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Why inexperienced people make mistakes

Tuesday, January 26th, 2010

A group of residents eagerly perform complex surgery in the middle of the night while the attending surgeons who are supposed to supervise them are happily sleeping at home. Why is this very real scenario a bad idea? Why do interns, residents, nurses, and others make errors that injure patients? The answer lies in learning theory.

The Dreyfus Model of Skill Acquisition used by Pat Benner, a nursing theorist, breaks knowledge into two components: “techne” and “phronesis”. Techne knowledge is book knowledge: the information that is captured from procedural or scientific knowledge. The student must be given safe and clear directions on how to proceed, as there is no previous experience on which to draw. For example, a student nurse I supervised discovered her patient was short of breath. She attributed the symptom to anxiety, talked to the patient about her concerns, and held her hand. A more experienced person would have applied oxygen.

The second kind of knowledge is phronesis, which is acquired through learning in the practice setting. A nurse who makes a series of rapid decisions during an emergency draws on phronesis. The rapid response team members in hospitals are made up of experts who use this kind of knowledge.

The evolution of the expert practitioner passes through stages

Benner’s model of expertise, which is based on the Dreyfus model, describes how an individual may pass through five stages in developing expertise. Not everyone reaches the proficient or expert stage.

The novice rigidly adheres to rules or plans, has little situational perception and can’t make judgments. This individual is learning skills in clinical settings and must be closely supervised when delivering patient care.

The advanced beginner is a new graduate. The person functions with limited situational perception (the ability to put clues together to make decisions) and has difficulty discriminating between what is important.

The competent practitioner can see his or her actions within a broader context, and is capable of making sounder judgments. Conscious deliberate planning takes place along with standardized and routine procedures.

The proficient individual sees the situation holistically rather than in terms of its component parts. This individual more readily makes decisions, perceives differences from the normal pattern of a patient, and functions better with ambiguity. The proficient person has learned from experience and has an easier time making decisions.

The expert practitioner no longer relies on rules, guidelines or maxims, and intuitively grasps what is important in a situation. A registered nurse with expert knowledge may well exceed the knowledge of inexperienced physicians and may save a patient’s life by insisting on evaluation, diagnostic testing, change in medication, or another needed course.

A clinically experienced person enters a new healthcare setting as a new employee without knowledge of the politics, procedures, and policies. It takes time to learn “how we do it here.”

And thus we face the dilemma in health care: an inexperienced person will not learn without the opportunity to do so. He or she has to start somewhere. Yet, we don’t want that person to learn on us, our mother or father or child. When my husband had a triple bypass three months ago, the cardiac surgeon at Johns Hopkins proactively told us that he performed surgery. He said he had people in the operating room helping him, but he did the surgery. We were relieved to hear that.

A fair number of medical or nursing malpractice cases that come into Med League involve errors made by inexperienced people, whether they are new employees or new healthcare practitioners. Here are my suggestions:

Attorneys handling medical or nursing malpractice cases should be careful to determine the level of experience of the defendant. Determine the degree of supervision that should have been provided versus what was actually provided.
Ask about the orientation program the new employee should have received. Determine how much orientation staff agency employees received.
Ask the defendant if he or she sought help. Some of us, whether because of age, culture, or personality, would rather try to solve problems without help. This can be a recipe for disaster.
If you or a loved one needs care, seek the most experienced practitioner or hospital you can find.
If you or a loved one detects the person assigned to your care seems unfamiliar with your needs or medical equipment, insist that individual seek help from a more experienced person. Be an advocate for safety.
If you or a loved one needs surgery in a teaching hospital, insist that the attending physician be present. You may even cross off the consent form that allows residents and interns to perform parts of the surgery.

What do you think? How should inexperienced people learn? Send us a comment.

Parts of this blog post came from Moniaree Parker Jones, “Nursing Expertise: A Look at Theory and the LNCC certification Exam”, Journal of Legal Nurse Consulting, Spring 2007. Other parts came from the School of Hard Knocks.

What are these?

