Hello. This is the blog of Melissa Clarkson. I created this blog to inform the public about the need for disclosure of medical errors and to document my family’s efforts to make disclosure a routine part of healthcare in Kansas.
The wall of silence
In April 2012 my father died after a serious medical error. After my father’s death I took steps to investigate what happened during his care, and my family began to ask some questions. What we encountered is “the wall of silence.” No patient or family should ever be put through this experience. Being harmed by a medical error is horrible. Refusal by healthcare providers to acknowledge that error is maddening.
The purpose of this blog
It is my hope that this blog will bring attention to the need to disclose medical errors. Disclosing medical errors has two purposes: First, it shows respect for patients and helps patients (and their families) to heal emotionally. Second, I believe that the only way to reduce the number of medical errors in the U.S. is for citizens to become knowledgeable about errors. Until we hold healthcare providers accountable for errors, there is little incentive for them to take steps to prevent errors.
My father died while I was a Ph.D. student at the University of Washington in the Biomedical and Health Informatics program. I had learned about medical errors as part of my course work. I never imagined I would be on the other side. But now that I am, I cannot remain silent.
My father’s story
People don’t become patients’ rights advocates because they simply decided it was a worthy cause. They become patients’ rights advocates because something terrible happened to them or a family member. Here is my father’s story:
My father was helping with a controlled grass burn at the housing development in rural Kansas where he and my mother lived. The fire got out of control and he was caught in it. He was taken to the local hospital and diagnosed with second degree burns over 30% of his body. He actually had third degree burns (meaning that his skin was burned all the way through, down to the tissue below). But getting the diagnosis exactly right that evening was not the biggest problem. It was the physician’s decision to admit him to their local hospital. My father was there for about 15 hours until he was transferred to a burn center. By the time he was transferred he was severely dehydrated, in renal failure, and on a number of heart medications to try to keep his heart beating normally.
My father far exceeded the guidelines of the American Burn Association for transfer to an accredited burn center, and the transfer should have happened as soon as possible. That 15-hour delay was a serious medical error.
He died after 11 days at the burn center. It is not certain that my father would have lived even with an immediate transfer, but according to his burn doctor the delay in transfer greatly reduced his chance for survival.
My family has so many questions. Does the physician at that local hospital know my father should have been immediately transferred? Did the physician seek any advice before making the decision to not transfer? Did the doctor and nurses have the training for dealing with severe burns? Did they know about the American Burn Association’s criteria for transfer to a certified burn center? Will this happen again to someone else?
My family thinks these questions are important, but we have no way to get answers if the physician and hospital cannot acknowledge that an error was made.
We may have encountered the wall of silence, but I will not remain silent.