Hospital tells of surgery on wrong side
By Stephen Smith
20july 2008--An experienced surgeon at Beth Israel Deaconess Medical Center operated on the wrong side of a patient this week, a serious medical mistake disclosed in an e-mail that hospital administrators sent to staff members yesterday.
State authorities are investigating the errant surgery, which happened Monday during an elective procedure. A hospital administrator declined to provide specifics about the operation but said it did not involve removal of organs and did not cause permanent damage to the middle-aged patient, who was expected to suffer short-term discomfort. A state health regulator described the operation as an orthopedic procedure.
The mistake happened as hospitals, regulators, and insurers are devoting unprecedented attention to combating medical errors. Last month, the state said it would stop reimbursing hospitals for medical costs associated with mistakes.
Figures from the state show that in the first five months of the year, hospitals statewide reported five wrong-sided surgeries. On average, about 15 such errors are reported annually, said Paul Dreyer, director of the state's Bureau of Health Care Safety and Quality.
The error was made at a hospital whose chief executive officer, Paul Levy, has embarked on a personal crusade to reduce medical mistakes, regularly blogging about the issue. Levy has challenged other hospitals to be as forthcoming as his own in publicly disclosing rates of hospital-acquired infections and other preventable events.
A national specialist in the field of patient safety said hospitals are increasingly owning up to mistakes but described Levy's decision to send an e-mail to hundreds of staff members as an unusual act of openness.
When a medical mistake happens, "it's everybody's worst nightmare," said Jim Conway, a senior vice president at the Institute for Healthcare Improvement, a Cambridge think tank that works with hospitals to improve safety. "So what you want to do is disclose it to the [hospital] community, so the community can figure out how they can advance their practice and advance their role so this never happens again."
Dr. Kenneth Sands, senior vice president of healthcare quality at Beth Israel Deaconess, said it had been "at least several years" since such an error had been made at the hospital, an affiliate of Harvard Medical School.
The memo signed by Sands and Levy describes the surgery as "a horrifying story."
According to that document and an interview with Sands, the patient underwent surgery on a hectic day. The memo depicts the surgeon as being "distracted by thoughts of how best to approach the case" in the minutes preceding the operation.
While declining to go into detail, Sands said "there are procedures that happen every day and then there are procedures that are somewhat less common, and this was in that latter category." He said the surgery was designed to repair a problem and did not "involve compromise to any vital organ."
The hospital did not disclose the identity of the patient or surgeon, saying that if too many details were revealed, the patient's confidentiality could be compromised.
Sands said medical workers used a marker to correctly label the side of the patient that should have been operated on, but that, somehow, the surgeon failed to notice the marking.
"I think he began prepping without looking for the mark and, for whatever reason, he believed he was on the correct side," Sands said.
Perhaps most crucially, the team of medical workers in the operating room neglected to conduct what is known as a "time out" before the surgeon placed his scalpel on the patient.
Time outs are routine safety procedures that require the operating team to verbally call out, "Right patient, right procedure, right location."
No single individual was to blame for the event, Sands said, and once the surgery began, nothing in the surgical site itself made it apparent to the surgeon he was operating in error.
The mistake was discovered when the patient was in the surgical recovery area. Later that afternoon, the patient was told about the mistake.
"We waited until the patient was awake enough to get the news, and at that point, the surgeon talked to the patient and gave a full explanation and a full apology," Sands said. The surgery left the patient with post-operative discomfort, but no "life-threatening deficit or permanent organ damage."
A state investigator will visit the hospital next week and depending on the findings, the hospital could face sanctions.
The patient has left Beth Israel Deaconess and has made no decision about whether to have the correct operation - and if so, at which hospital, Sands said
Showing posts with label medical errors. Show all posts
Showing posts with label medical errors. Show all posts
Sunday, July 20, 2008
Monday, May 19, 2008
Doctors Say ‘I’m Sorry’ Before ‘See You in Court’
By KEVIN SACK
CHICAGO — In 40 years as a highly regarded cancer surgeon, Dr. Tapas K. Das Gupta had never made a mistake like this.
As with any doctor, there had been occasional errors in diagnosis or judgment. But never, he said, had he opened up a patient and removed the wrong sliver of tissue, in this case a segment of the eighth rib instead of the ninth.
Once an X-ray provided proof in black and white, Dr. Das Gupta, the 74-year-old chairman of surgical oncology at the University of Illinois Medical Center at Chicago, did something that normally would make hospital lawyers cringe: he acknowledged his mistake to his patient’s face, and told her he was deeply sorry.
“After all these years, I cannot give you any excuse whatsoever,” Dr. Das Gupta, now 76, said he told the woman and her husband. “It is just one of those things that occurred. I have to some extent harmed you.”
For decades, malpractice lawyers and insurers have counseled doctors and hospitals to “deny and defend.” Many still warn clients that any admission of fault, or even expression of regret, is likely to invite litigation and imperil careers.
But with providers choking on malpractice costs and consumers demanding action against medical errors, a handful of prominent academic medical centers, like Johns Hopkins and Stanford, are trying a disarming approach.
By promptly disclosing medical errors and offering earnest apologies and fair compensation, they hope to restore integrity to dealings with patients, make it easier to learn from mistakes and dilute anger that often fuels lawsuits.
Malpractice lawyers say that what often transforms a reasonable patient into an indignant plaintiff is less an error than its concealment, and the victim’s concern that it will happen again.
Despite some projections that disclosure would prompt a flood of lawsuits, hospitals are reporting decreases in their caseloads and savings in legal costs. Malpractice premiums have declined in some instances, though market forces may be partly responsible.
At the University of Michigan Health System, one of the first to experiment with full disclosure, existing claims and lawsuits dropped to 83 in August 2007 from 262 in August 2001, said Richard C. Boothman, the medical center’s chief risk officer.
