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What To Do When Mistakes Happen

Thanks to KevinMD for highlighting an interesting discussion about the ethics of disclosing another physician’s error. It reminded me of a case I witnessed many years ago.

A young man had been in a car accident and was transferred to the rehab unit after several orthopedic surgeries and a long inpatient stay. Prior to beginning physical therapy, he was sent for doppler ultrasounds of his deep leg veins to make sure that he didn’t have a thrombus (clot) that might break off and lodge in his lungs during exercise. The ultrasound was actually positive for a large DVT. Unfortunately, the radiology note listed all the large veins that were patent (had no clots) first, and then finished with a notation of (+) DVT in one of the veins. The patient was transferred back upstairs to the rehab unit, the physical therapist glanced at the radiology report (where the first several sentences indicated normal findings) and took the patient to group therapy.

The patient got up out of his wheelchair, stood for a few seconds, and immediately collapsed. His DVT broke off and traveled to his lungs, causing a massive occlusion of his vessels. The crash cart arrived as he coded, the vascular surgery team quickly took him to the OR to crack his chest and try to remove the clot, but he didn’t make it. It was shocking and terrible.

What happened afterwards was memorable. The rehabilitation medicine attending notified the family of the error, explained exactly what happened and apologized with tears. The hospital administration was notified, the physical therapist, radiologist, residents, and attending physicians got together for a meeting in which a new reporting protocol for positive doppler findings was created. To my knowledge, there has not been another case of pulmonary embolism on that rehab unit since.

The family members did not sue. They were deeply grieved, but grateful for the transparency. The dangers of DVTs were indellibly burned into the minds of all physicians and staff working in the rehabilitation unit – and I believe that our lifelong vigilance may save many other patients from a similar fate.

That’s what should be done when mistakes happen.


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3 Responses to “What To Do When Mistakes Happen”

  1. Strong One says:

    Mistakes, while massively preventable DO happen. That’s why they are called mistakes.
    The only way of ensuring the continued prevention is full disclosure no matter how minimal or how severe the mistake may be.

    While to err is human, to admit your err is humane and just.

  2. Anonymous says:

    I thought the Chest/ACCP guidelines said bedrest was not advised anymore? Perhaps we have to go back to conventional wisdom?

    Bedrest vs. Ambulation in Initial Treatment of DVT or PE

    Physicians have been taught to recommend bedrest in patients with acute venous thromboembolism during the initial two to four days of treatment. However, bedrest is not recommended in the American College of Chest Physicians guidelines for treating acute venous thromboembolism. The bedrest recommendation was based on the assumption that movement may dislodge the clot and cause a fatal pulmonary embolism (PE). This assumption has never been evaluated systematically to determine whether it is accurate. Three small trials found no difference in morbidity or mortality in patients with deep venous thrombosis (DVT) who were assigned to bedrest versus those who were allowed to ambulate. There are no studies that evaluate this issue in patients with PE. Trujillo-Santos and associates evaluated clinical outcomes in patients with venous thromboembolism assigned to strict bedrest versus those who were allowed to ambulate.

    Participants in the study were patients with symptomatic, acute DVT or PE confirmed by an objective test. Those who met these criteria were enrolled in a national data bank. Patients were excluded if they had any contraindication for ambulation. Immobilization was defined as total bedrest to limit activity for up to three days. The study period was the first 15 days after the diagnosis of DVT or PE was established. The primary outcome was the development of symptomatic, objectively confirmed PE after initiation of treatment. Secondary outcomes included development of bleeding complications and death.

    There were 2,650 patients enrolled in the study; 2,038 had acute DVT and 612 had PE. Of the patients with DVT, 1,050 were allocated to bedrest during the study and 988 were allowed to ambulate. Of the patients with PE, 385 were assigned to bedrest and 227 to ambulation.

    Eleven patients with DVT and four with PE developed new symptomatic PE after treatment was started. These were confirmed with diagnostic studies. Five of these patients died as a result of the new PE (four with DVT and one with initial PE). The two most common risk factors for developing PE after treatment was started were age younger than 65 years and comorbid diagnosis of cancer. Comparing bedrest with ambulation groups, the researchers found no significant difference with regard to new PE events, fatal PE, or bleeding complications.

    The authors conclude that bedrest has no impact on the risk for developing new PE in patients with acute DVT or PE. The risk of developing PE after starting treatment was low but was associated with a significant mortality rate.

    KARL E. MILLER, M.D.

    Trujillo-Santos J, et al. Bed rest or ambulation in the initial treatment of patients with acute deep vein thrombosis or pulmonary embolism. Findings from the RIETE Registry. Chest May 2005;127:1631-6.

  3. drval says:

    Interesting abstract. The difference in this case was that the patient wasn’t being treated (he hadn’t received heparin yet) when he started exercise. This study questions the need for bed rest once treatment is initiated.

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