Your Patient Safety Survival Guide
Page 18
We must also consider whether the behavior in question deviated from the accepted performance standard for the person’s profession and/or employer. This requires that we ask a host of questions: Did the individuals involved in a patient safety event have (or should they have had) sufficient exposure to the ideal practice standard vis-à-vis their professional education, on-the-job training, or continuing education courses? Did the facility where the error occurred have (or should it have had) relevant policy or practice standards in place? Were there mitigating factors that prevented the individual from behaving in a manner that was consistent with the ideal standards and/or hospital policy? Or, more basic: Would most anyone have done the same thing under the same circumstances?
Returning to Kimberly Hiatt, here is what a retired physician wrote about the incident in The Seattle Times.
Managing Error in Medicine
One of the well-accepted principles of error management in medicine today is that mistakes are most commonly the result of system problems, not mere negligence on the part of the provider . . . If we fire everybody in medicine who makes an error, we will soon have no providers. We all make errors. It is only by the grace of God that most of them do not result in great harm or death. It is my belief that if the nurse had been dealt with appropriately—with compassion and insight—that she, today, would be a valuable and happy nurse. But she was fired. I, in no way, want to minimize the tragedy of the death of this infant, however, the death of Kimberly Hiatt is no less tragic.20
The physician’s public commentary nailed it. We all make errors. Our errors rarely result from the willful disregard for others. Factors beyond the control of providers often influence the emergence of error, and, when errors occur, providers are often in need of compassion—just like the event’s primary victims. If we continue to place healthcare providers on pedestals of infallibility, they are guaranteed to fall from grace and leave us feeling excessively disappointed.
The Lure of Hindsight
Not only do healthcare providers typically not receive compassion after being involved in a patient safety event, their employers, peers, and patients often avoid or reject them. While it may be reasonable to expect an overtly angry response from patients and families (especially after the immediate shock begins to wear off), colleagues and institutions can and must display greater equipoise and compassion. Even when a provider’s action (or lack of action) appears to be in the wrong, our initial impression of what went wrong is apt to fall prey to the subtle but insidious problem of hindsight bias.
Hindsight bias refers to the knew-it-all-along phenomenon in which an event seems obvious when looking back with more facts in hand, although somewhat unpredictable with what was known at the time of the incident. In their groundbreaking book Wall of Silence, Rosemary Gibson and Janardan Prasad Singh recounted a sad but true story of three nurses who were wrongfully convicted in the minds of others before considering all the relevant facts.
The Denver Case
In a Denver hospital, a newborn infant died as a result of a medication error. Three nurses who were taking care of the infant were indicted for criminally negligent homicide. Two of the nurses accepted a guilty plea, the terms of which included a two-year probationary period, because they didn’t want the third nurse, who had a negligible role in the error, to be found guilty by association. Experts on medical errors who were helping the nurse who stood trial conducted an in-depth analysis of the cause of the mistake and uncovered fifty separate failures in the hospital that contributed to the error. If any one of these failures had been detected, the infant would not have suffered harm. Some of the failures included a drug order—handwritten by a physician—that was unclear; a pharmacist who filled the order with a tenfold overdose; and the absence of a warning system to alert the pharmacist to the overdose.
After hearing the analysis, and after only forty-five minutes of deliberations, the jury found the nurse on trial not guilty. More than that, the jurors demonstrated their personal support for the nurse by tearfully hugging her after they rendered their verdict. They recognized that the nurse was not to blame, because she was working in an organization whose management did not put systems in place that could have prevented the chain of mistakes that led to the tragic error.21
Obviously healthcare is a dangerous, complex, and complicated industry, so it usually takes time to reconstruct a case in order to understand what happened from the point of view of those who were involved in it. A rush to judgment is likely to precipitate more unnecessary harm. Moreover, as explained by Malcolm Gladwell in Outliers, at least seven consecutive errors typically occur before culminating in a serious safety event.22
Accidents, Mistakes, and Failures
There are legitimate instances of negligence that warrant punishment. For example, I was recently involved with a case of psychiatrists who kept prescribing Adderall—a highly addictive stimulant drug—to an aspiring medical student who had clearly become addicted to the drug. As reported by The New York Times in a front-page story about Richard Fee, one of the psychiatrists even continued to prescribe Adderall after Richard had been hospitalized for his addiction to the drug and after his parents showed up to personally warn the psychiatrist that their son would die if he continued to receive Adderall prescriptions. Part of the problem was that the psychiatrist was prescribing the medication at a dose that was higher than the maximum recommended dosage.23 To make matters worse, Richard clearly never had the condition for which the drug was being prescribed—ADHD. There were so many egregious errors in Richard’s care, and failed opportunities to rely on established safeguards, that the Virginia Board of Medicine recognized the psychiatrist’s negligence and he was put out of practice.24 When it comes to patient safety events, such obvious and blatant negligence is the exception, not the rule. (Sadly, misdiagnosis and unwarranted medicalization of everyday life struggles continue to plague the mental health field.)
