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.

I believe the public at large has for decades laboured under the impression that here we enjoy the best medical care available (Untrue. By most measures both Germany and France do better).   Perhaps this is the reason that despite the real problems Americans have faced because of the increasing cost of health care the debate to day is chiefly focused on how to pay for it and how to maintain the choices we now have.

The cost of health care has increased because health care is a business and at some level those with the power to decide where the money flows have no more interest in the wellfare of patients than Ford motor company had in the safety of auto passengers when designing the Pinto (inexpensive part would have prevented death by fire but the Ford board decided that they would rather pay off victims and their families who filed claims than prevent the fires).

According to the Institute of Medicine, 100,000 deaths due to medical care are preventable.
Medicare has recently floated an interesting concept. They will not pay for the care resulting from preventable incidents.
We should be addressing the quality of care. The cost of care will then take care of itself.
Tue Aug 04 2009 13:02:30 GMT-0400 (Eastern Daylight Time) Comment to NPR http://bit.ly/sFhSs

Communication is essential between health care providers but sometimes communication fails because of the arrogance or carelessness of the persons involved in the needed medical communication.

Several years ago, a female client about to enjoy an important anniversary was admitted to a University affiliated hospital for the purpose of having a colostomy wound debrided (cleaned up).

This was to be a one-day inpatient hospital procedure and was associated with little to no risk. As a part of the procedure, however, a prophylactic antibiotic was to be administered.

Unfortunately in this particular case, when the antibiotic (Cefotin) was administered the patient suffered a sudden cardiac arrest. This cardiac arrest resulted from a rare but well-known allergic reaction to this antibiotic. The patient was successfully resuscitated.  No harm done.  A substitute antibiotic was employed uneventfully.  Because the patient suffered a cardiac arrest before her surgery could be performed,  the procedure was rescheduled to occur approximately thirty days later with the same surgeon who had earlier been involved.  The anesthesiologist, who had saved this patient’s life earlier,  recorded in the order sheet, in the progress notes and even in a typed signed note provided to the patient, notice of what had happened to her, “You are allergic to the drug Cefotan. Don’t allow this drug to be administered to you. You may die.” Who could have done more to protect the patient from a similar future occurrence?

The patient showed her surgeon the note her anesthesiologist had provided and,  rather than openly disagreeing with the note, he simply said he was aware of that.

Thirty days after the patient’s original cardiac arrest she was readmitted for a repeat of the same procedure that was originally planned. The patient had ugly premonitions about what might happen which she shared with the admitting nurse. The admitting nurse was sufficiently concerned that she assured the patient that an anesthesiologist would attend the patient before the patient went to the operating room to ease the patient’s mind. The anesthesiologist who came to the patient’s side assured the patient that everyone knew she was allergic to Cefotan.   She said reasuringly,”You will not receive Cefotan.”   Were she to receive Cefotan she might die.   The wristband the patient was wearing revealed the presence of this allergy as did numerous references in the hospital records that no one could possibly miss.   The anesthesiologist promised the patient, “You will not receive this drug.”

Notwithstanding all these assurances the patient went to the operating room for her one-day procedure and as the same anesthesiologist entered the room who had just offered such reassuring promises, this anesthesiologist observed the patient was about to receive a prophylactic antibiotic intravenously. The anesthesiologist promptly inquired as to the type of antibiotic and was told, “Well its  Cefotan.” The anesthesiologist replied, “But she is allergic to that.”

Amazingly, the surgeon present, who was the same surgeon present at the time of the original cardiac arrest, insisted that the patient get the prophylactic antibiotic and the anesthesiologist present and the nurse anesthetist present lacked the courage to refuse.  Instead the anesthesiologist said to the nurse anesthetist, Well, make sure you don’t give to much.”  The drug was administered.  The patient died.

These facts are taken from a real case. Agreements and legal restrictions prevent the identification of names and places or even institutions.

The case was concluded in such a way that all involved were aware of their involvement and what they did, how it contributed to the patient’s death and what should have been done otherwise.   It is not always possible to prevent malpractice before it occurs but it is certainly essential to see to it when it has occurred with unfortunate results that those involved are made aware of what they have done and with what consequence.   It is the least we can do to assure that it is less likely the catastrophe be repeated.

According to the American Association of Nurse Anesthetists1 mortality rates for conditions studied were from 0.11% to 1.2%. While these percentages may seem small when one considers the hundreds of thousands of surgical cases performed annually under anesthesia an ominous picture emerges. The average for all patients is 0.38%. This means that out of every 1000 cases, 38 patients die. The mortality rate adjusted by operation does reveal certain patterns. Mortality rates were lower, 10 times lower for mastectomies and hysterectomies than they were for cholecystectomies. In a more recent risk-adjusted study of 117,440 surgical cases in Pennsylvania, Silber, et al.2, observed an increase of 2.5 deaths per 1000 patients when an anesthesiologist was not involved in the case. This statistic is alarming in light of the Institute of Medicine’s Review which concluded: “Today anesthesia mortality rates are about one death per 200,000 to 300,000 anesthetics administered.”

Nevertheless the Institute of Medicine in a study more broadly considering anesthesia practices throughout the United States does not confirm a difference in overall anesthesia-related mortality based on whether an anesthesiologist or a nurse anesthetist was present.3 Though the above-cited materials focus on whether there is a different risk and whether an anesthesiologist or nurse anesthetist is present, what gives one greater pause and concern is the fact that the risk for anesthesia-associated deaths is so high. Even stranger is the ten-fold increase in anesthesia mortality when a cholecystectomy is done as opposed to a mastectomy or hysterectomy. All are major operations.
In any event, mortality from anesthesia should be so infrequent that its occurrence always justifies a proper investigation and explanation.

This law firm has investigated countless anesthesia-related cases and has therefore considerable experience in assisting survivors and family members as well as injured patients in learning whether a suspected anesthesia complication was unnecessary or not.

[1]April 2003; 71:109-106

[2]Silber, J.H., Kennedy, S.K., Even-Shoshan, O., et al., Anesthesiologist Direction in Patient Outcomes, Anesthesiology 2000:93:152-163.

[3]Institute of Medicine, To Err is Human Building a Safer Health System, Washington, D.C. National Academy Press, 1999:27