“We Made a Mistake”

Consider a hypothetical conversation:

A surgeon was thinking to himself after he makes a mistake during surgery: “I shouldn’t have cut that artery. I knew I was off from this morning before I went into the operating room. Do I have to tell the family? She’s old. I can say that we did everything we could but we ran into unexpected complications. The daughter is not well educated. They will never know she was bleeding and that’s why we had to transfer her to ICU. If my colleagues find out I cut the artery, I’ll lose my reputation. They won’t think of me first when they are ready to refer a patient who needs surgery. They’ll think I am losing my touch. I will get sued. It will get into the newspapers. I will spend endless hours with lawyers. I will get reported to the National Practitioner Data Bank. No, I can’t tell. I can say she had a heart attack. Yes, that’s what I’ll do. The daughter will accept that maybe even thank me.”

Too often this hypothetical conversation has governed the responses of healthcare providers who make mistakes. In the above situation, the operating room staff did not come forward to tell the family what really happened. After the patient spent a month in the ICU before dying, the son, who is a doctor, reviewed the chart. Then the truth came out. Forcing health care providers, to tell the truth, is one of the goals of the new patient safety standards of the Joint Commission on Accreditation of Healthcare Organizations going into effect on July 1, 2001. They are designed to improve patient safety and reduce risk to patients. The standards mandate the creation of an environment that encourages recognition and acknowledgment of risks to patient safety and medical/health care errors. The standard that directly addresses disclosure of errors is as follows: “RI 1.2.2: Patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes.” As defined by the Joint Commission, the intent of this standard states: “The responsible licensed independent practitioner or his or her designee clearly explains the outcome of any treatments or procedures to the patient and, when appropriate, the family, whenever those outcomes differ significantly from the anticipated outcomes.” The implementation of this standard is causing widespread concern in the healthcare field. Although accreditation by the Joint Commission is voluntary for hospitals, reimbursement for the care of Medicare patients is often dependent on being accredited by this organization.

How often are we making mistakes in healthcare? We have some data, but the reality is that no one really knows with any degree of accuracy. In the Harvard Medical Practice Study, a random sample of 30,000 patients from a random sample of 51 hospitals in one state, New York, was selected for the study. Medical records were examined to detect evidence of adverse events. Based on that data, the researchers concluded that 1.3 million people in 1984 were injured each year from adverse events, approximately 120,000 died. The actual numbers of deaths projected by the Harvard Medical Practice Study are believed to be underestimated. The retrospective review of medical records in this study did not reveal all of the adverse events, as much relevant information is not contained in medical records. It did not include the records from physician offices, nursing homes, ambulatory surgery centers or any healthcare setting other than hospitals. The actual numbers of people dying each year may be 200,000 or more. The frequency of adverse events is believed to be higher now that it was in 1984 due to the increasing complexity of medicine, and care being delivered to sicker patients in today’s American hospitals.

Research has confirmed that many medication errors go undetected, including those that harm patients. Even when the errors are detected, they may not be reported. Studies have shown that only 5% of medication errors are reported. Healthcare organizations persist in disciplining nurses who report errors by disciplining, suspending or firing them or reporting the error to the licensing board. Relying on incident reports is the least reliable method of detecting errors. In several studies, the observation method yielded the highest error rate detection. In other words, if we watch the healthcare providers, we will see the mistakes.

What do our mistakes cost? The Harvard Medical Practice Study concluded that the cost of these 1984 adverse events was roughly $50 billion. At least two-thirds of these events were preventable. With inflation, using 1998 dollars, the cost of adverse events was about $100 billion. The costs of these errors include unnecessary healthcare expenditures, disability and lost productivity, which involve billions of dollars. Add to these the costs associated with litigating medical and nursing malpractice cases. Loss of Joint Commission accreditation status negatively impacts a hospital’s revenue and reputation. Consumers are increasingly investigating such issues before deciding where to have their care. Mistakes are costly, but the act of concealing mistakes is becoming even more costly.

Med League legal nurse consultant supplies expert witnesses who evaluate cases for defense and plaintiff attorneys. We also help attorneys by Screening cases for merit, analyzing medical records, locating expert witnesses, preparing demonstrative evidence including time lines, chronologies and medical illustrations.

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