Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments (3)

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.


You may also like these posts

Read comments »


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.

Return to article »

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

Read more »

See all interviews »

Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

See all cartoons »

Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »