A former emergency room resident acknowledged a mistake she once made with a patient that could have proved fatal in an op-ed piece for the New York Times in an effort to end what she calls a culture of shame regarding medical errors. But the piece also sheds light on how easily medical malpractice can happen – busy doctors and crowded hospitals can lead to hasty decisions.
Dr. Danielle Ofri, now a professor at New York University School of Medicine, describes her error as a “near miss.” An elderly patient with dementia was sent to the emergency room by staff at her nursing home who described her as having an “altered mental status.” Dr. Ofri said she rolled her eyes, after all that is the nature of dementia. Since she was dealing with people with heart failure and active infections, she wanted to get the elderly patient discharged as soon as possible.
But Dr. Ofri did her due diligence – she ordered a CT scan and other tests. However once she received the results, she quickly ran through them with the preconceived notion that the patient had no treatable injury. She found nothing unusual in the tests. She assured the lead doctor that nothing was wrong with the patient, who then sent the patient to the intermediate care unit, a holding station for patients with no active medical issues who were awaiting discharge. The whole incident was forgotten quickly as she returned to patients with obvious needs.
The next day, Dr. Ofri said she got news that left her with “an acrid mix of shame and guilt churning inside me.” The lead doctor tracked her down to tell her that the patient had an intracranial bleed that showed up in the CT scan she reviewed. Luckily a radiologist caught the error and neurosurgeons were able to fix the bleed preventing any serious damage.
Dr. Ofri was relieved that no harm occurred, but wondered what would happen if the patient had been discharged before the radiologist caught the bleeding. She said because of the shame she never told anyone about her mistake, not even the intern who worked with her on this patient. But she wanted to tell her story now to change medical culture to be more open and to learn from mistakes. She said that there were an estimated 1.5 million medication errors in a year, but the “near misses” dwarf that number, and talking about them can improve patient care.
“When the chief of medicine or the director of nursing stands up and talks about his or her biggest medical error, it will get noticed by the rank and file. Hearing how a person in authority handled the emotional fallout and the feelings of incompetence may give others the courage to come forward. Until we attend to the culture of shame that surrounds medical error, we will be only nipping at the edges of one of the greatest threats to our patients’ health.”
Unfortunately, a culture of openness does not yet exist for near misses or actual medical malpractice. Consulting an experienced personal injury trial attorney is a must for anyone who suspects medical error.