Can We Be Honest When Medical Errors Occur?Posted: June 28, 2012
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.