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confessions about patient harm

A couple of days ago, Nancy Agee, president of Carilion Clinic's hospital division, distributed a sobering article from the Reader's Digest about the importance of patient safety It is moving, because it consists of a number of "confessions" of doctors, nurses, and pharmacists who inadvertently caused harm to patients, and have lived with the knowledge of this harm for the rest of their careers. Such experiences happen to EVERY HEALTH CARE PROVIDER at some time in their careers, and are responsible for unnecessary harm to patients and unnecessary cost to our health care system. The article has stirred me to confess an episode from very early in my career that has haunted me, too, and led to my dedication to patient safety.

When I was an intern (first year of training following graduation from medical school) I was assigned to care for a one month old with congenital heart disease, following surgery to repair a "hole" in his heart known as a ventricular septal defect (VSD). He had only moved out of the pediatric ICU the day before, and we were checking certain laboratory values on him frequently. On that particular morning, the patient's bedside nurse came to tell me that one value--potassium--had been called to the floor urgently because it was VERY HIGH. She asked me whether I wanted her to perform an electrocardiogram (EKG) to look for evidence of potassium's effect on the heart.  Most of the time, high potassium values are a result of the way the blood specimen is obtained from infants, and not representative of a true value. Since I had just examined the child, and he seemed to be doing fine, AND I was due in XRAY rounds at that moment, I simply asked the nurse to repeat the labwork, and told her I would check back in when I returned to the floor. I did not discuss this with any of my supervisors, since deep down in my heart, I did not believe the potassium could be that high.

Minutes after arriving in the basement for XRAY rounds with our professors, I heard an overhead announcement for a cardiac arrest on the 5th floor, the pediatric unit, and my heart sank. I ran up the stairs two at a time (I was nimble enough to do that when I was younger) and arrived nearly breathless to the treatment room, to find the nurses doing CPR, trying to revive my patient. I was in a panic, but somehow managed to order all the right medications and fluids, because I knew then that the cardiac arrest had been caused by a high potassium value, and the baby recovered and was moved to the ICU. He did fine and was able to go home a week later without any obvious long-term effects.

There were many problems with this scenario, not the least of which was that I, as a very junior doctor was making life-and-death decisions on my own, and also that in those days, nurses were taught that the doctor's word was law. No one questioned my decision to NOT do an EKG on the infant after the potassium value came back high, although they may have thought it. Had I ordered the EKG, I would have seen evidence of the impact of the high potassium on the heart, and could have intervened BEFORE the infant's heart stopped. The nurses told the family they were lucky that I had arrived so quickly in the room, and provided the correct resuscitation for this infant. I never told the family that my inexperience was what led to the cardiac arrest to begin with. There was very little transparency in medicine in those days.

Although this happened over thirty years ago, it might have happened yesterday. I remember so clearly feeling like I nearly destroyed a young life, and that of his parents. I dedicated myself, from that day onward, to ensuring that I always pay attention to the suggestions made by the other staff around me, and that I always tell families when something has happened that shouldn't have.

The nurses, physicians and other clinical staff at the Carilion Clinic Children's Hospital work together as a team to ensure that such events do not happen to OUR patients. Medical providers are not perfect, and honest mistakes still occur, as we know from the attention this topic continues to receive in the press. However, by paying attention to details, ensuring appropriate supervision of junior level physicians and other staff, and by encouraging EVERYONE to participate in making care safer and better, we are working every day to prevent harm.

I would like to hear from others about their experiences, and I would like to continue to explore in this blog, with your comments, the kinds of things we are doing currently, and can continue to do in the future to keep patients from harm. There are many topics we can explore that impact heavily on patient safety, such as TeamStepps, Patient and Family Centered Care, and our Pediatric Quality plan and Quality Council.

Please let me know which, if any, of these topics you would like to see addressed in subsequent posts.

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