Tags: making mistakes, medical errors, Medical malpractice, personal effectiveness
Posted in Healthcare Risk Management, Legal nurse consulting, Medical malpractice, Nursing malpractice, Patient safety, medical errors | No Comments »

Why risk tampering with medical records? By Pat Iyer

Wednesday, November 4th, 2009

Altering medical records has huge consequences

A physician gets a notice that he is being sued. He gives into the temptation to review his office records. He decides to change an entry to 1. More completely describe events 2. Make it look as if he did something that he did not. But it is way too late. The plaintiff attorney and her legal nurse consultant already have the record and spot the change when they receive a second set of medical records. A charge of spoliation of evidence is added to the suit.

What is the impact on the person who tampers with medical records?

1. Insurance coverage
A medical malpractice claim that includes an allegation of alteration of records may not be covered by a commercial professional or individual’s liability policy. The insurer may reserve its rights to not pay any judgment that might be entered against the provider. Institutional providers participating in self-insured trusts may have similar coverage limitations. Some states recognize a separate cause of action for alteration of medical records, whereas other states deal with it as a jury charge. If the provider admits that he or she has made the alteration, the policy may be completely voided, including coverage for the medical negligence, depending on the state law. An individual who has his or her own insurance policy may find the carrier refusing to renew the policy the following year after the insured was found to have altered records or on whose behalf a settlement was paid in a case involving alleged alterations.

2. Regulatory agencies and privileges
Some state regulatory or licensing boards may investigate the healthcare provider. Disciplinary action may follow. The healthcare system that has provided privileges to the healthcare provider may be reluctant to allow that individual to continue on the staff. Those who falsify medical records risk more than just the loss of a malpractice case. Medical boards have been known to suspend or revoke the licenses of healthcare professionals caught tampering with records. In January 2009, a physician in London lost his license to practice for a year after a disciplinary inquiry showed that he engaged in a sexual relationship with a patient, tampered with and or improperly caused inaccurate changes to be made in her records, and failed to keep accurate records. He also failed to record details of her visits, medical condition, and results of medical examinations, and failed to maintain patient confidentiality by improperly disclosing to his lover confidential information related to the care of two patients.

3. Shame and embarrassment
Loss of reputation, shame, guilt, and being exposed as a wrong doer can all have a profound impact on the individual who altered medical records. A British physician hid her error for 16 years before confessing. When she was 26-years-old and working as a junior physician, she made a medication error that resulted in the patient’s death within an hour. She changed her chart entry to make it appear she had prescribed a smaller dose of the medication than had been ordered. She was questioned by police and later gave evidence at an inquest but did not tell anyone what she had done. In 2001, she could not live with her guilt any longer and wrote a letter to the patient’s family confessing her mistake. After an investigation and a formal written warning, the General Medical Council decided to allow her to continue practicing.

4. Criminal/civil offenses
In many states, falsification of medical records is also a criminal offense punishable by fines and incarceration, see e.g., California Penal Code §471.5. The Healthcare Insurance Portability and Accountability Act was used to put a Pennsylvania nurse in prison who altered nursing home records.

Most healthcare providers who tamper with medical records have a mistaken belief that their actions cannot be detected. The guilt or fear of being found negligent swamps their good judgment.

Med League assists attorneys who suspect tampering with medical records by performing chronologies and timelines that identify discrepancies. Please note that our ethical codes prohibit us from working with people who have not yet retained an attorney.

What are these?

Tags: altered medical records, Medical malpractice, spoliation of evidence, tampering with medical records
Posted in Healthcare Risk Management, Legal nurse consulting, Medical malpractice, Medical records | No Comments »

Hospital Professional Liability Claims on the Rise by Pat Iyer

Monday, November 2nd, 2009

A retained clamp is a never event

This is from Business Insurance, October 20, 2009.

According to the 10th annual Hospital Professional Liability and Physician Liability Benchmark Analysis, the number of hospital professional liability claims is increasing and is expected to increase by 1% per year. The study, released by Aon Corp. and the American Society for Healthcare Risk Management, both based in Chicago, polled more than 1,500 facilities to examine trends in claims and loss costs related to hospital and physician professional liability. The study attributes the rise in claims to the economic downturn, less public sympathy toward health care providers, and a 2008 rule that prevents the Baltimore-based Centers for Medicare and Medicaid Services from reimbursing hospitals for certain errors known as “never events” because they are considered preventable and should never happen.