“Improving patient safety and patient communication is more likely to cure the malpractice crisis than defensiveness and denial,” Mr. Boothman said.
Mr. Boothman emphasized that he could not know whether the decline was due to disclosure or safer medicine, or both. But the hospital’s legal defense costs and the money it must set aside to pay claims have each been cut by two-thirds, he said. The time taken to dispose of cases has been halved.
The number of malpractice filings against the University of Illinois has dropped by half since it started its program just over two years ago, said Dr. Timothy B. McDonald, the hospital’s chief safety and risk officer. In the 37 cases where the hospital acknowledged a preventable error and apologized, only one patient has filed suit. Only six settlements have exceeded the hospital’s medical and related expenses.
In Dr. Das Gupta’s case in 2006, the patient retained a lawyer but decided not to sue, and, after a brief negotiation, accepted $74,000 from the hospital, said her lawyer, David J. Pritchard.
“She told me that the doctor was completely candid, completely honest, and so frank that she and her husband — usually the husband wants to pound the guy — that all the anger was gone,” Mr. Pritchard said. “His apology helped get the case settled for a lower amount of money.”
The patient, a young nurse, declined to be interviewed.
Mr. Pritchard said his client netted about $40,000 after paying medical bills and legal expenses. He said she had the rib removed at another hospital and learned it was not cancerous. “You have no idea what a relief that was,” Dr. Das Gupta said.
Some advocates argue that the new disclosure policies may reduce legal claims but bring a greater measure of equity by offering reasonable compensation to every injured patient.
Recent studies have found that one of every 100 hospital patients suffers negligent treatment, and that as many as 98,000 die each year as a result. But studies also show that as few as 30 percent of medical errors are disclosed to patients.
Only a small fraction of injured patients — perhaps 2 percent — press legal claims.
“There is no reason the patient should have to pay the economic consequences for our mistakes,” said Dr. Lucian L. Leape, an authority on patient safety at Harvard, which recently adopted disclosure principles at its hospitals. “But we’re pushing uphill on this. Most doctors don’t really believe that if they’re open and honest with patients they won’t be sued.”
The Joint Commission, which accredits hospitals, and groups like the American Medical Association and the American Hospital Association have adopted standards encouraging disclosure. Guidelines vary, however, and can be vague. While many hospitals have written policies to satisfy accreditation requirements, only a few are pursuing them aggressively, industry officials said.
“We’re still learning the most effective way to have these most difficult conversations,” said Nancy E. Foster, the hospital association’s vice president for quality and patient safety. “It’s a time of high stress for the patient and for the physician. It’s also a time where information is imperfect.”
The policies seem to work best at hospitals that are self-insured and that employ most or all of their staffs, limiting the number of parties at the table. Such is the case at the Veterans Health Administration, which pioneered the practice in the late 1980s at its hospital in Lexington, Ky., and now requires the disclosure of all adverse events, even those that are not obvious.
To give doctors comfort, 34 states have enacted laws making apologies for medical errors inadmissible in court, said Doug Wojcieszak, founder of The Sorry Works! Coalition, a group that advocates for disclosure. Four states have gone further and protected admissions of culpability. Seven require that patients be notified of serious unanticipated outcomes.
Before they became presidential rivals, Senators Hillary Rodham Clinton and Barack Obama, both Democrats, co-sponsored federal legislation in 2005 that would have made apologies inadmissible. The measure died in a committee under Republican control. Mrs. Clinton included the measure in her campaign platform but did not reintroduce it when the Democrats took power in 2007. Her Senate spokesman, Philippe Reines, declined to explain beyond saying that “there are many ways to pursue a proposal.”
The Bush administration plans a major crackdown on medical errors in October, when it starts rejecting Medicare claims for the added expense of treating preventable complications. But David M. Studdert, an authority on patient safety in the United States who teaches at the University of Melbourne in Australia, said the focus on disclosure reflected a lack of progress in reducing medical errors.
“If we can’t prevent these things, then at least we have to be forthright with people when they occur,” Mr. Studdert said.
For the hospitals at the forefront of the disclosure movement, the transition from inerrancy to transparency has meant a profound, if halting, shift in culture.
At the University of Illinois, doctors, nurses and medical students now undergo training in how to respond when things go wrong. A tip line has helped drive a 30 percent increase in staff reporting of irregularities.
Quality improvement committees openly examine cases that once would have vanished into sealed courthouse files. Errors become teaching opportunities rather than badges of shame.
“I think this is the key to patient safety in the country,” Dr. McDonald said. “If you do this with a transparent point of view, you’re more likely to figure out what’s wrong and put processes in place to improve it.”
For instance, he said, a sponge left inside an patient led the hospital to start X-raying patients during and after surgery. Eight objects have been found, one of them an electrode that dislodged from a baby’s scalp during a Caesarian section in 2006.
The mother, Maria Del Rosario Valdez, said she was not happy that a second operation was required to retrieve the wire but recognized the error had been accidental. She rejected her sister’s advice to call a lawyer, saying that she did not want the bother and that her injuries were not that severe.
Ms. Valdez said she was gratified that the hospital quickly acknowledged its mistake, corrected it without charge and later improved procedures for keeping track of electrodes. “They took the time to explain it and to tell me they were sorry,” she said. “I felt good that they were taking care of what they had done.”
There also has been an attitudinal shift among plaintiff’s lawyers who recognize that injured clients benefit when they are compensated quickly, even if for less. That is particularly true now that most states have placed limits on non-economic damages.
In Michigan, trial lawyers have come to understand that Mr. Boothman will offer prompt and fair compensation for real negligence but will give no quarter in defending doctors when the hospital believes that the care was appropriate.
