Saturday, February 21, 2009

Week Eight Online Challenge

"Nobody's Perfect!"

So goes the saying to console friends and colleagues when we fall short of goals or expectations. Personally, I have the feeling that in medicine, not being perfect isn't good enough. For this week's challenge, we're inviting you to do one of two things:
  1. Write an account of a mistake you made or observed in a clinical setting. You may simply describe the mistake or reflect upon it by listing implications, detailing feelings or citing the ethical principles at stake.
  2. Answer this question: What is different about mistakes made by health care providers that makes us uncomfortable to admit to them?
My contribution requires you to go to a different website. Last July, I made a mistake in the ED that was an amazing learning experience. Read it here then find your way back to post your own comment.


  1. " You can bet on my listening to every injection drug user’s heart from this point forward."

    I've always thought this was the real key.

    I have made a ton of mistakes in my life, and I learned once that I can train for 8 weeks on how to do something right... and maybe I will do it right when I have to.
    But I only have to screw it up one time, and I will remember it forever.

    If only I could learn that well without actually hurting people.

  2. "Thomas, you are and will be a fine doctor. In my 25 years as a practicing RN, I've learned that MDs with "heart" become doctors. Some... end up as extremely well educated plumbers." - Christi

    Marvelous - couldn't have said it better!

    I think that everyone has points of self reflection, and I would say I have had many... However, in my clinical experiences, I am lucky to be under the umbrella of others and reflection has come through my questions to them and not physically with the patient.

    The one time I know I made a mistake, things were flipped - I was the patient. Over a year ago I became very ill - stubborn minded I decided to just take rest and try to deal with it myself. Fluids & sleep for a cure! Over four days my respiratory rate climbed and although I knew I did not feel well, I refused to believe it was serious.
    When my son came home I barely made it down the stairs, he looked up at me and started balling, then asked me if I was going to die. Oh, the diagnostic skills of a four-year-old...

    After being driven to the ED, I was intubated soon after and had surgery two days later. Over ten months I had two hospital stays and four surgeries - The insight of my experiences coupled with my stubbornness, will forever imprint my practice.

  3. I have two mistake experiences to share, one is mine, and one is a friend's story.

    I recently took care of an 80ish year old man who was sent up from the ER for sepsis. As soon as I saw him, I realized he was sicker than billed. I immediately intubatd his trachea and started him on pressors for severe sepsis. I then talked to his family and got consent to place a central line, in this case a subclavian due to his cervical contractures that would have made placing an internal jugular difficult. The line went easily and I placed it on the second pass of the first stick despite his low blood pressure. I got everything cleaned up, ordered a chest X-ray and then went to go do some consults on the floor instead of waiting for the X-ray to be done. 30 minutes later a Code was called to the patients room and he was in PEA arrest. CPR was started and I found that he had absent breath sounds on the side where I had placed his line and tracheal deviation away from that side as well, all arguing for a tension pneumothorax. I decompressed his chest with a needle, but did not have return of spontaneous circulation. I then started to place a chest tube, when his family asked that we stop CPR.

    In retrospect, he likely would have died: he was over 80, was in shock with multi-system organ failure (kidneys, heart, lungs, skin, brain, heme) with an expected mortality rate over 80%, however, I felt that I hastened his death, and not in a comfortable way. What contributed to this? I am experience at central lines, and felt that this one went easily, which made me more comfortable with the procedure and did not wait around for th X-ray before leaving the bedside. I was also very busy (14 ICU patients, 5 floor patients and 3 new consults to get done) which decreased my ability to wait patiently for the film. Would waiting have really made a difference? Not when you know that the film wasn't uploaded for my review until 5 minutes before the code. Not sure that I would have been able to get consent and set up that quickly.

    What about my friend? Well his is a story of being a patient.