“Worsening economic conditions in 2008 may have influenced individuals to assert claims against hospital systems,” Erik Johnson, health care practice leader for Aon’s Actuarial and Analytics Practice and author of the analysis, said in a statement. The frequency of hospital liability claims had been decreasing for about a decade before this year, the study said. Claims severity, which includes indemnity and defense costs, is now projected to increase 4% per year. Hospital loss costs per occupied bed, which is a major part of the total cost of risk, is anticipated to rise 5% in 2010, according to the study.

One-quarter of all claims and about 24% of hospitals’ professional liability costs are connected to hospital-acquired conditions such as infections, medication errors, objects left in the body after surgery and pressure ulcers, the study said. The market for health care industry professional liability coverage likely will remain stable for the rest of the year, but pricing is expected to increase in 2010, Aon said.

Pat says:
The AON study points out that ¼ of claims are related to “never events”. The never events defined by CMS are deemed outcomes that should not occur. The unwillingness of public and private payors to pay for what is defined as bad care leading to a bad outcome puts financial teeth behind efforts to improve patient safety and care. The definition of these outcomes clarifies concepts of liability. It becomes easy for the medical malpractice attorney to argue that there was a deviation from the standard of care when such an outcome occurs. Who could argue that operating on the wrong limb is acceptable or that leaving a clamp behind is okay? The AON study is important in that it shows the shifting trends. Those in hospitals who are reluctant to implement change, or take a strong position with recalcitrant staff who don’t want to change, need to know that the financial consequences of unsafe patient care will continue. The AON study confirms what we see in the nursing and medical malpractice world-seriously injured people wanting answers to questions and for the system to change so that someone else is not hurt.

What are these?

Tags: AON study, hospital liability, medical negligence, never events, Nursing malpractice, retained instruments
Posted in CMS never events, Damages, Healthcare Risk Management, Medical malpractice, Nursing malpractice, Personal injury, medical errors | No Comments »

2010 National Patient Safety Goals by Pat Iyer

Wednesday, September 16th, 2009

MRSA skin infection

The Joint Commission has released the 2010 National Patient Safety Goals. The Joint Commission sets standards for, evaluates, and accredits more than 16,000 healthcare organizations and programs in the United States. These include hospitals and home health agencies as well as ambulatory care services, behavioral health programs, clinical laboratories, and long term care organizations. In addition, The Joint Commission provides certification of disease-specific care programs, primary stroke centers, and health care staffing services.

The 2010 effort has streamlined the goals, refined language, and emphasized the importance of the healthcare-associated infections goal. This goal was first released in 2009 and is to be fully implemented in 2010. There has been increased attention paid to the development of healthcare-associated infections due to multi-antibiotic resistant organisms. Some states collect information from hospitals and report on the incidence of such infections. Some plaintiff attorneys have filed suits related to hospital-acquired infections, under these theories of liability:

Transmission of infection to the patient
Delay in diagnosis of infection
Improper treatment of infection

The 2010 Goal applies to methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile (c-diff), Vancomycin-resistant enterococci, multidrug-resistant gram-negative bacteria, among others organisms. The goal focuses on:

Conduction of periodic risk assessments for multidrug-resistant organism acquisition and transmission
Provision of education for staff at the time of hire and annually thereafter
Education of patients and families who are infected or colonized with a multidrug –resistant organism about healthcare-associated infection strategies
Implementation of a surveillance program for multidrug-resistant organisms based on the risk assessment
Measurement and monitoring of prevention processes
Provision of multidrug-resistant organism process and outcome data to key stakeholders, including leaders, licensed independent practitioners, nursing staff and other clinicians
Implementation of policies and practices aimed at reducing the risk of transmitting multidrug-resistant organisms
When indicated by the risk assessment, implementation of a laboratory-based alert system that identifies new patients with multidrug-resistant organisms
When indicated by the risk assessment, implementation of an alert system that identifies readmitted or transferred patients who are known to be positive for multidrug-resistant organisms

What can you do to protect yourself and your loved ones in a healthcare environment? The single biggest action you can take is to insist that healthcare providers wash their hands before contact with the patient. This is not the time to be shy. Speak up. This is an issue foremost in my mind this week as my husband prepares to enter the hospital for a triple bypass. I’ll be washing my hands before touching him and trusting that the healthcare providers will do the same.

