurring within this healthcare system that would allow not just one, but eight failures to keep patients safe?
These are all very important breeches of safety that should be shared with the public. However, an article in the Los Angeles Daily News about one of these incidents was quick to point out that a nurse failed to perform an accurate sponge count and then erroneously signed off on the count being correct. The same news story revealed that a doctor had improperly placed the sponge in the first place. I can’t help but wonder what this reporter, or whomever threw these specific individuals under the media bus, knows or understands about the full investigation (or Root Cause Analysis) that hopefully was completed after this patient harm event. Or what this reporter knows about “just culture”.
In a high reliability organization (HRO), the entire OR team, all hospital leadership and the hospital board would be responsible for this error. According to James Reason, whose body of work in human error and organizational processes is the foundation for system’s change in healthcare, the focus should first be on faulty systems and not faulty individuals. A just culture manages honest mistakes made by good people as a system failure. (See another post by Wachter, On Swiss Cheese and Patient Safety, for more information). Reason’s model also does not allow for a system to take a hit in the name of an individual exhibiting egregious or negligent behavior that causes harm. Those who knowingly violate safety policies and procedures for personal gain must be identified and held accountable for their egregious actions. If hospitals continue to have repeated occurrences of the same medical error, one has to ask how engaged leadership is in the quality/safety mission within their hospitals. Do they ensure the repetitions are not from the same caregivers who do not want, or care, to follow evidenced-based safe policies and procedures?
Regulation by the state of California that institutes administrative penalties and fines to hospitals and health system that put their patients at risk is one way to manage medical error, but there must be culture change that also occurs, or like Reason’s swiss cheese model, it’s only a matter of time before the holes eventually line up once again. Over the last 5 years, CA has collected a total of $8.575M in fines that will now be used for Quality Improvement programs throughout the state, which includes an analysis of the harmful events and how/if they were reported–another tenet of HROs. I would hate to think that culture change in medicine has nothing to do with Reason’s work, or Lucian Leape’s work or Don Berwick’s work–and that it is simply a matter of only making health systems write a negatively reinforcing check every time they have another significant safety event.
Movies that address important issues can ignite strong emotions universal to all of us. Some movies make us angry, some make us laugh–others strike a nerve that motivates us to do better or join a cause. From an educational point of view, emotion generated through film and visual images can create teaching moments unachievable through traditional methodologies. When these moments are reinforced with interactive group discussion, the stories remain in the heart and the knowledge encoded in ways unique to visual and emotionally driven stimuli.
Two additional patient safety educational films that do a wonderful job of educating through our hearts and motivating through the emotional response they evoke are: First, Do No Harm® (FDNH) and The Josie King Story. Both films use true stories to motivate audiences and create lasting change so that similar mistakes do not happen again.
The film First, Do No Harm® (FDNH) helps healthcare teams navigate the complex issues we as care providers face in our efforts to deliver the best outcomes for our patients. The three part film series takes on a multitude of important topics, including:
- How systems fail
- Teamwork, handoffs and communication
- Creating just organizational cultures
- The importance of board and executive engagement in supporting frontline healthcare professionals
- Managing media coverage of medical errors
Based on incidents drawn from real malpractice claims, the First, Do No Harm® series presents the dramatic story of how a healthcare community responds when a healthy pregnancy turns to tragedy as a result of a series of medical failures. Through one expectant mother’s journey, the film shares the spectrum of safety and ethics issues that can arise in a busy healthcare system. The series consists of three sequential case studies, each approximately 20 minutes in length. The film also includes commentary from leading experts in healthcare and other industries, as well as facilitators’ guides developed by risk management educators that detail scene-by-scene learning objectives and discussion points.
The second outstanding patient safety educational film is The Josie King Story. In 2001, Sorrel King, Josie’s mother, addressed the Institute for Healthcare Improvement (IHI) conference. It was the first time Sorrel had spoken publicly about the medical errors that led to Josie’s death. Captured on film, Sorrel’s sharing of Josie’s story and her powerful educational insights have inspired caregivers and hospital administrators to take up the cause of patient safety in their daily work. The film showcases a mother who asks medical professionals to look, listen, and communicate in order to create a culture of patient safety. According to the Josie King Foundation, over 1,200 healthcare institutions around the world use this educational movie as a training tool to emphasize the importance of communication and teamwork in patient safety.