    At the age of 32 he had the onset of chest pain and shortness of breath. He told me after the event, that it just wouldn't go away and was bothersome that he went to the ED at 3am. His baseline is a triathlete who finished Ironman Canada 3 months prior. His dyspnea was bothersome, but not noticable unless he tried to climb stairs. He was also worried because his baseline heart rate is 40 and his heart rate with this pain was 95 at rest. He apparently had an EKG and a Chest X-ray and was told everything was fine and to go home. To this day he, his wife, and his friend, all swear that NO ONE ever listened to his heart. The pain persisted so his wife took him to see his PMD the next day who noted a systolic murmur that had not been previously noticed, and then did a CXR. He was subsequently found to have a 7cm ascending thoracic aortic aneurysm with dissection into the root with wide open aortic insufficiency. He is doing well now after valve and aortic graft repair, but could have died had he not sought care that next day.

    What to learn from this? I was not the clinician, but I think it behooves us to not blow off young people with chest pain and symptoms of dyspnea even at 3 am. It also probably is reasonable to learn from a patient's reported baseline; something I used to blow off in my practice.

  4. What is different about mistakes made by health care providers that makes us uncomfortable to admit to them?

    I think there are a lot of things that make us uncomfortable to admit mistakes. One of the more obvious reasons is the fear of consequence or retribution, which can be substantial in the case of medical error, and even more so when we (as providers) feel that we may not really be at fault. We may not be forthcoming with our patients because we are afraid of getting sued, but is this fair to the patient? Does it encourage lying or deception on the part of the provider?

    That leads me into my second point, that there are two kinds of mistakes a provider can make: ones that hurt the patient, and ones that do not, either b/c they were caught in time or that they were just not that substantial. Two different outcomes, but the same response on the part of the provider: fear (of hurting the patient, of being sued, etc) and uncertainty (about what to do next). Unfortunately, there are no clear guidelines for what we should do when we make a mistake.

  5. The hardest parts of my journey as a healer have been the mistakes I have made. There is a story that is told that at the bed of each patient, death either stands at the foot of the bed, and the person will live, or at the head of the bed, and the person will die. And we can't know where death stands. The fatalism in that could be reassuring, yet I know that I do everything I can to, well, tell death where to stand. Making peace with our imperfections as human beings, and yet never letting ourselves off the hook, is the hardest knife-edge we travel, I think.

    The difficulty in disclosing our errors is in part about the extent to which we have made peace with this truth. It is alot more, too, and Thomas' excellent essay outlined one other important part: training and practice in this area of communication, just as in other kinds of communications (ie delivering bad news) can make a difference in knowing whether to say anything, what to say, and how to say it.

  6. Gosh, I just remembered the greatest story.

    Once, I was driving an ACLS unit, and my nurse was running the show. Anyway, we were delivering a rather sick person to a busy local ER which shall remain unnamed. I don't know the pharmacological details, but my nurse had run two fluids together that shouldn't have been. I guess they precipitate or something.

    ANYWAY.. when we got into the ER, and everyone gathered round, a temperamental charge nurse who ALSO will remain nameless grabbed that IV, he yelled "who the hell hung these together?" and threw it on the ground, then KICKED it under the bed. Yelling and cursing us the entire time. All in front of half a dozen staff, 4 students and everyone else.

    It was basically the wildest reaction I have ever seen.. . and obviously, we were humiliated.
    Our reaction? Shame. Prolonged humiliation at the hands of our cohort. Luckily, no adverse outcomes for the patient came of it.

  7. I do not have a personal story to contribute, even as a patient. I must admit that I'm pretty happy about that since I've had a fair amount of medicine practiced on my behalf!

    For me, it is obvious why the mistakes made in the ER, in any medical forum really, are worse than the mistakes the rest of us make. Medical mistakes have the potential to significantly impact a person's health and even hasten her death. Not many professions carry this responsibility, especially on a daily, even hourly basis.

    In reading the previous posts, it is clear that the "mistakes" the contributers remember became great teachers. It is also clear that those who made the mistakes were horrified by them.

    In one of this week's readings, we were exposed to a doc who stopped caring about what happened to his patients as long as he could make more money. This seems like the exception to me, but I wonder if anyone has been confronted with this situation. So my question is: Have you ever been the colleague of the doctor described and what did you do about it? Was the article accurate on that account?

  8. health care providers also may be hesitant to disclose mistakes because they are afraid of losing the patient's trust. However, hiding the information may cause further distrust in the patient/physician relationship.

