On the Wrong Side of a Wrong Sided Surgery
Written by David Mayer, MD, Executive Director, MIQS
Many of us know medical errors are the third leading cause of death in the United States. We are also aware that healthcare is a high-risk industry like aviation and nuclear energy. But unlike other high risk-industries, healthcare has been slow to adopt tools, techniques and behaviors proven to lower risk. As a result, errors made by well-intentioned caregivers continue to cause unintentional harm and even death to patients at alarming rates.
What comes next however, after a preventable medical error is discovered to be just as alarming. Largely driven out of fear, many times medical mistakes are “buried” by the hospital system. An approach, known as “delay, deny, and defend” has become common place in the healthcare industry. When hospital leaders begin to hide or even lie about medical errors a second set of harm is occurring – to the afflicted patient, family and even caregivers. During my anesthesia residency, I was involved in a medical error…
As the anesthesiologist, my job was to bring our patient into the operating room, put the required monitors on him, and then administer the general anesthetic that would keep him unconscious during his right-sided hernia surgery. Focused on my job, like others in the operating room, I didn’t notice that the senior surgical resident had taken the scalpel and made the surgical incision on the patient’s left-side by mistake. Two minutes later the attending surgeon, who had been detained with a question from another surgeon, came into the operating room, looked at the patient on the operating table and asked, “I thought this was a right-side hernia repair?” When the surgical resident realized the mistake, she passed out.
Covering Up More than Incisions
The surgeon closed the incision on the left side and then proceeded to fix the hernia on the right side. The patient now had two surgical bandages on their abdomen: one to cover the hernia repair, the other to cover our mistake. I dreaded having to discharge the patient from the recovery room after they fully woke up and explain my part in the medical error that harmed him. I had never been involved in a medical error before, and was very nervous about the anger he might feel towards me and our team. When I went to see the patient about an hour later, I noticed he had a big smile on his face as I approached his bed. Before I could say anything, he looked at me and said, “Today is my lucky day.” I was dumbstruck. He continued, “Yes, today is my lucky day because under anesthesia my surgeon told me he discovered I had two hernias, one on each side, and was able to repair both at one time so I don’t have to miss another day of work to get the second one repaired. It then hit me. The plan was to lie to the patient and cover up our mistake. I didn’t know what to say or how to react. After a very long pause, I responded, “Yes, today is your lucky day,” and I discharged the patient.
Courage and Transparency: The Path Forward
In defining professionalism in healthcare, we use words like altruism, honor, integrity, respect, caring, compassion, and accountability to name a few. In telling my patient “Yes, today is your lucky day”, I violated every one of those principles we take an oath to honor when becoming a caregiver. Not only was my lie morally and ethically wrong, our lack of honesty and transparency kept us from learning from our mistake and finding ways to prevent others from suffering similar harm. As a result, wrong-sided surgeries continued to occur far too frequently.
It is said healthcare “buries” our medical mistakes. Fear of malpractice claims and multimillion dollar settlements, fear of losing our license, fear of admitting we are fallible and can make a mistake are just a few of the reasons caregivers and hospital leaders try to hide or even downright lie when medical errors cause patient harm. This approach, known as “delay, deny and defend”, is a common legal and malpractice insurance strategy, not only in healthcare but in other insurance-based industries.
Historically, the role of hospital risk managers has been to protect the hospital at all cost, even if it meant lying to patients and families. Refusing to answer questions, denying patients access to their medical records, not returning phone calls, or referring patients to hospital lawyers has been routine practice for many health systems. Many patients and families wait years to have their calls returned, and still fail to receive truthful answers on what really happened when there is a conversation. As many plaintiff attorneys have shared through the years, “There’s a lot of lying going on out there.” The only option patients and families often have to get their questions answered, is to hire their own lawyer and file a lawsuit against the hospital and the physician. Once both sides “lawyer up”, the only thing that matters is to win the lawsuit, regardless of the financial cost or additional suffering incurred by all stakeholders. No one wins in a medical malpractice trial.
Fortunately, some courageous health systems, hospitals and medical malpractice carriers are discovering there is a better way. They are embracing CANDOR – being fully open and honest when preventable harm occurs. We will talk more about this disruptive new approach to preventable harm in my next post.