What are these?

Tags: hospital-acquired infection, MRSA, National Patient Safety Goals, nosocomical infections
Posted in Damages, Healthcare Risk Management, Joint Commission, Medical malpractice, Patient safety | No Comments »

How a medical malpractice suit can make a difference by Pat Iyer

Thursday, September 10th, 2009

The story of Josie King

Why do people file medical malpractice suits? One reason is to get answers about what happened to result in the injury. Another is to prevent the same thing from happening to another person. Although risk managers, practitioners, and administrators may make changes after a bad outcome has occurred, it is not often that the plaintiff gets the satisfaction of knowing that. It is even rarer the terms of a settlement to solidify a plan to share the details of a medical tragedy.

A recent Oregon case shows the power of sharing a lesson that will protect other patients. The plaintiff was an 8-month-old infant who entered a hospital for removal of a cyst that extended through his nose to his brain. The surgery was without complications. After surgery, the infant had fevers, pneumonia, and showed signs of a possible cerebral spinal fluid leak. The discharging physician was a first year resident; the attending neurosurgeon did not see the infant on the day he was discharged. Eight hours after discharge, the infant was taken to the emergency department of another hospital because he was vomiting and lethargic. The emergency department physician called the defendant hospital and was advised that the infant was probably having a medication reaction. The parents returned eleven hours later, when their child was profoundly ill. There was no clear evidence of a systemic infection and possible brain damage.

The infant was emergently transported back to the defendant hospital. He was diagnosed with meningitis, brain damage, and organ failure and suffered a stroke. He requires a ventilator twelve to twenty hours a day, is tube fed, and without effective use of his legs or left arm. He is profoundly developmentally delayed and does not talk. A $12.2 million settlement was reached. The hospital also committed to use the case as a teaching example for its residents for the next ten years and to provide certification of this to the plaintiff’s parents each year from the president of the university.

Source: Lewis Laska, “Infant discharged following brain surgery without being seen by anyone other than junior resident”, Medical Malpractice Verdicts, Settlements, and Experts, February 2009, page 19

The power of sharing the lessons learned from a tragedy of this nature is huge. Unfortunately, it is rare for plaintiffs to achieve this kind of gain. I can think of another case – one we handled at Med League-in which this occurred. I was involved in a Philadelphia case of a young man who developed leg pain and shortness of breath on the day of discharge. The nurse did not inform the physicians, and the man was discharged via telephone order. He collapsed at home and died from a pulmonary embolism. As part of the settlement, the hospital made a policy that a patient had to be seen in person on the day of discharge. They also agreed to use this case in teaching each group of interns and residents.

Anyone not familiar with the story of Josie King, an 18-month-old child who died as a result of medication error, should visit the Josie King Foundation . I heard Sorrel King, Josie’s mother, talk three years ago. Her story lingers. Sorrel took the settlement money provided by Johns Hopkins, the hospital where the incident occurred, and put it back into patient safety efforts. Her work has saved lives of people all over the world. A new book pictured above, has just been released, which describes her crusade.

The key to educate, change, and inspire healthcare professionals with lessons learned so that deaths and injuries make a difference in daily practice.

What are these?

Tags: Josie King, Medical malpractice, medication error, why people sue
Posted in Damages, Healthcare Risk Management, Medical malpractice, Medication errors, Nursing malpractice, Patient safety | No Comments »

How much error can we tolerate in health care? by Pat Iyer

Monday, August 31st, 2009

Swiss Cheese Model

The Joint Commission, one of the preeminent bodies that accredits a wide variety of healthcare organizations, is shining a spotlight on the critical role of leadership in reaching a zero-defect level of safety. Although other industries, such as aviation, manufacturing, and energy, have developed safety interventions needed to reach a zero-defect level, health care has not been as successful. We have an incredibly complex system with multiple opportunities for error. I envision patient safety as resting above a safety net. The holes in the safety net range from small to wide.

