Imagine you’re in the hospital receiving treatment for an aneurysm, and the radiology team comes by to perform a routine procedure to ensure that your latest surgery was successful. Your family’s expectation is that the procedure you are having is routine and that you will be in the same condition after the procedure as you were before going to the radiology department. The radiology technician is tasked with obtaining the contrast dye needed for the procedure. In the procedure room, there are 3 identical containers all filled with colorless solutions. The technician knows that the contrast dye is colorless, so he draws up a syringe full of liquid from one of the containers to give to the radiologist to inject into you. Trusting the solution given to him, the radiologist administers the solution as usual. Soon after injection, your health rapidly deteriorates. It turns out that the colorless liquid given to you was not contrast dye… it was chlorhexidine, a toxic chemical used to disinfect the skin before surgery. The three containers with colorless liquids were not labeled, and they all had different solutions. The technician accidentally drew up the wrong liquid, as they all looked the same. It was a simple, yet fatal mistake.
While this story may appear to be hypothetical, it is unfortunately a true story from 2004 about a patient named Mary McClinton, who was receiving treatment for a brain aneurysm at the Virginia Mason Medical Center in Seattle, Washington. Worse, Mary McClinton is not alone. While the exact number of deaths attributed to medical errors is disputed, medical errors injure millions of Americans every year. I had the privilege of speaking with Dr. Ron Kuppersmith about how hospitals can rebuild trust after committing an unintentional medical error. Dr. Kuppersmith is a head and neck surgeon who has previously served as the President of the American Academy of Otolaryngology-Head and Neck Surgery. He is also a professor of surgery at the Texas A&M College of Medicine.
Medical errors are preventable adverse events, such as giving a patient the wrong medication, performing the wrong procedure, or providing an inaccurate diagnosis. These errors are devastating and, too often, deadly. However, Dr. Kuppersmith made clear that there is an important distinction between errors and complications. During any medical intervention, unexpected complications may occur that are not the fault of the physician or the patient. As Dr. Kuppersmith says, “Every patient’s anatomy and physiology is different, so while the steps of a procedure may be the same, no two surgeries are the exact same.” Dr. Kuppersmith added it is sometimes hard to determine whether an unexpected outcome was caused by an error, saying “Unless a hospital commits a sentinel event, which is a ‘never-ever event’ such as amputating the wrong leg, the complexity of a specific case may make it difficult to look at a sequence of events and determine if an error occurred that led to a negative consequence. Often times when looking at what happened in retrospect, the issues seem obvious. In real time and with limited information, the decision making can be much more complicated. For example, let’s say a patient has a life-threatening reaction to a medication that is prescribed, and the patient did not disclose to the treating team that they previously had a reaction to a related medication. Reviewing old medical records that were not available at the time of treatment reveal that the patient previously had been seen in the emergency room on several occasions for similar events. This was not disclosed by the patient as they were unaware of the type of medication that previously caused the problem, and they were not great at providing previous medical history. Additionally, the old medical records were not immediately available to the treating team because they were in a different computer system from a different hospital system. As seen in this case, cause and effect are often difficult to determine.”
Dr. Kuppersmith continued by saying that, on the front-end, patients may not fully understand all the risks of being treated in a hospital, saying “In our culture, surgery is often glorified on television…especially new technologies, cosmetic and elective surgery. But, everything we do is filled with risks. Physicians need to communicate with patients what they expect to happen while clearly acknowledging all the things that could happen, using language and explanations that patients can understand.”
And when an error does occur, what can the hospital do? First, Dr. Kuppersmith says, “you have to be transparent with the patient and the family.” Then, it’s important for physicians and hospitals to take steps to ensure that the error does not happen again. Dr. Kuppersmith says, “Physicians and hospitals have multiple mechanisms to review complications and errors that occurred over a period of time. This may occur through a peer review process or through departmental conferences to review morbidity and mortality events. There is a very long tradition in medicine of looking at errors and complications and learning from them.”
From a patient’s standpoint, these learnings and improvements may not be known, but that doesn’t have to be the case. While filing a malpractice lawsuit and/or hospital complaint are always available, hospitals can take the effort to ensure an affected patient’s story positively impacts others. Going back to the death of Mary McClinton, Virginia Mason took substantial measures to ensure that the situation never occurred again. The hospital profusely apologized and publicly took responsibility for their mistake. In addition to a legal settlement, the hospital “declared that, going forward, it would have a single goal: To ensure the safety of our patients through the elimination of avoidable death and injury.” As their Vice President of Quality and Compliance said after the incident, “if we cannot ensure safety of our patients, we shouldn’t be in business.” In Mary’s honor, Virginia Mason sets aside one day every year to reflect upon their safety improvements over the past year, and teams at the hospital annually compete for the Mary McClinton Patient Safety Award. Additionally, The Joint Commission, a nationally recognized hospital accreditation organization, began requiring hospitals to label all medications and medication containers. The steps taken at the hospital and national level made it clear to the McClinton family that Mary did not die in vain. In fact, her death has saved the lives of many others.
When errors occur, physicians and hospitals need to learn from the event and be willing to change policies and practices to ensure that the error does not occur again. Just as in Mary McClinton’s case, hospitals should tangibly show how a patient’s death was not taken lightly and show how the patient is leaving a legacy that will protect and save those who walk through the doors of the hospital in the future. Medical errors have affected the lives of far too many Americans, but if all hospitals choose to follow a strong mission of safety, regardless of costs, we can have trust in knowing that our healthcare won’t kill us.
Caring for Healthcare 