    In addition, some of the reasons for physicians mistakes are unique to the field. Such as, (as David stated) taking care of 22 patients at one time, or lapse in attention because they were on-call last night & haven't had any sleep.

  9. I honestly can't say I've been exposed to medical mistakes. The only thing that may pertain was really more of a relatively substantial lab error in characterizing the results of a patient's PAP smear. Unfortunately, they sent the results of another patient to the physician I was precepting last year. I interviewing the patient with the false positive PAP smear results. She just so happened to have severe anxiety disorder, was arguably a hypochondriac, and as a result of these tendencies has been shuffled through many physicians who have ignored or disregarded her often exhausting complaints.

  10. One mistake I made occurred on the first weekend shift I had in the Harborview ED. I was trying to make a good impression, of course, as I wanted to go into EM and wanted to look at least somewhat competent to my attendings. Anyhow, I can’t remember exactly what I did but I had several patients and had to order labs on two of them. I ended up switching the tags on the lab slips (or something to that effect) so that I ordered the wrong labs for both patients. The mistake was “harmless” except for the cost of running unnecessary lab tests and not getting the appropriate ones (I was able to call the lab and get the correct studies with the blood they already had). Despite it being seemingly innocuous, I remember it because I made this mistake without any real good reason. I wasn’t pressured for time. I wasn’t overloaded with patients. I wasn’t unfamiliar with the procedures. I simply put the wrong label on the lab slips.

  11. Medical mistakes unlike some others can carry with it a large price tag. at the store when the cashier forgets to give you your receipt or your 13 cents of change the harm done is minior. In the medical setting, errors can kill and because although unlikely this final consequence makes medical mistakes different than others. It is also important to note that our actions directly affect patients both good and bad.

    Taking this into account however, is that most medical mistakes are not harmful and are caught by others. This is why medicine is a team sport. The nature of our training is based on the help of others to aid us in helping the patient. Mistakes are bound to happen and the reponse becomes most important at that point.

  12. I don't have a whole lot of experience with medical mistakes (thankfully), but there was one experience that hit close to home. About a year ago my grandfather became ill and landed in the ED due to a super low hematocrit. He was losing blood and they couldn't figure out where it was leaking from. While in the hospital he talked with a GI doc who suggested doing an endoscopy and colonoscopy to check things out. For some reason only the endoscopy was preformed, but not the colonoscopy (mistake 1). They found 3 ulcers in his stomach and figured that was where the bleeding was coming from so the GI doc gave him 2 PPI prescriptions. It was not explained to him to fill one or the other, and being elderly and on a fixed income he had to borrow $300 from family to get both of the PPI's filled (mistake 2). To make a long story short he continued to lose blood and after another bout with a super low crit and an expensive hospital stay they finally discovered he had colon cancer which was a major source of his blood loss all along.

  13. I too do not have a lot of experience with medical mistakes... But I think the fact that we are supposed to be experts in medicine and we are working on human beings, not repairing cars, or fixing computers, or constructing buildings. Therefore, patients expect the highest level of care because their health and personal well-being is at stake. The mistakes we make can be as little as a simple medication mishap that can be easily rectified or as serious as severe injury/death. We have the obligation to our patients and the larger medical community to serve people with the utmost care and concern.

  14. I used to work as a cardiovascular tech, conducting stress tests with a supervising RN and cardiologist. While performing a dobutamine stress test (phamacological stimulation of the heart with echo monitoring for indications of ischemia/infarction) , the nurse accidentally switched the lines between the dobutamine drip (which should not have been on yet) and the free-flowing saline before the test. A significant amount of dobutamine was accidentally administered to the patient without their knowledge, and without physicians orders.
    Generally, this much dobutamine won't cause problems beyond increasing heart rate and contraction force, but severe reactions can occur. Additionally, this impacted the results of the test be elevating the heart rate at which the baseline echo pictures were taken.
    I waited to see if the nurse would tell the cardiologist what had occurred. She didn't. As I was responsible for monitoring the ECG traces during the test, I could tell that nothing serious had occurred and that the test was safe to administer. I didn't say anything.

    Some reasons physicians don't like to admit mistakes:
    Loss of patient trust