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.

Recent Comments

I have read this article as well and it has received much deserved attention. This is an interesting issue for all of us in medicine and one which we historically have not openly discussed for obvious reasons. Even today these type of discussions can be distorted and taken out of context for the sake of sensational impact which does not advance the meaningful nature of discourse. This dialogue is very important for us all to continue to change the "culture" of transparency in medicine.

As a pediatric intensivist I have been involved in many scenarios over the years that have precipitated deep reflection of what my role was in a patient's outcome. I must say I can not recall a specific fatal mistake (maybe it's surpressed) that I personally made but certainly a collective failure of a team,process or system, etc. which is no better. Whenever there is an outcome that does not "feel right" or meet acceptable benchmark standards I have always personalized this so it does not feel any different to me, or for that matter, the patient. I think many physicians are the same along these lines. When the day comes that I am not effected or moved by outcomes of my patients then it's off to the restaurant business.

No healthcare provider wants to harm a patient!! What is important for me personally and us here at CCCH is to continue to develop a cultural environment immersed in transparency, mutual support and professional honesty. We have worked hard at CCCH to live a culture of safety and continuous quality improvement for our patients as Dr, Ackerman has stated.

This begins with the ability to openly admit mistakes amongst ourselves and the patient's families while building an infrastructure and system goals that support outstanding patient quality. Nothing else is acceptable.

Tom, in this month's issue of The Journal of Pediatrics, an article by Brilli and colleagues from the Nationwide Children's Hospital in Columbus, Ohio discusses the use of something they have entitled "the preventable harm index" to try to drive their health care system toward zero patients harmed. They believe that instead of reporting our events such as hospital acquired infections as a rate such as the number of ventilator associated pneumonias per 1000 ventilator days, we should actually be looking at the real number of patients who have developed a problem, to make it more real and palpable to their staff. The article can be found at the following link:

I find this interesting, because we have always been held to a standard of benchmarking--comparing ourselves to others--in how we know how well we are doing. However, Dr. Brilli and colleagues believe that by benchmarking, we may become complacent with a number--we can say we are better than average, so we are ok. In fact, he has a point. When is good, good-enough.

I would be interested to know what other people think about the use of such a measure as compared to the traditional measures we have used.

Wow. I could not agree more with Dr. Brilli's suggestion. I think benchmark's are a useful barometer of basic level of performance from a quality standpoint but certainly not comprehensive. I agree that we need higher impact measures to guide us in the complex medical environment of the 21st century. I have often thought in addition to a clearer measure of harm done to patients (harm index) we should have a culture index with an individual score given to each physician and nurse based on a history of performance, personality and communication skill evaluation. The more difficult personalities and poor communication skill increases risks to patients.
Thanks for the heads up on the article!

I am in the middle of my quarterly resident reviews with the Transitional Year residents. Patient safety is one of the most important items on their radar screen. I think the conversations opened up about "To Err is Human" by the IOM and the leadership by IHI and NICHQ in this arena have led to our ability to be open about patient safety and using incidents such as yours to teach important lessons. The good news is that a culture of patient safety is present with our training physicians.

I found it very interesting to read Dr. Ackerman's posting "Confessions About Patient Harm" and I've pondered its many implications. At the Jefferson College of Health Sciences (JCHS), we are always thinking about ways of improving how we teach and prepare our students for working inside the myriad of healthcare environments. Our recently launched Interprofessional Education Program involving JCHS, VTC-SOM and Carilion Clinic is designed to encourage students to have open lines of communication with all members of the healthcare team to minimize errors and improve the overall clinical quality of the patient experience. This article, along with many other topics I've been reading in these postings, helps clarify the need and validate that our efforts at the College are both timely and appropriate.

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About Dr. Ackerman

Alice Ackerman, MD, MBA, FAAP, FCCM is the Chair of the Department of Pediatrics at Carilion Clinic and Professor and Founding Chair of Pediatrics at the Virginia Tech Carilion School of Medicine. Dr. Ackerman is recognized nationally as an expert in pediatric critical care.

She has been at Carilion Clinic since June of 2007. Her primary goals are to enhance the health care of children in the Roanoke Valley and Southwest Virginia, and is actively working to do this both as physician in chief of the children's hospital, as well as through involvement with many state-wide initiatives.

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