Joe Kika writes at readersdigest.com a remarkable set of interviews of physicians and nurses confessing medical mistakes for the record which either could have or did lead to wrongful death. Among those interviewed was Peter Pronovost, a professor at John’s Hopkins University School of Medicine, who has received considerable notoriety as a patient safety advocate.
Pronovost and his work at Hopkins was the subject of one of my prior posts. In Pronovost’s interview he provides us considerable insight as to how his views concerning patient safety evolved. We learn for example, that his father died because of medical errors at age 50. Also, during his training in critical care medicine, he prematurely removed a breathing tube in a patient recovering from esophageal surgery performed earlier the same day. The patient arrested and though successfully resuscitated, remained unconscious for a time. Pronovost admits that his shame at having made a very serious error prevented him from candidly explaining to the patient’s wife the reason for the arrest.
The medical culture of Pronovost’s early years remains today as a true impediment to patient safety. The widespread refusals of physicians and other health care providers to admit their errors allows the errors to be repeated by others.
Ironically, today as I was writing this post, I visited Kevin MD.com and found a very interesting and compelling article authored by Brian Goldman (an emergency physician) addressing the issue of the culture of patient safety. Goldman agrees that medical errors must be confessed in order for change to occur. He appears to reject the view shared by many advocates of tort reform the Dr.’s will not confess except in secret.
Confession is good for the soul and indispensable if a culture of patient safety is to be established.
The mother heard speaking in the above ad was present when a teenage driver recklessly careened down a quiet street striking her young son. The teen pulled into the nearby driveway of his home not even having realized he had hit and dragged the child. Miraculously, the child had only suffered severe scrapes and bruises.
The child was promptly taken to an emergency department of a large teaching hospital where a thorough survey confirmed the child had suffered no head injury or internal injury and the family was relieved. During the course of the various studies that were performed an endotracheal tube was inserted through the child’s mouth and into his airway to assure control over the child’s breathing should an, as yet, undetected injury to the lung or the space surrounding the lung be present. Because the child naturally resisted having a tube in his throat and respirator breathing for him, the child was chemically paralyzed so that he could not interfere with the respirator breathing for him. Though by end of day the tests were all negative the tube and respirator were left in place.
The child was transferred out of the emergency department to a monitored unit with the plan being that the tube and ventilator be removed the next morning.
That night, while a physician was teaching a less experienced resident physician to perform a procedure on the child the tubing connecting the respirator to the endotracheal tube in the child was unintentionally bumped by the doctors and the endotracheal tube was displaced such that the respirator was no longer ventilating the child. This event went unrecognized because alarms on the ventilator designed to warn immediately and loudly of the occurrence of such an event had been turned off. The disconnect was not therefore discovered until the child was virtually in cardiac arrest. Though the child survived following resuscitation, brain injury which resulted from the tube displacement and ensuing respiratory failure left him initially comatose.
The child’s mom and dad though present in the hospital were not in their child’s room when this catastrophe occurred. When they saw their son the next day they weren’t alarmed that he wasn’t moving because they knew he was chemically paralyzed. Excuses were given for why the child wasn’t removed from the ventilator that day and required continuation of the paralytic drugs for another day or so. Then the paralytic drugs were removed and the child was successfully able to be removed from the ventilator and have his endotracheal tube removed and he breathed on his own. He did not however wake up until much later.
Doctors provided the family with no explanation for why their child who had been admitted for bumps and bruises was now in coma. The delayed resuscitation of their child and the physicians’ role in unintentionally displacing the endotracheal tube was not disclosed.
These unique circumstances led the parents to contact a lawyer. I had the privilege of being the lawyer who was contacted. My investigation revealed that the child had an unexplained need for a resuscitation because of an allegedly sudden drop of oxygen levels in his blood which coincidentally occurred at the same time that the child’s endotracheal tube suddenly became displaced for no particular reason. Being a former respiratory therapist who had worked with respirator-dependent patients for many years, I was well aware that, in this child who had no lung disease or lung injury, there would not have been any sudden drop in his oxygen level from a displacement of an endotracheal tube because such a displacement would be immediately recognized if the alarms were properly set.
Eventually, I was able to discover and establish that the airway accident was easily avoided and that improper monitoring had led to such a delay in the recognition that a tube displacement had occurred. The child was needlessly suffocated and anoxic brain damage had occurred.
Because of requirements of confidentiality imposed by a state agency on all medical malpractice cases, I am unable to report the means by which I was able to discover and prove the truth. Similar confidentially requirements also prevent me from reporting the method or means by which we were able to help this child and his family meet the many economic and other challenges they faced.
This story is just one of many such stories untold. Regrettably, because so many of these stories are untold, many victims of malpractice are unaware of what happens and where it happens and that it happens in every hospital.
When unexpected tragedies occur and doctors have inadequate or suspicious explanations, an experienced lawyer may be the only way victims can ever discover the truth. By then taking action victims are no longer powerless. Indeed, they help make the healthcare system better. After all, you cannot fix something you don’t think is broken.