As Megan McArdle explains in The Up Side of Down, there are important distinctions between accidents, mistakes, and failures. Such distinctions can prove to be significant when considering culpability, compensation, and punishment. An accident involves a situation “that could not have been plausibly expected or planned for” with this hallmark sign:
While there may be lots of things you could have done differently, there is absolutely nothing you should have done differently. Aside from perfect foresight, there is no hard-won knowledge that you wish you could have applied, no error in judgment that can inform your decisions in the future.25
Sometimes accidents turn out all right, sometimes they don’t. As an example of an accident that didn’t end in disaster, McArdle describes a car crash that a friend experienced with a rental car. The car was rented from a reputable company, and there was no driver error involved in the accident. However, the steering system failed without warning, causing the vehicle to careen out of control and sending five cars flying across the highway. By an apparent miracle, McArdle’s friend was essentially unharmed.
Just like that car accident, genuine unforeseen complications can happen during the delivery of clinical care. For example, when a patient has a severe first-time allergic reaction to medication during a surgical procedure, things can spin out of control (much like the rental car). Provided that the appropriate recovery medications are on hand, things might turn out okay. However, if the patient’s medical status was compromised before surgery, the unforeseeable allergic reaction could precipitate complications from which the patient might not be able to recover. Yet even if the patient were to die, no error—just unpreventable complications—would have occurred.
A mistake is practically the opposite of an accident:
It’s where you could and maybe should have done something differently, but nothing really bad happens as a result. You spell embarrass wrong and the spell-checker corrects it before you’re finished typing. You enter the wrong number into the budget s
preadsheet, and then have to spend your lunch hour hunting down the discrepancy. You forget the grocery list and come home with wine instead of the milk your spouse wanted. Most mistakes are trivial. But even big mistakes usually turn out all right.26
A mistake is when a doctor or nurse forgets to wash their hands but no harm comes of it in that particular instance; it is when a nurse gives Tylenol to the wrong patient without realizing it and without causing harm to anybody; or when my physical therapist initially treated the wrong leg. In each case, there were things that could have and should have been done differently or done better to avoid the mistakes.
Think back to Josie’s story in chapter 5. The first time Josie needed naloxone as a rescue drug, one could argue that mistakes had been made—she was prescribed too much pain medication relative to her medical status, and she was not monitored closely enough. Even so, things turned out all right that first time. But when Josie was oversedated a second time, the story was altogether different. A series of errors snowballed (holes in the proverbial Swiss cheese lined up), and Josie was oversedated beyond the point of recovery. This was an instance of a failure—a catastrophic event that culminated from a series of mistakes. As McArdle describes it, a failure is “a mistake performing without a safety net.” Said another way, failure occurs when:
The fail-safes aren’t failing safely any more. Suddenly, something has gone terribly wrong, and worse, if someone had only done things differently—better—it could have been prevented.27
McArdle goes on to describe her mother’s hospital experience of having a ruptured appendix misdiagnosed. There were a number of small errors in judgment, “simple things, but each error made the other ones more dangerous, like sticks of kindling to a roaring fire.”28 Unfortunately, the person who commits that last in a series of errors, or the error that is most immediately evident, is often blamed for the whole cascading debacle. Upon further review, this person is typically found to be only partially to blame and sometimes to be entirely blame-free by virtue of having been set up for error by defects in broader system or workflow processes.
Sometimes a devastatingly poor outcome can occur in the hands of knowledgeable and caring providers because what transpires at the “sharp end of care” (at the bedside, so to speak) is affected by decisions that are made and policies that are developed at the “blunt end of care” (in the board room and executive offices). Exactly as the Swiss Cheese Model predicts, a wide range of blunt end (system) factors can determine the likelihood of a catastrophic failure. Notable among harm-inducing blunt end factors are inadequate staffing and training; unrealistic reliance on technology; and toxic working environments where people are threatened, bullied, or intimidated if they speak up about safety.
