There are two lessons to be learned from a long CNN story on the power of an apology after a medical error.
The first, obviously, is to say sorry. As CNN medical correspondent Elizabeth Cohen reported:
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The basic human desire to hear “I’m sorry” and an explanation of what went wrong — whether in the operating room or elsewhere — is behind a movement to encourage hospitals and doctors to move away from the traditional “deny and defend” approach, to “acknowledge and apologize.”
“I’m sorry” laws in 36 states say apologies cannot be used against medical professionals in court.
Cohen told two harrowing stories of medical errors. In one case, Stanford’s Lucile Packard Children’s Hospital apologized right away after a toddler died due to an alarm that had been turned off. The parents never sued, and the mother now consults for Stanford on medical error resolution.
The featured case in the story, though, involves a messy lawsuit against Yale New Haven Hospital by a woman who had the wrong rib surgically removed last year. Her lawyer said not only was there no apology, but a surgeon actually lied about what happened to cover his own rear end.
Only this week, after CNN shared with the patient and her attorney a report Yale filed with Connecticut health officials, did the woman learn what else transpired. According to CNN:
“The Yale report mentions an ‘outage of the radiographic imaging’ and pledges to ‘institute a method of communication that will provide timely notification of system outages including, but not limited to, Picture Archiving and Communication System (PACS) and Epic.'”
And that brings us to the second takeaway. The story said the patient now is wondering whether the PACS or the Epic Systems electronic health record was down during the botched surgery.
Did the Yale doctors know about it? If they didn’t, why not? And if they did, why did they proceed with the surgery? And what about other hospitals that use PACS and Epic — should they know about these “outages” so a mistake doesn’t happen there, too?
It’s safe to say that pretty much every hospital has a PACS today. Certainly, every large academic medical center like Yale New Haven does. It’s also safe to say that outages aren’t limited to hospitals running Epic.
How prevalent are health IT-related medical errors? The Institute of Medicine famously raised this question in 2011. But, unfortunately, we still don’t know the answer five years later.
Gag clauses in EHR contracts may be the culprit here. So might the culture of silence that pervades medicine.
Politics isn’t helping, either. The Office of the National Coordinator for Health Information Technology set up the Health IT Safety Center, but it’s mostly toothless. The 2011 IOM report recommended mandatory health IT error reporting, but reporting to the Health IT Safety Center is strictly voluntary.
Is anyone sorry about that?
Photo: Flickr user butupa
