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In defense of medical errors


I gasped at the guilty verdict that interrupted my indifferent scrolling through the News Feed.

In the line of duty, a nurse – who accidentally administered the wrong medication, reported her mistake herself, and remorsefully admitted her mistake to a group of her peers – was turned into a criminal.

If this standard were applied generally to medical accidents, health care as we know it would not exist. We will all be worse off. It also smelled like a scapegoat. Is there a doctor or nurse reading this who doesn’t need to say, “There, but for the grace of God, I’m going?”

Is there anyone who has truly practiced and gone through an entire career unscathed from unintentional mistakes that inadvertently hurt or even killed? A medical professional who has felt no remorse over unintended consequences?

Forever etched in my mind is a late night battle with a feeding tube for a very sick patient that required many attempts and confirmatory x-rays (involving climbing stairs from the ICU to the x-ray department in pre-PACS days) . Eventually I saw what wasn’t and erased the x-ray. Tube feeding was initiated until the error was discovered. It wasn’t my last mistake. The passage of time and “extenuating circumstances” (e.g. being on call virtually 24/7 with no more than a few hours of sleep, if that) are nothing but lame excuses.

Like a phoenix rising from the ashes, our healthcare system has gone from the domain of crooks at the turn of the 20th century to one that has become the envy of the world. One of the reasons is that we have learned consistently, including from our mistakes.

A persistent “flaw” in a conscientious provider is to exert superhuman effort day in and day out to serve our calling to relieve the pain of others.

Then we are shot because we are only human.

Fixing this error is a work in progress. Residents of today cannot be subjected to endless work hours or treated like fodder for the healthcare machine, largely because of such a mistake.

In one case of wrongful death, the underlying cause was found to be residents defeated by insane hours and inadequate supervision. The doctors involved were not imprisoned but instead were able to pursue their vocation. The whole system has become better because the subsequent constructive steps have undoubtedly saved lives and avoided harm to patients and practitioners.

The importance of learning from mistakes cannot be overstated. Morbi-mortality or peer review conferences are confidential precisely for this reason.

The goal is achieved by candidly acknowledging, analyzing and correcting mistakes. The goal is achieved by actors exactly like this nurse, with her seemingly inherent honesty and insight. The case is lost by either version of pleading the fifth.

Like any human endeavour, this system is not perfect. It is susceptible to abuse and manipulation. That’s a story for another day.

This is not to say that healthcare providers should be above the law or should enjoy legal immunity. They must suffer exemplary consequences when they intentionally stray and injure for material gain. Punish the doctor or nurse who intentionally performs an act knowing that he will benefit and that the patient will suffer harm. That’s not the case here.

The photo associated with the article shows eyes familiar with exhaustion but still carrying a hint of that glow she must have started her career with. The face, wearing an incongruous expression of one in shock, with a trace of a forgotten smile. A defeated person who surrenders to the verdict of a crime not committed. A person failed by his profession, his peers and his employer. It’s so bad!

Those in the know will tell you that the reported information indicates a system failure. She is just the tip of the iceberg.

Consider the following: Were Versed and Vecuronium placed in such close proximity that the possibility of selecting the wrong vial (and subsequent consequences) arose? Was it easy or difficult to collect the drugs? Were the drugs stored at his workplace without further thought than in alphabetical order? Were there any checks in the system to warn her against too human error? Are there visual or auditory cues to warn of potential error?

Even a mindless task like closing a file on the computer results in the “brainless” computer asking, “Are you sure?” and warning, “All unsaved changes will be lost!”

What was the workload that day and the previous days? Is the system stressed, frequently bypassed security controls? How robust is a system that fails due to human error? What were the roles of supervisors, co-workers, physicians, and administrators that contributed to or could have prevented the accident? Of course, it did not operate in a vacuum.

How many times have we used administrative jargon requiring a nurse to continue well beyond her working hours because there is no one to replace her? Where would resistance to the process be at the risk of job loss?

When the prosecution attorney unknowingly compared her to a drunk driver, he was right. Studies show that drunkenness and lack of sleep are comparable.

Why not look at the system that compensates for shortages by running an exhausted workforce ragged – in other words, drunk – and then rewards their selflessness by throwing them under the bus? More than the doctors, it is the nurses who cure the patients. They all make us look good. If that’s how society treats them, don’t bother going to the hospital. Most of them and the doctors are drunk!

Shah-Naz H. Khan, MD, is a neurosurgeon.

This post appeared on KevinMD.