One of the first things I learned after being appointed president of Strong Memo
ID: 397797 • Letter: O
Question
One of the first things I learned after being appointed president of Strong Memorial Hospital in Rochester, NY, was to deal openly with patients and families (and the community) when we made mistakes. Here’s one example that has always stuck with me: A 6-year-old patient with a defect in bowel function was hospitalized for severe constipation. He was given a dose of neostigmine (a drug that helps muscles contract and relax to move food through the system) that was 10 times the normal amount because of a decimal point error made by the resident who ordered the drug. Instead of 0.4 mg, the patient received 4.0 mg. Tragically, the patient died the same day from the overdose. My human resources director advised me to immediately hold a press conference to announce our mistake. I did. The conference lasted for two hours and centered on reporter questions about why the resident and nurse had not been fired. I explained that both were highly regarded and that the problem was a “system” problem, not a problem of an incompetent physician or nurse. I explained that we should have a fail-safe system in place to prevent such a mistake. (Today, hospitals have electronic medication error avoidance systems. We didn’t have that in 1984.) I indicated to the reporters that we would be examining the medication administration procedures in place from the point the medicine is ordered to the time it was given, and would put in place a procedure or procedures to ensure that such an error would not happen again. This story contrasted sharply with an experience I had with a wealthy patient from Geneva, Switzerland, who came over to the states each year for a comprehensive examination. Before coming to Rochester after his overseas flight, his routine was to spend a few days in New York City and visit friends. On one such annual trip, he fell while walking along a street in New York, fracturing his pelvis. He was admitted to a well-known hospital and spent three weeks recovering in bed. After three weeks, I received a call from him asking to be transferred to Strong Memorial Hospital in Rochester. He was unhappy with his care, indicating that no one seemed to be attending to him. We arranged the transfer and, when I saw him that afternoon, I was astounded to find that he had a pressure ulcer on his heel that was an inch deep. The ulcer wouldn’t heal, so I secured a vascular surgeon to perform arterial bypass surgery. The surgery, which improved circulation in the patient’s leg, was successful and, after a period of weeks, the ulcer healed completely. I wrote a letter to the president of the New York hospital to discuss the patient’s care. Some weeks later, after not receiving a response, I called his office. I was transferred to the hospital lawyer. I indicated the reason for the call and asked why I had not received a response. He said, “Oh, we would never acknowledge a mistake. We might get sued.”
Discussion Questions
1. What is the difference between the two stories? Why do you think they were handled differently?
2. Pretend you were a reporter at the first press conference. What question would you ask the CEO? Why?
3. How would you respond to the lawyer in the second story?
4. Why is transparency important after a medical error?
5. Have you ever made or observed an error involving a patient? Was the patient harmed? How did you handle the error?
Explanation / Answer
Here, in the first story the error was made by the Strong Memorial Hospital itself. But in the second story a regular patient of this hospital who was admitted in some other hospital in New York because of some emergency made error. In the first story as a president of the Strong Memorial Hospital I handled the situation very well by openly communicating with the patients and families and also confessing our mistake through media as because of our system problem a patient died because of overdose of medicines. Our staff was very much caring for the patients. In the second story the error was made by the other hospital as their staff did not take proper care of the patient and is was not a system problem at all. So, here I wrote a letter to the president of the New York hospital to discuss the patient’s care. But they are not at all responsive for their mistakes, so I called the office and transferred to the hospital lawyer. If I were a reporter at the press conference in the first story, then I would ask the CEO that how could he be so much irresponsible regarding the overdose of medicines? Instead of 0.4 mg, the patient received 4.0 mg. I would ask him why the nurses had not been fired for their careless behaviour. And then the CEO said that it was a system problem then I would ask him that today, hospitals have electronic medication error avoidance systems. So, why don’t you have such a system in your hospital? I would be very angry with the CEO because of this silly mistake a patient died which is not a forgiving matter at all. In the second story as I transferred to the hospital lawyer for their reckless mistakes and told him about this, the lawyer said that they would never acknowledge a mistake and they might get sued. It means he is not agreeing that he made a mistake. So, I would go to their hospital and show him the report with proof that such a patient was admitted in your hospital and your staff did not take proper care of him as had a pressure ulcer on his heel that was an inch deep and we had to do surgery of his leg and heal it. If he was not transferred to my hospital it would have never be healed as your hospital did not care about the patient and he would be in big trouble. So, I would tell him to also hold a press conference and admit the mistake that they did and how we saved the patient. Transparency is very important for a hospital after a medical error to save the reputation afterwards otherwise there will be rumours regarding your hospital and no one will come to you for their illness. Timely medical error disclosure is essential to maintain a strong bond of trust between physicians and their patients. However, there is a wide gap between patients’ demands of transparency in disclosing all medical errors and attempts of healthcare providers to do so. A recent study revealed that in hypothetical situations, 90% of the healthcare providers stated that they would disclose medical errors; however, in real-life circumstances, only 41% actually reported doing so. Medical schools play central roles in cultivating the significance and developing the communication skills needed for proficient and effective medical error disclosure. Yes, I have observed an error involving a patient nearby my residence. It was a maternity hospital. They were not able to deliver the baby on the due date and the patient also died. They already knew that they can’t save the baby but they did not tell the patient as they needed only money from them and they did not care about the patient. If they would have said it earlier then the patient would have been transferred to some other hospital and the mother and child both could have been saved. So at that time, I disclosed all the matter with most of the people so that they be aware of that hospital and don’t go there at all. The hospital should understand that they have made a big mistake.
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