Last year my daughter became suddenly ill. Really sick. She was in a coma without a clue as to why. After tons of tests the doctor said it was viral encephalitis; she was unresponsive for a couple of days. While she was in the hospital I watched
everything like a hawk. I took notes
about every medication she received and every conversation we had with the
intensive care staff. I wanted to be an
advocate for her care. It was a horrible, frightening time. Three days later we were blessed. She awoke but became
restless and unreasonable. After long
hours at her bedside, we went to the cafeteria for dinner while she rested in
bed. In her delirium, she got out of
bed, ripped out her central IV line and her catheter, and decided she was going
home. She was irrational and didn’t know
what she was doing, but could have really caused herself physical harm. The
nurses caught her and put her back in bed and got control of the
situation. We were informed about all
this when we got back from dinner; it
had all happened in an hour. I was glad
we were told about the incident and that they rectified the situation quickly
and appropriately. We were accepting of
the situation and grateful for her care even after we were told of all that had
taken place. It was scary, but we were
glad she was okay. The nursing team did
the right thing by keeping us informed and explaining everything that
occurred. It actually helped us trust
them more.
Adverse events in a hospital are considered those injuries
that affect a patient due to the medical intervention. These events are not planned. They aren’t supposed to happen. They are errors. The tricky part about medical adverse events
is that the patient is often ignorant to the procedures and medications that
are used to treat the condition. The
patient puts his entire trust in the hands of the caregivers, assuming that the
right care will be given. He is totally
vulnerable.
As a hospital leader I
consider patient safety one of the most important aspects of my job. My work requires me to review all errors that
are reported by staff members in my department.
There are about 300 per month.
Some are really minor: a word spelled wrong in a report with no impact
on the meaning, a wrong sample collection time recorded in the computer that
gets corrected within the shift, or a biopsy sent through the tube system
instead of by courier. These represent a
deviation from our standard operating procedure and are recorded so that we can
track and trend the problem and address those that float to the top. Other errors are more serious. They are an adverse event. When I am informed of these serious errors
they make my heart sink. I worry for the
patient and I investigate the issue inside and out. One thing that really bothers me is
mislabeled samples. I fear that the
wrong results will be reported on a patient just because a sample had the wrong
label. The treatment provided may really
belong to someone else. There’s a big
potential for harm. I worry and I
struggle to prevent it again.
This leads to the question about whose perspective is the
most important when determining whether an adverse event has occurred. It would be easy to say that I, the
healthcare provider, am the most important because of the broad and deep
knowledge required to even understand that an error in treatment has
occurred. Some would argue that the view
of the doctor, nurse, administrator or risk manager will matter the most since
they know best about optimal medical interventions. Others will contend that
regulators, judges, or lawyers are the ones that matter most since they will be
the ones to take legal action against the offender.
I disagree. If I, as
a patient, am ignorant to the details of my medical care, I won’t know whether
my treatment is appropriate or whether it is totally off-base. I won’t know that my sample was mislabeled until
it’s too late. Even if the patient is
not a healthcare professional, and his understanding of medical treatment
protocols is negligible, his perspective is most important. It may be that the patient discovers the
error himself and informs his caregiver of the problem (such as wrong medicines
or wrong operations). This would
certainly validate that his perspective is most important. It could be that the hospital staff must
reveal the adverse event to the patient (as when our daughter jumped out of bed
and ripped out the lines). When this is
exposed, the patient’s response becomes most important. If the patient is not understanding and
forgiving, he may decide to take legal action, therefore, managing the
conversation and the patient’s reaction is vital to reducing the risk of
litigation. The reason for admitting the
error is not only for regulatory reasons or for mitigating legal action, but
also because it is the right thing to do.
The patient will decide whether the event is tolerable (and forgivable)
or whether restitution is more acceptable.
The patient has the most important point of view when considering
adverse events. It’s the healthcare
provider’s obligation to review the facts, address the problem, and compensate
the patient properly.