When researchers looked at nurse staffing levels and outcomes among surgical patients in two hospitals for an entire year, they discovered that every patient added to a nurse’s caseload resulted in a 7 percent increase in patient deaths during hospitalization. Each additional patient added another 7 percent increase in patient deaths within thirty days of being discharged from the hospital.29 Research has also documented a direct and sizable link between nurse-patient staffing ratios and medication errors.30 Likewise, the less favorable the patient-nursing ratio, the longer patients need to be hospitalized,31 which, in turn, increases the odds that they will suffer from healthcare-induced harm. Even the degree of disrespectful communication among staff members affects patient outcomes and survival rates.
Although system issues affect the frequency of human error and the likelihood of catastrophic failure, sadly, we tend to disregard or devalue these facts. Far too often, people respond by blaming and shaming the “last man standing.” The impulse to seek others to blame is not without cause. It wasn’t too many years ago when a hospital CEO told one of the authors of Wall of Silence that the way he tracked patient safety events was by nurse firings—every time a nurse was fired, he knew there had been an incident. In a few cases, public rallying cries have emerged in an effort to protect providers who have been judged too harshly.32 More typically, though, providers suffer in isolation, which undoubtedly contributes to many providers changing jobs or leaving the profession.33
Culture Trumps Policy
In addition to feeling guilty and ashamed about having one’s errors exposed, physicians worry considerably about being sued. It is difficult to gather comprehensive information about the number of malpractice claims filed each year because there is no universal tracking system. However, a large-scale study in the New England Journal of Medicine estimated that 75 percent of US physicians in low-risk specialties and 99 percent of them in high-risk specialties could expect to face a malpractice claim during the course of their careers. When surveyed, 5 percent of physicians indicated that they had faced a malpractice claim within the previous year.34 One objective source indicated that for each year between 1991 and 2005, over 7 percent of physicians had a malpractice claim filed against them with close to 20 percent resulting in a payment—a rate that is just slightly higher than the self-reported rate.35
For over one hundred years, the code of medical ethics has demanded that physicians self-report malpractice claims against them, but, on the whole, physicians have ignored this standard. Moreover, in most states, American physicians are not legally compelled to disclose malpractice to their patients. To address the gap between ethical and legal obligations, as of 2001 the Joint Commission began requiring that hospitals have policies that support the disclosure of adverse outcomes. Accordingly, full disclosure refers to:
Communication of a healthcare provider and a patient, family member, or the patient’s proxy that acknowledges the occurrence of an error, discusses what happened, and describes the link between the error and outcomes in a manner that is meaningful to the patient.36
Gradually, hospitals began writing policies to support the concept of full disclosure. Ironically, as the table below suggests, full-disclosure practices stand to benefit everyone, not just patients. The process breaks down the wall of silence and secrecy that interferes with opportunities for all parties to identify mistakes, fix causes of error, and heal. Nonetheless, the knee-jerk reaction of most physicians and hospitals continues to be to deny culpability.37
Table 7.1.
Responding to Medical Mistakes
Impact
Typical Reaction
Full Disclosure
Patients and Families
Blame the “last man standing”
Threaten legal action
Cut off contact with providers
Reduce anger, support the grieving process
Ask questions, expect answers
Participate in the investigation, if desired
Foster healing and opportunities for forgiveness
Providers
Feel guilty, lose confidence and joy
Deny error, blame others
Avoid patient and family
Seek emotional support
Communicate openly with patient
Apologize to patients, families, and coworkers
Recover sense of confidence and joy
Hospitals
Sweep errors under the rug
Limit contact with family
Avoid all liability
Apologize to patient and family
Investigate the event thoroughly
Invite patients to contribute to inquiry
; Accept responsibility, as appropriate
Deny culpability, as appropriate
Resolve legal issues in a timely fashion
Tend to emotional needs of staff
Find and fix causes of error
Share lessons learned
Create safer facilities and providers
Society
Undermines Progress and Healing
Safeguards People and Institutions
Some studies suggest that physicians disclose errors to patients only 25 percent to 30 percent of the times required by ethical standards and policy.38 More recent evidence from one of the largest US healthcare systems suggests that full disclosure may be practiced much less often—even if full-disclosure policies are well publicized.39 Most physicians and hospitals still do not disclose medical errors unless forced to do so,40 but even then they tend do so ineffectively.41 When confronted with hypothetical cases, physician responses included instances of partial disclosure that often made it difficult to connect provider error to the adverse outcome.42
Why, in spite of requirements that direct physicians to speak openly and plainly about medical errors, does full disclosure occur so infrequently? In addition to fears of litigation and reputation loss, physicians are subjected to a hidden curriculum that trains them to bury their mistakes. The hidden curriculum refers to: