Sometimes things go wrong in the hospital. Something happens that you didn't want or expect, and as an involved caregiver, you sit there scratching your head or clutching your chest or wiping your tears because of it.
Sometimes it's because of something you did or didn't do. Yep, I said it. Sometimes doctors make mistakes. Foul-ups, bleeps, and blunders that many times fly under the radar, but other times become headlines on CNN. This is not unique to Grady Hospital at all. This is a universal truth for any hospital anywhere, and one that, no matter how much we want to pretend isn't true...just is.
My mentor, friend and fellow Grady doctor, Neil W., has expertise in medical errors. We were talking recently during one of our mentor/mentee meetings about what happens after an adverse event or error in a teaching hospital. Our verdict was that, most of the time, it's handled pretty poorly. Either it is ignored or someone is berated, or there is a discussion that focuses more on how “the system” plays into errors and adverse events—and the assailant gets off the hook.
But sometimes a person just made the wrong choice. Sometimes he or she was supposed to do one thing, like come back to check on a patient again, and didn't. In such situations, it isn't “the system” at all.
So here's the burning question: At what point is it just your fault?
Dr. Bob Wachter, the hospital medicine guru/coiner of the word “hospitalist” and all-around hospital medicine wizard, wrote a lovely article about this very thing in the Oct. 1, 2009 New England Journal of Medicine. He talked about physicians and accountability, and how at some point–depending upon the error–folks have to just own the blame for what they did or did not do. Period. A much less warm-and-fuzzy approach than the “it was the system” theory, but definitely one that made me pause.
From his article, I realized a lot of my own shortcomings, both as an error-prone human and a supervisor of other error-prone humans. I recognized that my default over the years when I had a part in an adverse event was self-deprecation. I'd have this internal recoil where I'd replay something over and over again, repeatedly cringing and demanding of myself with disgust, “How could you not have fill-in-the-blank?” or “I can't believe you fill-in-the-blank.”
Then there were the learners. My go-to response for dealing with learners who fell short was: “You're still a wonderful doctor...,” followed by a launch into all of the system things that could have caused something to happen. Yeah. The system.
The more I listened to Neil that day—and to Dr. Wachter in that article—the more I knew that my approach to processing medical mishaps needed to be revised.
Of course, the goal should really be to avoid mistakes altogether, right? But since we know they can and will happen, another acceptable goal is to make every effort to not repeat the same mistakes. This starts with learning from them, and learning from them starts with owning them. You have to own your part in an adverse event instead of chalking it all up to the system. Otherwise, the take-home point will get lost in the shuffle.
Bringing the lesson home
This is story of one of my mistakes.
A few years ago, I had a patient who was very, very ill. He was in the stepdown ICU with complications of advanced AIDS, and we were treating him for a condition that could be life-threatening. He was turning the corner, and I spent several hours taking care of him and building a rapport with his family. At the close of one of the days I cared for him, I walked out of the hospital feeling extremely proud of the care my team had offered him, and even happier with his improvement.
The next morning, I was walking into the hospital when I overheard a code being called on his floor. When I reached the floor, there was the characteristic pack of doctors and students pouring out of the unit, swarming near the doors. I asked a couple of residents what was going on, and they told me that the person who had coded was indeed my patient. “But the critical care team has it under control,” they told me. “He's been intubated and should do okay from what we saw.” Whew.
Right before I started to enter the threshold of the stepdown unit, I heard my patient's family calling my name. They were crying and screaming and very upset. They ran up to me and clung to me. They even squeezed my hands and included me in their circle as they prayed for him boldly and loudly—not in the hushed voice that I often use when praying.
“Is he going to die?” his mother pleaded with me. “Is this it? Is the Lord trying to take him home? Oh please, Jesus! Please! Tell me...am I losing my baby?” She was shaking like a leaf, terrified at the thought.
All I had to go by was what those residents told me. The mom in me imagined burying one of my sons. No, he will get past this, I told myself. I made a choice and started talking.
“No, he isn't dying. He is sick, yes. But they have him on a breathing machine and the doctors who work in the ICU got to him very fast. He is still young and is a fighter. He is sick, yes, but you are not losing your baby.”
I looked my patient's mother dead in her eyes and said this. And it was a tremendous comfort to her, and this whole family who, before I began speaking, thought he was dead.
Two seconds later, the doors whooshed open and the ICU crew came out looking very somber. I thought I would vomit the second I saw them. The first words from the ICU fellow:
“We are so, so sorry.”
Reflections on a mistake
I told that family something that was completely untrue. I took a family on the brink of the horrible tornado into its calm center through my unsubstantiated words...only to see them dragged straight back into the twister again with the truth.
My patient had died. I told his family—his mother—that he was okay, when he wasn't.
When his family collapsed to the ground crying, trembling and praying, I wanted to disappear. It was awful. I wished so badly that I hadn't made things harder for them.
But now, I reflect on that differently. I should not have based such sensitive information on a drive-by account from two house officers who weren't even involved in his care. I should have told the family that I would be right back—and spoken to them after confirming his clinical status. That was a bad move on my part—and although it isn't as egregious as pushing the wrong medication into an IV line, on some level it is just as hurtful.
Yet instead of dwelling only on the bad, I can now recount the good things that took place with that patient, too. He was diagnosed promptly, received standard-of-care treatment and therapy, and had nursing staff who responded quickly when he took a turn for the worse. I established such a great comfort level with this family that they felt safe enough to call my name from across the room, weep into the shoulder of my starched white coat, and pull me into their unapologetic petition to God before I could even process whether or not it was appropriate for me to do so. They treated me like a trusted family member—a distinction I achieved after only two days of caring for him in the hospital. I think that the approach I used in getting to know them provided comfort to a patient and his family during a tough time. I learned that in the future, I can use those same skills when caring for my hospitalized patients, but must remember the importance of having all my facts straight before opening my mouth.
The truth is that I took good care of a patient, but at one point in his care screwed up. That wasn't about “the system,” either. That mistake was about me.
With regard to this patient: There was something I did that was good. There was something I did that was bad. But at least I can proudly say it wasn't because I was indifferent.