“The filing of a lawsuit at the University of Michigan is now the last option, whereas with other hospitals it tends to be the first and only option,” said Norman D. Tucker, a trial lawyer in Southfield, Mich. “We might give cases a second look before filing because if it’s not going to settle quickly, tighten up your cinch. It’s probably going to be a long ride.”
By KEVIN SACK
CHICAGO — In 40 years as a highly regarded cancer surgeon, Dr. Tapas K. Das Gupta had never made a mistake like this.
As with any doctor, there had been occasional errors in diagnosis or judgment. But never, he said, had he opened up a patient and removed the wrong sliver of tissue, in this case a segment of the eighth rib instead of the ninth.
Once an X-ray provided proof in black and white, Dr. Das Gupta, the 74-year-old chairman of surgical oncology at the University of Illinois Medical Center at Chicago, did something that normally would make hospital lawyers cringe: he acknowledged his mistake to his patient’s face, and told her he was deeply sorry.
“After all these years, I cannot give you any excuse whatsoever,” Dr. Das Gupta, now 76, said he told the woman and her husband. “It is just one of those things that occurred. I have to some extent harmed you.”
For decades, malpractice lawyers and insurers have counseled doctors and hospitals to “deny and defend.” Many still warn clients that any admission of fault, or even expression of regret, is likely to invite litigation and imperil careers.
But with providers choking on malpractice costs and consumers demanding action against medical errors, a handful of prominent academic medical centers, like Johns Hopkins and Stanford, are trying a disarming approach.
By promptly disclosing medical errors and offering earnest apologies and fair compensation, they hope to restore integrity to dealings with patients, make it easier to learn from mistakes and dilute anger that often fuels lawsuits.
Malpractice lawyers say that what often transforms a reasonable patient into an indignant plaintiff is less an error than its concealment, and the victim’s concern that it will happen again.
Despite some projections that disclosure would prompt a flood of lawsuits, hospitals are reporting decreases in their caseloads and savings in legal costs. Malpractice premiums have declined in some instances, though market forces may be partly responsible.
At the University of Michigan Health System, one of the first to experiment with full disclosure, existing claims and lawsuits dropped to 83 in August 2007 from 262 in August 2001, said Richard C. Boothman, the medical center’s chief risk officer.
“Improving patient safety and patient communication is more likely to cure the malpractice crisis than defensiveness and denial,” Mr. Boothman said.
Mr. Boothman emphasized that he could not know whether the decline was due to disclosure or safer medicine, or both. But the hospital’s legal defense costs and the money it must set aside to pay claims have each been cut by two-thirds, he said. The time taken to dispose of cases has been halved.
The number of malpractice filings against the University of Illinois has dropped by half since it started its program just over two years ago, said Dr. Timothy B. McDonald, the hospital’s chief safety and risk officer. In the 37 cases where the hospital acknowledged a preventable error and apologized, only one patient has filed suit. Only six settlements have exceeded the hospital’s medical and related expenses.
In Dr. Das Gupta’s case in 2006, the patient retained a lawyer but decided not to sue, and, after a brief negotiation, accepted $74,000 from the hospital, said her lawyer, David J. Pritchard.
“She told me that the doctor was completely candid, completely honest, and so frank that she and her husband — usually the husband wants to pound the guy — that all the anger was gone,” Mr. Pritchard said. “His apology helped get the case settled for a lower amount of money.”
The patient, a young nurse, declined to be interviewed.
Mr. Pritchard said his client netted about $40,000 after paying medical bills and legal expenses. He said she had the rib removed at another hospital and learned it was not cancerous. “You have no idea what a relief that was,” Dr. Das Gupta said.
Some advocates argue that the new disclosure policies may reduce legal claims but bring a greater measure of equity by offering reasonable compensation to every injured patient.
Recent studies have found that one of every 100 hospital patients suffers negligent treatment, and that as many as 98,000 die each year as a result. But studies also show that as few as 30 percent of medical errors are disclosed to patients.
Only a small fraction of injured patients — perhaps 2 percent — press legal claims.
“There is no reason the patient should have to pay the economic consequences for our mistakes,” said Dr. Lucian L. Leape, an authority on patient safety at Harvard, which recently adopted disclosure principles at its hospitals. “But we’re pushing uphill on this. Most doctors don’t really believe that if they’re open and honest with patients they won’t be sued.”
The Joint Commission, which accredits hospitals, and groups like the American Medical Association and the American Hospital Association have adopted standards encouraging disclosure. Guidelines vary, however, and can be vague. While many hospitals have written policies to satisfy accreditation requirements, only a few are pursuing them aggressively, industry officials said.
“We’re still learning the most effective way to have these most difficult conversations,” said Nancy E. Foster, the hospital association’s vice president for quality and patient safety. “It’s a time of high stress for the patient and for the physician. It’s also a time where information is imperfect.”
The policies seem to work best at hospitals that are self-insured and that employ most or all of their staffs, limiting the number of parties at the table. Such is the case at the Veterans Health Administration, which pioneered the practice in the late 1980s at its hospital in Lexington, Ky., and now requires the disclosure of all adverse events, even those that are not obvious.
To give doctors comfort, 34 states have enacted laws making apologies for medical errors inadmissible in court, said Doug Wojcieszak, founder of The Sorry Works! Coalition, a group that advocates for disclosure. Four states have gone further and protected admissions of culpability. Seven require that patients be notified of serious unanticipated outcomes.
Before they became presidential rivals, Senators Hillary Rodham Clinton and Barack Obama, both Democrats, co-sponsored federal legislation in 2005 that would have made apologies inadmissible. The measure died in a committee under Republican control. Mrs. Clinton included the measure in her campaign platform but did not reintroduce it when the Democrats took power in 2007. Her Senate spokesman, Philippe Reines, declined to explain beyond saying that “there are many ways to pursue a proposal.”
The Bush administration plans a major crackdown on medical errors in October, when it starts rejecting Medicare claims for the added expense of treating preventable complications. But David M. Studdert, an authority on patient safety in the United States who teaches at the University of Melbourne in Australia, said the focus on disclosure reflected a lack of progress in reducing medical errors.
“If we can’t prevent these things, then at least we have to be forthright with people when they occur,” Mr. Studdert said.
For the hospitals at the forefront of the disclosure movement, the transition from inerrancy to transparency has meant a profound, if halting, shift in culture.
At the University of Illinois, doctors, nurses and medical students now undergo training in how to respond when things go wrong. A tip line has helped drive a 30 percent increase in staff reporting of irregularities.
Quality improvement committees openly examine cases that once would have vanished into sealed courthouse files. Errors become teaching opportunities rather than badges of shame.
“I think this is the key to patient safety in the country,” Dr. McDonald said. “If you do this with a transparent point of view, you’re more likely to figure out what’s wrong and put processes in place to improve it.”
For instance, he said, a sponge left inside an patient led the hospital to start X-raying patients during and after surgery. Eight objects have been found, one of them an electrode that dislodged from a baby’s scalp during a Caesarian section in 2006.
The mother, Maria Del Rosario Valdez, said she was not happy that a second operation was required to retrieve the wire but recognized the error had been accidental. She rejected her sister’s advice to call a lawyer, saying that she did not want the bother and that her injuries were not that severe.
Ms. Valdez said she was gratified that the hospital quickly acknowledged its mistake, corrected it without charge and later improved procedures for keeping track of electrodes. “They took the time to explain it and to tell me they were sorry,” she said. “I felt good that they were taking care of what they had done.”
There also has been an attitudinal shift among plaintiff’s lawyers who recognize that injured clients benefit when they are compensated quickly, even if for less. That is particularly true now that most states have placed limits on non-economic damages.
In Michigan, trial lawyers have come to understand that Mr. Boothman will offer prompt and fair compensation for real negligence but will give no quarter in defending doctors when the hospital believes that the care was appropriate.
“The filing of a lawsuit at the University of Michigan is now the last option, whereas with other hospitals it tends to be the first and only option,” said Norman D. Tucker, a trial lawyer in Southfield, Mich. “We might give cases a second look before filing because if it’s not going to settle quickly, tighten up your cinch. It’s probably going to be a long ride.”
Saturday, March 15, 2008
Granny victim of colostomy confusion
German authorities said on Friday they are investigating an incident medical of malpractice involving an elderly woman in Bavaria, who has mistakenly received a colostomy instead of a leg operation.
(10 Mar 08) The Friday edition of local daily Frankenpost reported a 78-year-old woman in the Bavarian town of Münchberg has been the victim of an operating table mix-up.On February 29, the woman mistakenly underwent a colostomy procedure instead of a leg operation, the paper reported. Members of medical team involved in the incident have since been suspended from their duties. According to Frankenpost, two of these doctors were chief physicians. A hospital official said the facility regrets the mistake, and reacted to the mix-up immediately by notifying the patient, her relatives, and the appropriate authorities.
German authorities said on Friday they are investigating an incident medical of malpractice involving an elderly woman in Bavaria, who has mistakenly received a colostomy instead of a leg operation.
(10 Mar 08) The Friday edition of local daily Frankenpost reported a 78-year-old woman in the Bavarian town of Münchberg has been the victim of an operating table mix-up.On February 29, the woman mistakenly underwent a colostomy procedure instead of a leg operation, the paper reported. Members of medical team involved in the incident have since been suspended from their duties. According to Frankenpost, two of these doctors were chief physicians. A hospital official said the facility regrets the mistake, and reacted to the mix-up immediately by notifying the patient, her relatives, and the appropriate authorities.
Wednesday, January 16, 2008
Physicians Believe in Reporting Errors but Rarely Do
By Charles Bankhead
IOWA CITY, Iowa, Jan. 15 -- Most physicians support the concept of reporting medical errors, but few have actually reported one, investigators here have found.Three-fourths of physicians surveyed said they would report an error that caused minor harm to a patient and more than 90% would report an error causing major harm, Lauris C. Kaldjian, M.D., Ph.D., of the University of Iowa, and colleagues reported Jan. 14 in the Archives of Internal Medicine.However, only 17.8% of the physician respondents had actually reported a minor error, and only 3.8% had ever reported a major error.
In addition to the low rates of actual reporting of medical errors, the survey results showed that 16.9% of respondents conceded they had kept mum on a minor error they had committed or witnessed, and 3.8% had done the same on a major error they had committed or witnessed.
The survey responses also reflected widespread lack of understanding about the reporting of medical errors. More than half of the respondents (54.8%) did not know how to report errors, and only 39.5% knew what types of errors should be reported.
"The results of this study suggest that physicians' attitudes about the value of error reporting may not be matched by actual behavior," the authors concluded. "If correct, the potential causes of this discrepancy ought to be addressed."
Considering all acknowledged errors, both reported and unreported, leads to the conclusion that only 36% of the respondents acknowledged ever making a minor or major error, Dr. Kaldjian said in an interview. "We know that's probably not the whole story. There's a certain amount of underreporting."
Health care institutions need to establish an environment that emphasizes the educational aspects of error reporting and ensures confidentiality, the authors added.
The authors surveyed faculty members and residents at three medical centers in the midwest, mid-Atlantic region, and northeast. At the time of the survey, two of the three states included in the study had enacted mandatory reporting legislation.
The survey included a hypothetical clinical case in which a medical error occurred. The case had three possible patient outcomes: no harm, minor harm, and major harm. Survey respondents indicated how likely they would be to report the error for each of the three outcomes.