The Swiss Cheese Model is another way to view patient safety. In James Reason’s model, the holes line up in the system; a patient passes through and is injured. When a series of errors occur, if anyone along the chain of events had done something different, the patient would not have been injured. Those of us who work in the medical malpractice arena can think of cases where this unfortunate cascade of errors has occurred. For example, I worked on a nursing malpractice case involving a man who received the wrong type of blood. Another patient and he had the same name; a mix up of identity occurred. The admissions clerk, laboratory technician, unit secretary, hematologist and several registered nurses were part of the chain. The blood bag was not checked at the bedside with the patient’s identification band; he died as a result of receiving the incorrect blood type.

What does the concept of zero-defects mean in practical terms? I am reminded of the reaction I saw when a surgeon told a patient there was a 1 in 100 risk of a certain complication occurring in the operating room. The patient asked, “What number am I in your total of 100?” It is only human nature to want the other guy to be the one case while we cling to the 99.

Attention to the goal of zero-defects also reveals what risk managers and family members fear: some patient injuries are not reported, starting with the person directly involved in the incident and ranging through leadership. The Joint Commission acknowledged this reality: “Leaders must consistently make safety a top priority in their decision-making. Safety must be supported at all levels of the organization and by both administrative and clinical leaders. Unfortunately, patients and health care staff may perceive a considerable difference between what leaders say and what is actually occurring—for example, when leaders do not support the reporting or managing of errors for fear of litigation.” In reality, it it’s the hiding and cover-up that sends some patients to plaintiff attorneys so that they can get answers to the question of what went wrong.

I recall sitting in a hospital Pharmacy and Therapeutics Committee meeting some years ago while the director of nursing had to explain each of the 6 medication error incident reports that had occurred that month in a 600 bed hospital. The physician said, “I want there to be zero errors!” I pulled the vice president of nursing aside and said, “We’re not getting accurate reporting. Statistically, there should be a much larger number of incident reports.” She disagreed. However, the nursing department disciplined nurses who made errors. The policy was to terminate the nurse after three errors had occurred. Not surprisingly, nurses were reluctant to report errors, as they functioned within a culture of fear.

That culture of fear is being replaced by a culture that focuses on just handling of staff after an error occurs. The Joint Commission addressed this inherent conflict in the new Sentinel Event Alert: “Actions taken in response to adverse events can be administrative or disciplinary as well as safety-related. These actions must not only be fair, they must be perceived to be fair; otherwise, future reporting of events may be discouraged. Such an approach is consistent with a culture of safety and is symbolic of a ‘just’ culture. A just culture is not wholly blame-free. It is one that has a clear and transparent process for evaluating errors and separating egregious unsafe acts from the small errors that people make every day, because we are human. The large errors are considered for disciplinary action with a set of guidelines that are applied equitably and consistently across all groups within the organization. It is the small errors that should not be cause for blame or punishment but should rather be recognized as important sources of information about system vulnerabilities.”

Leaders have critical roles to play in supporting staff who report errors and in making the changes needed to plug holes. The Joint Commission’s Alert is a needed directive to add more light to a subject that can hide in the shadows of the corner.

What are these?

Tags: error reporting, just culture, Medical malpractice, Patient safety, The Joint Commission, zero defects
Posted in Healthcare Risk Management, Joint Commission, Medical malpractice, Nursing malpractice, medical errors | No Comments »

Medical-Legal Topics

Archive for the ‘Healthcare Risk Management’ Category

Why inexperienced people make mistakes

Why risk tampering with medical records? By Pat Iyer

Hospital Professional Liability Claims on the Rise by Pat Iyer

2010 National Patient Safety Goals by Pat Iyer

How a medical malpractice suit can make a difference by Pat Iyer

How much error can we tolerate in health care? by Pat Iyer

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