Medical error spurs transparency

Posted June 28, 2010, at 6:16 p.m.

Two weeks ago a small hospital in Maine told a patient’s family and the world it had made a deadly error in that patient’s care. The real news in the story unfortunately was not that someone in a hospital gave a patient a fatal overdose of medicine; that happens with heartbreaking frequency. The real news was that this little hospital in Dover-Foxcroft told us all about the terrible mistake it had made.

As a result, many hospitals around the country immediately looked at whether the same mistake could have been made by their doctors and nurses, and they discovered the answer was “absolutely.” The smart ones immediately pulled bottles with large amounts of epinephrine off the shelves of patient care areas, making it more difficult for their staffs to draw up and give too large a dose.

But Mayo Regional Hospital’s decision to go hang its imperfection out there for us all to see did more than help protect the next patient who needs epinephrine in an ER somewhere. It helped set a new standard for hospital honesty and transparency about errors in patient care that could help make us all safer when we are in the hospital.

That’s because sharing details about errors can lead to progressive error prevention in patient care, while simply hiding them may doom future patients and caregivers to the same tragic fate. It is the open, honest review of the root cause of errors that allows us then to develop overlapping systems of error prevention — comput-ers, cross-checking, good procedures, removal of high-risk options for error, strong team function, etc. — that offer real hope of dramatic reductions in the frequency of medical errors. Our previous assumption about error prevention — that smart, driven caregivers who make errors or see them made will avoid future errors by being shamed or scared into vigilant perfection — has proved itself to be a fatal error.

The importance of transparency about medical errors goes beyond their prevention, however. The core of the relationship between caregiver and patient — the emotionally invested caring of one human being for another — must be built on a foundation of trust or it has little value beyond an economic transaction of service bought from the caregiver and paid for by the patient. Hiding medical errors from patients who suffer from those errors fractures their trust just when they need to believe us the most.

Stonewalling a patient about an error in care puts the interests of the health care providers over the patient. That erodes our special relationship with all patients, a relationship that goes beyond what almost any other profession has with those it serves. That special relationship has given us a valued place in society, one of honor and status. It has given us greater credibility in debates about health care policy, cost, malpractice law, and other battles outside the exam room; without that relationship we are just one more voice in a chorus.

Transparency about harmful errors in patient care also is the only approach consistent with what any of us who are health care professionals would insist on when an error was made in our own care, or that of a family member. We cannot hide such errors from patients and families without violating what should be the Golden Rule of Medicine: Caregivers cannot have in their own care what they will not deliver in the care of others.

It is easy for those of us in health care to say all of that, and believe all of that. Doing it is far more difficult, which makes Mayo Hospital’s actions all the more laudable.

I have trouble admitting my own mistakes about anything, let alone about the care of a patient. But the challenges to face up to my inadequacies come daily, and will come again in patient care because I will certainly make more errors there. If I then am to follow Mayo Hospital’s example, I will have to stand before them and deliver the truth, accept their judgment, and apologize. Then I can work with the team around me to pick up the pieces and help build a better, safer system for the next patient.

I think I am ready.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region. He is also the interim CEO at Blue Hill Memorial Hospital.

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