When physicians get a real lesson in medical errors

As a student in Biomedical and Health Informatics at the University of Washington, medical errors were a frequent topic in my first-year classes. I learned how informatics can help to prevent errors, but also how poorly designed informatics systems can contribute to errors. But once I had completed my required classes and moved onto my research, I left the topic of medical errors behind. I don’t work in clinical informatics (I make tools to help researchers retrieve biomedical knowledge), so medical errors were simply someone else’s problem, not mine.

But then my father was the victim of a medical error. I was now seeing the other side of medical errors. The side that wasn’t real before. The side that wasn’t supposed to be a part of my life.

I have often wondered what medical students think about medical errors. I suspect that many have a view similar to the way I once perceived errors—scary and terrible, but abstract and detached from my own reality. But medical errors occur with alarming frequency. And that means that someday many of those medical students will experience a harmful error in either their own healthcare or that of a family member. And then they will see the other side, the side that wasn’t real before. The side that wasn’t supposed to be a part of their lives. And when that happens, I hope it is a transformative experience. Because those of us outside the healthcare system can push for change by speaking up about medical errors and refusing to be silent when they happen. But ultimately, safer healthcare comes from changes made by those inside the healthcare system, those responsible for delivering healthcare.

How would the perspective of a medical student or physician shift once they experienced the patient’s side of errors? Would they have the courage to talk about their experience—because publicly talking about how the healthcare system is injuring and killing people may not be viewed favorably by colleagues and employers who are a part of that system.

I have found two articles that provide some insight. Both of these physicians work at Brigham and Women’s Hospital in Boston. (This is probably not a coincidence. This organization is very vocal about patient safety.)

Dr. Elaine Goodman: mother undergoing treatment for breast cancer

You can read Dr. Goodman’s story on ProPublica. She had finished her first year of medical school when her mother spent months in a hospital near Seattle for treatments for advanced breast cancer. Her mother experienced numerous medication errors, including a major one involving her chemotherapy. Other patient safety issues included frequent falls and preventable side effects from drugs.

Dr. Goodman, who is now a resident at Brigham and Women’s Hospital, reflected on the experience by saying that she didn’t realize how difficult it was to keep patients safe in the hospital, and that she would have had a better understanding of patient safety issues if “instruction had been tied to individual patients.”

She also emphasizes the responsibility of healthcare providers to track errors and learn from them, but this is not something that everyone is going to easily accept. As she explains, “…when errors are reported, the response is not always constructive. I filed an error report a few days ago about a medication event. Most people responded well, but a few emails I got showed some people were not happy being involved in an error report.”

Dr. Jonathan Welch: mother taken to a hospital with sepsis during cancer treatment

Dr. Welch has written an essay for Health Affairs titled “As She Lay Dying: How I Fought To Stop Medical Errors From Killing My Mom”. The article is restricted to subscribers of the journal, so I will summarize it for you.

Dr. Welch’s essay begins with this:

Back when I was training to become an emergency physician, I’d worry about the day I’d be involved in a medical error. It seemed inevitable. With land mines everywhere—the possibilities of missed diagnoses, delayed treatments, miscommunication—it felt like almost anything could lead to catastrophe. I imagined attending the in-house case review afterward, chastened as my hospital colleagues dissected my decisions. Yet I also thought—and hoped—that something positive would come from the process, that lessons from an error would sharpen my clinical skills and improve care in the hospital.

But when I was entangled in my first medical error, I played an unexpected role: I was a thirty-three-year-old son trying to save my mom’s life.

Dr. Welch’s mother was undergoing chemotherapy when she was found barely responsive by his father one morning. She was taken to an emergency room. When Dr. Welch received a phone call from the emergency room physician telling him that his mother was in a Wisconsin hospital with a high fever and very low white blood cell count, he knew the diagnosis: neutropenic sepsis. His mother had a serious infection, but her body’s white blood cells—which should be fighting the infection—were wiped out from her chemotherapy. “The condition is well known, is easily diagnosed, and has a clear and standard treatment protocol. I also knew we were on the clock. The first twenty-four hours of my mom’s hospitalization would be critical to saving her life.”

Once Dr. Welch arrived in at the Wisconsin hospital, he was alarmed at the care his mother was receiving. “My mom’s blood pressure had crashed during the day. Her numbers now were half of what they’d been at her arrival in the emergency department. My mom’s emergency physician and oncologist had taken few, if any, of the essential and obvious interventions needed to save her life. The nurse seemed calm, as if everything was normal.” He did manage to get his mother moved to the ICU. But little changed. The hospital did have a sepsis treatment plan, but it had to be ordered by the oncologist, and the oncologist would have to consult with the intensive care specialist. “My mom now had been in the hospital for sixteen hours without receiving the sepsis protocol—made up of a standard group of treatments and actions—that she needed to save her life.”

I wish I’d done more at that point—raised hell, insisted on waking both my mom’s oncologist and the hospital’s intensive care doctor at home, demanded that they come to the hospital. Instead, by that point I felt lost and powerless. I’d already insisted that my mom be moved to the ICU. What would happen if I made additional demands?

The sepsis protocol was finally started twenty-three hours after his mother arrived at the hospital. She died less than a week later.

Dr. Welch ends his essay by discussing system improvements that have been implemented in other hospitals. These include a hotline for patients and families when they feel they are not receiving the care they need, interviewing patients and families after hospitalizations in which there was a poor outcome, and setting up patient and family advisory councils to help improve care. He also reflects how the experience with his mother changed his perspective. “In the Boston hospital where I work, we strive as a group to improve the quality of care we offer our patients. We review our process and outcome measures, and we create and track new approaches for improving care. We also make changes after examining specific patient cases. And yet, I now realize, before this experience I never sought patient or family feedback in any of these quality improvement activities.”

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