Can We Be Honest When Medical Errors Occur?

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.

Students As Superheroes of Healthcare

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:

The Current State of Patient Safety Education for Future Caregivers…Who Do You Believe?

The Lucian Leape Institute (LLI), named after the physician many consider the “Father of Patient Safety” was formed in 2007. The Institute functions as a think tank and its mission is to provide thought leadership and a strategic vision for improving patient safety. The initial work of the LLI has focused on identifying and framing key transforming concepts that require system-level attention and action. The five transforming concepts identified are:

1) Medical education reform
2) Active consumer engagement in patient care
3) Provision of fully transparent care
4) Integration of care across health care organizations and delivery systems
5) Restoration of pride, meaning and joy in professional work.

The LLI believes success in each of these concepts is critical in moving the national patient safety agenda forward.

The first concept addressed by the LLI was medical education reform and I was delighted to be an invited member of the educational roundtable. We all believe substantial improvements in patient safety will be difficult to achieve without major medical education reform. Medical schools must not only assure that future physicians have the requisite knowledge, skills, behaviors, and attitudes to practice competently, but also are prepared to play active roles in identifying and resolving patient safety problems as well as leading quality improvement initiatives in the future.

The Roundtable published a white paper about two years ago titled, Unmet Needs: Teaching Physicians About Safe Patient Care. The white paper concluded that medical schools today are not doing an adequate job of laying the educational groundwork needed in knowledge and skill development required for the provision of safe, high quality patient care, to wit: systems thinking, problem analysis, human factors concepts, transparency, communication skills, patient-centered care, teaming concepts and skills, and dealing with feelings of doubt, fear, and uncertainty with respect to medical errors.

Conclusions by the Institute caused a lot of push back and rebuttal from many national and local medical education organizations, who believed medical education was doing fine when it came to patient safety and quality improvement curricula for students and residents—and this debate continues. While progress has been made in bringing patient safety into undergraduate and graduate medical education curricula over the past two years, we are still nowhere close to where patient safety education should be  in meeting the needs of the patient. This concern really hit home the past two weeks at our Telluride Patient Safety Summer Camp when resident physicians and medical students shared the following:

On the current state of patient safety education and training in medical school:
Almost all medicals students acknowledged that the four days they spent on patient safety education at the Telluride Summer Camp was more training than they get in their four years of medical school. While all schools have some training in patient safety, it is still infrequent and rarely longitudinal.

On Informed Consent/Shared Decision-making training:
After residents watched the award-winning film The Faces of Medical Error…From Tears to Transparency: The Story of Michael Skolnik and engaged in a two-hour discussion on important differences between informed consent and shared decision-making, Paul Levy asked the residents how much informed consent training they get during their medical school and residency. With a show of hands, every resident acknowledged the three-hour session on informed consent/shared decision making at the Telluride Summer Camp was more training than they received during medical school and residency put together. One resident commented:

I don’t think that I’ve ever thought so much about informed consent as I did today.  A discussion about informed consent to the level of detail that we had today needs to be part of all residency training in the first days of orientation and as refresher training later on in training.  All physicians can, and should, do much better in providing informed consent.

On understanding nursing, and the nurse’s role in team-based patient care:
On day two and three of the Student Summer Camp, Kathy Pischke-Winn, RN and Joe Halbach, MD shared educational strategies and tools for team-based care and effective communication between caregivers. The sessions were powerful – using case-based learning and role-plays, the students gained great insight into communication tools like SBAR (or ISBAR as the Australians attending the summer camp were quick to point out), write-down read-back, CUS and others. At the end of the two-day session, the students shared their complete lack of knowledge (and medical school training) prior to attending the summer camp regarding the important role of the nurse in patient care and other team-based care concepts.

One medical student commented:

Our discussion on the roles of nurses at different institutions was eye-opening in the sense that many of my peer medical students had very little knowledge about other allied health professionals.”

Another fourth-year medical student pointed out this lack of team-based patient care training cuts even deeper:

The discussion about nursing and doctoring reminded me of conversations I had with fellow classmates at school. We were studying for the NBME Behavioral Sciences exam and joking about the ethical dilemma practice questions we were working on. A common theme that we noticed is that any answer involving soliciting a nurse for help or consulting with a nurse would invariably be wrong. We agreed that answers involving nurses can be crossed off and it would be nice to get one on the test because we could narrow down the answers easier. Almost like how there used to rarely be positive depictions of minorities in the cinema, early medical education is nearly void of positive depictions of nurses.

I think we can all agree medical training and educating the young is not near where we need it to be especially in the areas of team-based, patient-centered care.

Shooting Free Throws and Mastering Patient Safety Skills

With the National Basketball Association playoffs having just ended, I couldn’t help but be reminded about the relationship between great coaches and great educators. The best coaches through the years have been some of the best teachers and provided examples of role models for leaders in many industries. Tracy Granzyk, MS, illustrates this relationship in an excellent post, John Wooden’s Spirit Alive and Well in Telluride, about the benefits of using leadership examples outside of healthcare, such as that of legendary UCLA basketball coach John Wooden, to improve communication during the patient-provider encounter. She writes:

“If they haven’t learned it, you haven’t taught it.” This was a Woodenism oft quoted at the Resident Patient Safety Summer Camp in Telluride by special guest faculty, Paul Levy. Wooden and Levy are both coaches and teachers in their respective fields–one hospital administration and the other NCAA Men’s Basketball. With that quote, they both take responsibility to the fullest extent for successfully transferring knowledge to those they themselves are charged with educating.

