A Patient

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Whose Medical Error?
A Patients Thoughts on a Systems
Response Helen Haskell Mothers Against Medical
Error Columbia, South Carolina
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Lewis Wardlaw Blackman 1985-2000
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Synopsis of a Medical Error

• Lewis, a healthy 120-pound boy, is prescribed a
  five-day adult course of the NSAID ketorolac
  tromethamine following surgery.
• Adequate fluid levels are not maintained.
• Three days after surgery, Lewis begins
  complaining of severe, unremitting epigastric
  pain.
• Nurses and residents fail to act upon increasing
  signs of instability.
• Parents request for an attending physician is
  not honored.
• Four days post-op, following 30 hours of
  deteriorating vital signs, including four hours
  of completely undetectable blood pressure, Lewis
  dies. He has not seen an attending physician for
  over two days.
• Autopsy shows a giant duodenal ulcer and 2.8
  liters of blood and gastric secretions in the
  peritoneal cavity.

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AFTER OUR CHILD DIEDWhat we expected from the
hospital

• Alarm
• Remorse
• Compassion and support
• Urgent investigation
• Urgent change.

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How Does Full Disclosure Help Patients?

• It relieves guilt and fear.
• It restores trust.
• It allows them to believe that their healthcare
  providers care about them.
• It reassures them that they do not have to face
  a dark future alone.

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How Does Full Disclosure Help Providers?

• It allows them to maintain their compassion and
  integrity and to fulfill their mission as
  caregivers.

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What we wanted

• The option to meet with those involved in our
  childs death
• The chance to tell investigators what we had
  seen
• The chance to have input into change.

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Questions

• Would the residents have felt less abandoned if
  they had the opportunity to meet with Lewiss
  parents?
• Did investigators desire to spare the residents
  feelings prevent the residents from learning from
  their mistakes?
• What lessons did they then learn instead?

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Patients Emotional Needs after a Medical Injury

• Acknowledgment of the significance of the loss
• Learning and change
• Accountability.

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Root Causes of Errors

• Production pressure
• Inadequate training
• Poor care coordination
• Unsupervised trainees

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What do patients expect?

• Expertise
• Vigilance
• A plan
• A backup plan
• A system that delivers what it promises