The investigators received 338 completed surveys from FPs, internists, and pediatricians, representing a 74% response rate.
The authors said that 84.3% of respondents agreed that error reporting improves the quality of patient care. Additionally, 73% said they would likely report a minor error, and 92% said they would report a major error.
Multivariate analyses of responses to the clinical case showed that willingness to report medical errors was associated with the belief that reporting improves quality of care, knowing how to report errors, believing in forgiveness, and being a faculty (versus resident) physician.
Without institutional efforts that encourage and facilitate reporting of medical errors, "the effect of federally protected patient safety reporting systems is likely to be reduced and the reporting bias inherent in these systems will be unlikely to diminish," the authors concluded.
The authors noted several limitations of the study, including the possibility of social desirability bias, the fact that answers to hypothetical scenarios may not predict actual behavior, and data were collected in 2004 and 2005 and may not reflect more current attitudes or practices.
The study was supported by the Robert Wood Johnson Foundation.
The authors reported no potential conflicts of interest.
Primary source: Archives of Internal MedicineSource reference:Kaldjian LC, et al "Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals" Arch Intern Med 2008; 168: 40-46.
By Charles Bankhead
IOWA CITY, Iowa, Jan. 15 -- Most physicians support the concept of reporting medical errors, but few have actually reported one, investigators here have found.Three-fourths of physicians surveyed said they would report an error that caused minor harm to a patient and more than 90% would report an error causing major harm, Lauris C. Kaldjian, M.D., Ph.D., of the University of Iowa, and colleagues reported Jan. 14 in the Archives of Internal Medicine.However, only 17.8% of the physician respondents had actually reported a minor error, and only 3.8% had ever reported a major error.
In addition to the low rates of actual reporting of medical errors, the survey results showed that 16.9% of respondents conceded they had kept mum on a minor error they had committed or witnessed, and 3.8% had done the same on a major error they had committed or witnessed.
The survey responses also reflected widespread lack of understanding about the reporting of medical errors. More than half of the respondents (54.8%) did not know how to report errors, and only 39.5% knew what types of errors should be reported.
"The results of this study suggest that physicians' attitudes about the value of error reporting may not be matched by actual behavior," the authors concluded. "If correct, the potential causes of this discrepancy ought to be addressed."
Considering all acknowledged errors, both reported and unreported, leads to the conclusion that only 36% of the respondents acknowledged ever making a minor or major error, Dr. Kaldjian said in an interview. "We know that's probably not the whole story. There's a certain amount of underreporting."
Health care institutions need to establish an environment that emphasizes the educational aspects of error reporting and ensures confidentiality, the authors added.
The authors surveyed faculty members and residents at three medical centers in the midwest, mid-Atlantic region, and northeast. At the time of the survey, two of the three states included in the study had enacted mandatory reporting legislation.
The survey included a hypothetical clinical case in which a medical error occurred. The case had three possible patient outcomes: no harm, minor harm, and major harm. Survey respondents indicated how likely they would be to report the error for each of the three outcomes.
The investigators received 338 completed surveys from FPs, internists, and pediatricians, representing a 74% response rate.
The authors said that 84.3% of respondents agreed that error reporting improves the quality of patient care. Additionally, 73% said they would likely report a minor error, and 92% said they would report a major error.
Multivariate analyses of responses to the clinical case showed that willingness to report medical errors was associated with the belief that reporting improves quality of care, knowing how to report errors, believing in forgiveness, and being a faculty (versus resident) physician.
Without institutional efforts that encourage and facilitate reporting of medical errors, "the effect of federally protected patient safety reporting systems is likely to be reduced and the reporting bias inherent in these systems will be unlikely to diminish," the authors concluded.
The authors noted several limitations of the study, including the possibility of social desirability bias, the fact that answers to hypothetical scenarios may not predict actual behavior, and data were collected in 2004 and 2005 and may not reflect more current attitudes or practices.
The study was supported by the Robert Wood Johnson Foundation.
The authors reported no potential conflicts of interest.
Primary source: Archives of Internal MedicineSource reference:Kaldjian LC, et al "Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals" Arch Intern Med 2008; 168: 40-46.
Sunday, September 23, 2007
My Turn: Good Doctors Spot Mistakes, Save Lives
The reasons for medical error are varied and complex. But that doesn't make them acceptable.
By Richard C. Karl, M.D.
Newsweek
Sept. 24, 2007 issue - Where the devil is that thing?" I hear myself saying. It is almost noon, and I'm finishing a surgical procedure to remove a cancer of the esophagus from a 54-year-old man. I've already brought his stomach up into his chest to replace the esophagus. He should be able to eat normally within a week. Only our "sponge count" is incorrect, and I can't close the chest until we find the six-by-six-inch piece of cloth we call a "lap pad."
The nurses have turned the operating room upside down. They've emptied all the "biological" waste baskets, searched the floor, rustled all the sterile drapes and recounted the used lap pads.
Additional help has been summoned to the room while I am looking in the chest for the missing pad and seeing only the patient's steadily beating heart.
Everybody in the room knows that prolonging the operation has a deleterious effect on the man who has entrusted us with his care.
Body fluids evaporate from open cavities, and the patient's core temperature falls because of evaporation and the cool room temperature. Yet we can't close until we find the damn thing.
How can anybody lose a sponge the size of a dinner napkin inside a human being? It is easier than you might think. In fact, medical harm is more common than those of us who celebrate the "most advanced health-care system in the world" would like to admit.
In 2000, the Institute of Medicine published a book called "To Err Is Human," which claimed that as many as 100,000 patients are killed each year by medical error. A death from error is one thing; leaving a sponge behind is a less fatal but still stunning mistake.