It became clear to all the resident physicians attending the Telluride Patient Safety Summer Camp that as caregivers, we do indeed assume the role of educator on a daily basis. How many ways, and how many times, do we need to say the same thing to our patients so that they truly understand issues such as risks, benefits, treatment alternatives and the possibility of doing nothing? As many ways, and as many times, as it takes. For as John Wooden says, “if they haven’t learned it, we have not taught it…” our patients in a way that conveys an understanding of their diagnosis or their upcoming procedure, and how both could affect the quality of their life. The role of educator is subtext to a medical education, and few graduate medical schools prepare future doctors to teach or coach patients.

As Granzyk points out, these two very important educational themes from Telluride – communication and education– highlight the need to improve on the transfer of knowledge to our patients and family members, and identifies where holes in medical education still exist. How much time is dedicated to development of these two skills that are cornerstones of patient-centered care throughout medical education? Not enough. Looking to leadership in industries outside healthcare to fill these gaps is one way to jumpstart the transfer of knowledge in a meaningful way.

Telluride has also proven to be a fertile educational environment where the need for skill development in these areas is a top level agenda item. One excellent communication technique between caregivers that was discussed at length with residents in Telluride this year, was the “write-down, read-back” method for handoff of a patient. This technique calls for the caregiver receiving the patient to listen to the caregiver handing off the patient relate details about that patient’s care, preferably in the SBAR format. As the handoff caregiver shares important issues related to the patient’s care, the receiving caregiver writes down the important notes, and then read the notes back to the caregiver handing off the patient. This technique is powerful because writing down notes leads to better recall of the case details, and it provides a form of traceable documentation.

A second excellent communication method also shared in Telluride last week, was the story of a physician asking his patient, “May I tape this conversation?” As the patient agreed, the entire meeting was then tape-recorded, with the patient thinking this to be a self-serving attempt at medical malpractice prevention. At the end of the encounter, the physician removed the tape from the recorder and handed it to the patient saying, “I know we discussed a lot of information today and you might not have completely taken it all in. Please take this tape home and listen to it. Have your family and friends listen to it too, and then let me know if you have any additional questions.” What a great example of patient-driven care—what a great example of teaching until the knowledge is imparted and can actually be used by the patient.

A Case of Regulating the Old…and Maybe Educating the Press?

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.

Patient Stories Provide A Lasting Learning Experience

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:

  1. How systems fail
  2. Teamwork, handoffs and communication
  3. Creating just organizational cultures
  4. The importance of board and executive engagement in supporting frontline healthcare professionals
  5. 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.

Can A Conversation Change An Outcome?

Keeping with our recent theme of story, narrative and film as powerful patient safety education tools, the second day at the Telluride Patient Safety Summer Camp finished with the residents viewing the award-winning film, The Faces of Medical Error…From Tears to Transparency: The Story of Michael Skolnik. The film addresses the important differences between informed consent and shared decision-making–important differences as they relate to open and honest communication in healthcare. The movie asks the question “Can a conversation change an outcome? Can a conversation save a life?” Through Michael’s clinical course and resulting outcome, viewers understand and appreciate that a shared decision-making conversation can change an outcome and save a life.

After watching the film, residents engaged in a two-hour conversation with faculty and safety leaders on issues related to informed consent and shared decision-making. The audience engagement in discussions and the consensus building that follows a film like The Story of Michael Skolnik are always lively and very educating. One of our residents, Todd Guth, posted a great reflection on the session at the Transparent Health blog. Here is an excerpt from that post:

Informed consent is a shared decision-making opportunity between patient and physician.  At its core, informed consent is a conversation with the goal of allowing the patient to ask questions and hopefully come away with a clear understanding of the procedure to be performed, as well and the risks and benefits of the procedure. Procedures, diagnostic tests, and medications can all be conversations that are pursued with patients under the vigilance of informed consent.

While the conversation is the essential element of informed consent, the informed consent paperwork can serve as both a checklist for the provider and a physical reminder to the patient that we are discussing potential harm and the physician will need the patient’s approval before pursuing any potentially risky treatment plans.

A discussion about informed consent to the level of detail that we had today needs to be part of all residency training in the first days of orientation and as refresher training later on in training.  All physicians can, and should, do much better in providing informed consent.

At the end of the session, Paul Levy asked the residents how much informed consent training they receive during medical school and residency. With a show of hands, every resident acknowledged the three-hour session on informed consent/shared decision-making at the Telluride Summer Camp was more training than they received during their entire medical school and residency combined. We all agreed this was a sad commentary on the current state of medical education in areas of patient centered care, and the data around informed consent taking place in hospitals is also discouraging. According to a March 2010 JAMA article written by Harlan Krumholz MD, Harold Hines Jr. Professor of Medicine (Cardiology) at Yale University, informed consent documents from 157 randomly selected US hospitals were shown to have limited educational value. Krumholz also shares results from two additional studies which found almost 70% of surgical patients studied did not read the informed consent form, and that many patients misunderstand the benefits and risks of their procedure altogether.

We cannot achieve a true partnership with our patients unless we have meaningful shared decision-making conversations that include a full understanding of a patient’s needs, preferences, values and goals. I echo Todd’s reflective assessment – All physicians can, and should, do much better in providing informed consent.