Doctor Shares How Apologizing for a Medical Error Changed Her Life for the Better
“She’s crashing!” Dr. Kate McLean recalled the Anesthesiologist exclaiming during the start of a surgery event many years ago. She went on to share that “the next two minutes were complete chaos. I started chest compressions as our attending supervisor confirmed that the Veres hadn’t caused any internal bleeding”. In her new Huffington Post article, Dr. McLean writes how the event changed her life forever, not just for the missed medical error, but the support the patient provided her after she apologized. We share a bit of her story here and then recap contemporary discord from this year’s Patient Safety Movement Foundation Annual Summit, on the need for medical professionals and hospitals for transparency when medical error occurs. She shares:
My patient was dwarfed by the hospital bed she sat in, but her eyes danced brightly under her gray curls. She had a strong handshake and perfect posture, and instantly reminded me of my grandmother. The sounds of the hospital awakening were all around us: nurses shuffling paperwork, EKG monitors beeping, laundry trollies clattering by.
My heart leaped into my throat, because while I had been anticipating this moment, I still wasn’t sure what to do. The previous evening I had reviewed her pre-operative CT scan and noted that her liver was visibly enlarged. The radiologist hadn’t caught it, and neither had anyone from our team. It was the biggest mistake I had ever made, but I hadn’t been taught how to talk to patients about complications in medical school, and I’d never actually seen a supervisor apologize to a patient before. Was that because of a fear of being sued? Or because there’s this expectation that doctors are perfect? Either way, bringing it up felt like breaking some kind of unwritten rule.
“I’m so sorry I didn’t notice your liver was in the way before we started the procedure,” I said, going with my gut, my eyes starting to burn with tears. For a brief moment, it felt like the ground had opened up beneath me and I was free-falling. There was no taking it back now. She looked at me searchingly, taking my hand in hers. “Sweetie, the older I get, the more I’ve realized that nothing is certain,” she said. “I knew something might go wrong when I agreed to the surgery. What matters is that you all solved the problem. It matters that you care this much.” I pressed my lips together, willing my eyes to dry.
Kate McLean is a board-certified obstetrician-gynecologist at the University of Washington Medicine in Seattle. She’s working on a memoir about practicing medicine in the U.S. and abroad in Tanzania. You can read her full story on Huffington Post entitled “My Patient Almost Died From A Mistake I Made. I Apologized And It Changed My Life“.
Patient Safety Movement Foundation Supports Open Transparency
At the Annual Patient Safety Summit this year, a unique panel spoke on the need for transparency by medical professionals and hospital administration when medical errors happen. Owning the responsibility for the mistake is the first step in reducing the additional challenges those errors will cause patients, citing key examples where patients changed their immediately perspective about the error. Dr. Mayer opened the panel by suggesting that healthcare providers have to be open and honest with themselves. Savings come later from better care, not from malpractice legal strategies.
He then shared about the CANDOR (Communication and Optimal Resolution) program, a foundational element of the comprehensive patient safety program at MedStar Health. CANDOR, along with a commitment to fostering a learning culture, the principles of high reliability organizations, and a systems approach to identifying, examining, and resolving weaknesses in our system are hallmarks of the MedStar safety program. CANDOR itself is a paradigm shift from “delay, deny and defend” to early communication with patients and families leading to timely resolution and systems improvements where appropriate.
Dr. Kachalia explained that disclosure is becoming more prevalent, and that in fact, in many cases after starting transparency programs, litigation costs go down. As a lawyer, Jon Schochor shared that it is not so much the medical error that brings patients and their families to lawyers. Rather, victims come to lawyers because the hospital system turns against them when they need the help most; ignoring them, or lying to them.
Dr. Lachman suggests that part of the problem lies with the system, where providers don’t like being wrong and are not taught to deal with failure. He believes that change will only come when healthcare acts like aviation, and focuses first and foremost on safety, with healing services a close second after that. Dr. Durkin explained that in the UK, it took patients, providers and government working together to report data to really assess the data for patient safety issues. Following this, a financial incentive increased risk safety assessments dramatically.
Medical error victim Jack Gentry, joined the panel to share that although his heart breaking experience at MedStar left him quadriplegic, the immediate communication and apologies from the doctors, risk management team members, and hospital executives helped him start his healing process. By being open and transparent not only with the patient and the family, but also amongst themselves, is the most important aspect of such errors — so that something can be learned from the unfortunate circumstance.
Dr. Lachman poised an interesting perspective to maximize transparency: Ask the patient victim of medical error what they think should happen? He agreed with other panel members that an open and honest system starts with immediate responses to errors, by providers to institutions and victims.