The Institute for Health Care Improvement calculated last year that the medical profession inflicts 15 million "incidents of harm" (like a retained sponge) per year in this country.
The reasons for these almost unbelievable figures are multiple and interrelated. Medicine today is complex. Because medicine is a "profession" and many years of training are required to practice it, it is assumed that doctors have the patients' best interests at heart. But without any central database for our care, a patient I plan to operate on next week may be, right now, in a doctor's office getting a prescription for a drug that will make the proposed operation more dangerous. Unless I ask, I'll never know.
In addition, there are many more drugs, procedures and techniques today than when I graduated from medical school in 1970, yet we haven't learned how to keep up with it all. Information travels remarkably slowly in medicine.
Then there is the culture of the medical profession. Uncooperative behavior by physicians has been tolerated by frustrated nurses and hospital administrators whose bonuses are tied to the hospital revenue generated by these doctors. Intimidating behavior has long been a facet of surgical training. I learned from the best: surgeons who would slap residents during a case, intimidate nurses or throw instruments. Most didn't, but some did.
Recently a cardiac-catheterization-lab nurse told me she'd tried to get a cardiologist to use the right "guide wire" for an arterial catheter. He ignored her hint and perforated the patient's aorta, then told the family that the accident and subsequent emergency surgery were the nurse's fault. "Do you think I'll ever try to help him again?" she asked.
Most everybody I know in medicine is bright, hardworking and altruistic. Many, though, have been beaten down by hundreds of urgent pages, middle-of-the-night phone calls, decreasing reimbursement, more paperwork and less grateful patients. These doctors have become less careful, and their patients suffer as a result.
It is time for my colleagues and me to reclaim our profession. It is time for doctors and nurses to work together, time for electronic records to actually work in providing the right information to the right person, time for pharmacists and nurses and social workers and doctors to see patients together.
You'll notice I didn't say it is time to pay doctors more money. If we can see and help our patients in a more efficient and supportive way, we'll have all the compensation we need.
It turns out that the sponge had accidentally been sent to the pathology lab. An alert nurse, a longtime colleague of mine, thought to call the lab. It all ended well. I hope my profession does, too.
Karl lives in Tampa, Fla.
The reasons for medical error are varied and complex. But that doesn't make them acceptable.
By Richard C. Karl, M.D.
Newsweek
Sept. 24, 2007 issue - Where the devil is that thing?" I hear myself saying. It is almost noon, and I'm finishing a surgical procedure to remove a cancer of the esophagus from a 54-year-old man. I've already brought his stomach up into his chest to replace the esophagus. He should be able to eat normally within a week. Only our "sponge count" is incorrect, and I can't close the chest until we find the six-by-six-inch piece of cloth we call a "lap pad."
The nurses have turned the operating room upside down. They've emptied all the "biological" waste baskets, searched the floor, rustled all the sterile drapes and recounted the used lap pads.
Additional help has been summoned to the room while I am looking in the chest for the missing pad and seeing only the patient's steadily beating heart.
Everybody in the room knows that prolonging the operation has a deleterious effect on the man who has entrusted us with his care.
Body fluids evaporate from open cavities, and the patient's core temperature falls because of evaporation and the cool room temperature. Yet we can't close until we find the damn thing.
How can anybody lose a sponge the size of a dinner napkin inside a human being? It is easier than you might think. In fact, medical harm is more common than those of us who celebrate the "most advanced health-care system in the world" would like to admit.
In 2000, the Institute of Medicine published a book called "To Err Is Human," which claimed that as many as 100,000 patients are killed each year by medical error. A death from error is one thing; leaving a sponge behind is a less fatal but still stunning mistake.
The Institute for Health Care Improvement calculated last year that the medical profession inflicts 15 million "incidents of harm" (like a retained sponge) per year in this country.
The reasons for these almost unbelievable figures are multiple and interrelated. Medicine today is complex. Because medicine is a "profession" and many years of training are required to practice it, it is assumed that doctors have the patients' best interests at heart. But without any central database for our care, a patient I plan to operate on next week may be, right now, in a doctor's office getting a prescription for a drug that will make the proposed operation more dangerous. Unless I ask, I'll never know.
In addition, there are many more drugs, procedures and techniques today than when I graduated from medical school in 1970, yet we haven't learned how to keep up with it all. Information travels remarkably slowly in medicine.
Then there is the culture of the medical profession. Uncooperative behavior by physicians has been tolerated by frustrated nurses and hospital administrators whose bonuses are tied to the hospital revenue generated by these doctors. Intimidating behavior has long been a facet of surgical training. I learned from the best: surgeons who would slap residents during a case, intimidate nurses or throw instruments. Most didn't, but some did.
Recently a cardiac-catheterization-lab nurse told me she'd tried to get a cardiologist to use the right "guide wire" for an arterial catheter. He ignored her hint and perforated the patient's aorta, then told the family that the accident and subsequent emergency surgery were the nurse's fault. "Do you think I'll ever try to help him again?" she asked.
Most everybody I know in medicine is bright, hardworking and altruistic. Many, though, have been beaten down by hundreds of urgent pages, middle-of-the-night phone calls, decreasing reimbursement, more paperwork and less grateful patients. These doctors have become less careful, and their patients suffer as a result.
It is time for my colleagues and me to reclaim our profession. It is time for doctors and nurses to work together, time for electronic records to actually work in providing the right information to the right person, time for pharmacists and nurses and social workers and doctors to see patients together.
You'll notice I didn't say it is time to pay doctors more money. If we can see and help our patients in a more efficient and supportive way, we'll have all the compensation we need.
It turns out that the sponge had accidentally been sent to the pathology lab. An alert nurse, a longtime colleague of mine, thought to call the lab. It all ended well. I hope my profession does, too.
Karl lives in Tampa, Fla.
Sunday, August 26, 2007
Diagnostic Errors
By Internists Often
Go Unrecognized
In one case that was included in the study of
diagnostic errors, an elderly man with endstage
chronic obstructive pulmonary disease
(COPD) was admitted to the emergency department
at 1:00 a.m. for midabdominal pain
and a hematocrit that had declined from a
baseline of 36% to 29%. The patient was on 60
mg prednisone for the COPD.
Although he was delirious from pain, the
man related a history of a bleeding peptic ulcer
some months earlier with similar pain.
Upon examination he was confused, with mild
abdominal tenderness. His stool was negative
for occult blood, and a nasogastric tube could
not be passed.
“The clinicians who saw him in the emergency
room weren’t quite sure what was going
on, but their No. 1 impression was that the patient
had a recurrence of his peptic ulcer,” Dr.
Graber said.
When the patient was seen 6 hours later by
the ICU attending physician, there was no evidence
of melena or hematemesis, but the man
was now in shock. The attending physician
considered the possibility that the patient had
dissection of an aortic aneurysm. A 6-cm dissecting
aneurysm was confirmed by CT scan,
but the patient died in the radiology suite.
“An investigation found that the team had
not read through the patient’s old chart—nor
was it available—and had not contacted the patient’s
primary care physician,” Dr. Graber
said. “Either one of these sources would have
quickly told the story. The patient had a
known abdominal aneurysm.”
The data collection by the medical team
“was grossly incomplete,” he said. “The synthesis
of information was faulty. They had the
wrong context. They had never considered the
possibility of aneurysm. They were thinking
GI causes.”
As for the system errors in this case, “clearly
the lack of medical records was a problem,” Dr.
Graber said. “So was the culture of the organization.
How could someone in the emergency
department feel comfortable taking care of this
patient without seeing his old records or without
talking to his primary care provider?”
By Internists Often
Go Unrecognized
In one case that was included in the study of
diagnostic errors, an elderly man with endstage
chronic obstructive pulmonary disease
(COPD) was admitted to the emergency department
at 1:00 a.m. for midabdominal pain
and a hematocrit that had declined from a
baseline of 36% to 29%. The patient was on 60
mg prednisone for the COPD.
Although he was delirious from pain, the
man related a history of a bleeding peptic ulcer
some months earlier with similar pain.
Upon examination he was confused, with mild
abdominal tenderness. His stool was negative
for occult blood, and a nasogastric tube could
not be passed.
“The clinicians who saw him in the emergency
room weren’t quite sure what was going
on, but their No. 1 impression was that the patient
had a recurrence of his peptic ulcer,” Dr.
Graber said.
When the patient was seen 6 hours later by
the ICU attending physician, there was no evidence
of melena or hematemesis, but the man
was now in shock. The attending physician
considered the possibility that the patient had
dissection of an aortic aneurysm. A 6-cm dissecting
aneurysm was confirmed by CT scan,
but the patient died in the radiology suite.
“An investigation found that the team had
not read through the patient’s old chart—nor
was it available—and had not contacted the patient’s
primary care physician,” Dr. Graber
said. “Either one of these sources would have
quickly told the story. The patient had a
known abdominal aneurysm.”
The data collection by the medical team
“was grossly incomplete,” he said. “The synthesis
of information was faulty. They had the
wrong context. They had never considered the
possibility of aneurysm. They were thinking
GI causes.”
As for the system errors in this case, “clearly
the lack of medical records was a problem,” Dr.
Graber said. “So was the culture of the organization.
How could someone in the emergency
department feel comfortable taking care of this
patient without seeing his old records or without
talking to his primary care provider?”
Thursday, July 19, 2007
Survey finds many docs stress mistakes
By LINDSEY TANNER, AP Medical WriterWed Jul 18, 9:36 PM ET
Patients aren't the only ones harmed by medical errors, according to a survey released Wednesday that found many doctors who make mistakes — and even those who come close — suffer stress, sleep problems and loss of confidence.
Job stress related to medical errors potentially could make some doctors prone to depression, quitting or even making additional mistakes, underscoring the need for helping them cope, said Washington University psychologist Amy Waterman, the study's lead author.
Most doctors surveyed said they would have liked counseling or other help after making mistakes, but that hospitals and other health care organizations didn't offer much assistance.
The survey involved 3,171 doctors in St. Louis, Seattle and Canada who answered mailed or e-mailed questionnaires. Most — 2,909 of them — said they had been involved with a near miss, minor medical error or serious error, which includes mistakes causing permanent or potentially life-threatening harm.
The results appear in the August edition of The Joint Commission Journal on Quality and Patient Safety, published by an affiliate of The Joint Commission, a hospital regulatory group involved in nationwide efforts to reduce medical errors.
Many of those efforts stem from an influential 1999 report that estimated that at least 44,000 Americans die each year from medical mistakes.
While the survey's scope was limited, the results echo smaller studies and likely apply to doctors elsewhere, the authors and experts not involved in the research said.
Dr. Donald Berwick, a Harvard professor who runs the Institute for Healthcare Improvement, said even more doctors might be adversely affected in regions where reforms aimed at reducing medical errors haven't taken hold.
"Nobody thinks that this excuses or should minimize" the suffering of patients harmed by errors, but it's important to emphasize that doctors suffer, too, Berwick said.
Of surveyed doctors involved in errors, 61 percent said they felt increased anxiety about the potential for future mistakes, 44 percent said they became less confident in their job abilities, 42 percent experienced sleep problems and 42 percent had a loss in job satisfaction.
Only 10 percent said hospitals offered them adequate resources for dealing with mistake-related stress.
Doctors involved in serious errors were most likely to report increased job-related stress. Still, increased stress also was reported by one-third of those involved in near-misses.
Dr. David Jaimovich, chief medical officer for The Joint Commission affiliate in suburban Chicago, said he recalls feeling stressed after a colleague got a decimal point wrong and almost gave a young patient too much medicine. Jaimovich said he and a nurse noticed the error in time but that "the first thing you think of is, 'What if?'"
Another time, he had to treat a child who'd been sickened by an overdose resulting when a colleague calculated the dose based on kilograms rather than the child's weight in pounds.
The child recovered "but we still felt terrible," Jaimovich said. He was not involved in the survey.
Historically, physicians have been looked on as being almost "super human" and when they made mistakes, "they were supposed to bite their lip, suck it up and keep going," Jaimovich said.
That perception has eased, and hospitals are starting to offer services to help doctors cope, he said.
While hospitals are increasingly adopting a more open approach to acknowledging errors, many still fear lawsuits and won't let doctors even discuss their mistakes, let alone offer them help, Berwick said.
He said doctors need self-esteem and optimism to effectively treat patients, and that more openness and coping resources for doctors could lead to improvements that would reduce errors.
"Who wants a wounded healer?" Berwick said.
___
On the Net:
Joint Commission: http://www.jointcommission.org
By LINDSEY TANNER, AP Medical WriterWed Jul 18, 9:36 PM ET
Patients aren't the only ones harmed by medical errors, according to a survey released Wednesday that found many doctors who make mistakes — and even those who come close — suffer stress, sleep problems and loss of confidence.
Job stress related to medical errors potentially could make some doctors prone to depression, quitting or even making additional mistakes, underscoring the need for helping them cope, said Washington University psychologist Amy Waterman, the study's lead author.
Most doctors surveyed said they would have liked counseling or other help after making mistakes, but that hospitals and other health care organizations didn't offer much assistance.
The survey involved 3,171 doctors in St. Louis, Seattle and Canada who answered mailed or e-mailed questionnaires. Most — 2,909 of them — said they had been involved with a near miss, minor medical error or serious error, which includes mistakes causing permanent or potentially life-threatening harm.
The results appear in the August edition of The Joint Commission Journal on Quality and Patient Safety, published by an affiliate of The Joint Commission, a hospital regulatory group involved in nationwide efforts to reduce medical errors.
Many of those efforts stem from an influential 1999 report that estimated that at least 44,000 Americans die each year from medical mistakes.
While the survey's scope was limited, the results echo smaller studies and likely apply to doctors elsewhere, the authors and experts not involved in the research said.
Dr. Donald Berwick, a Harvard professor who runs the Institute for Healthcare Improvement, said even more doctors might be adversely affected in regions where reforms aimed at reducing medical errors haven't taken hold.
"Nobody thinks that this excuses or should minimize" the suffering of patients harmed by errors, but it's important to emphasize that doctors suffer, too, Berwick said.
Of surveyed doctors involved in errors, 61 percent said they felt increased anxiety about the potential for future mistakes, 44 percent said they became less confident in their job abilities, 42 percent experienced sleep problems and 42 percent had a loss in job satisfaction.
Only 10 percent said hospitals offered them adequate resources for dealing with mistake-related stress.
Doctors involved in serious errors were most likely to report increased job-related stress. Still, increased stress also was reported by one-third of those involved in near-misses.
Dr. David Jaimovich, chief medical officer for The Joint Commission affiliate in suburban Chicago, said he recalls feeling stressed after a colleague got a decimal point wrong and almost gave a young patient too much medicine. Jaimovich said he and a nurse noticed the error in time but that "the first thing you think of is, 'What if?'"
Another time, he had to treat a child who'd been sickened by an overdose resulting when a colleague calculated the dose based on kilograms rather than the child's weight in pounds.
The child recovered "but we still felt terrible," Jaimovich said. He was not involved in the survey.
Historically, physicians have been looked on as being almost "super human" and when they made mistakes, "they were supposed to bite their lip, suck it up and keep going," Jaimovich said.
That perception has eased, and hospitals are starting to offer services to help doctors cope, he said.
While hospitals are increasingly adopting a more open approach to acknowledging errors, many still fear lawsuits and won't let doctors even discuss their mistakes, let alone offer them help, Berwick said.
He said doctors need self-esteem and optimism to effectively treat patients, and that more openness and coping resources for doctors could lead to improvements that would reduce errors.
"Who wants a wounded healer?" Berwick said.
___
On the Net:
Joint Commission: http://www.jointcommission.org
Friday, June 29, 2007
Disclosure of Medical Errors to Patients Reviewed
A review in the current New England Journal of Medicine examines the current thinking on disclosure to patients of harmful medical errors.
After describing the evolution of "an environment ripe for change" on disclosure, the review:
-- describes the National Quality Forum's safe-practice guideline on disclosure as a "core component of high-quality health care";
-- discusses disclosure laws that have been proposed or enacted, as well as concerns about the ability of regulators to audit or enforce them; and
-- considers the status of current programs and likely future developments, including the likelihood that some organizations "will move the involved clinicians to the periphery and will rely on rapid-response teams to conduct disclosures."
It concludes that "within a decade, full and frank disclosure of these events to patients is likely to be the norm rather than the exception."
After describing the evolution of "an environment ripe for change" on disclosure, the review:
-- describes the National Quality Forum's safe-practice guideline on disclosure as a "core component of high-quality health care";
-- discusses disclosure laws that have been proposed or enacted, as well as concerns about the ability of regulators to audit or enforce them; and
-- considers the status of current programs and likely future developments, including the likelihood that some organizations "will move the involved clinicians to the periphery and will rely on rapid-response teams to conduct disclosures."
It concludes that "within a decade, full and frank disclosure of these events to patients is likely to be the norm rather than the exception."
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