Resident Readiness General Surgery (67 page)

Peter Angelos, MD, PhD, FACS and Debra A. DaRosa, PhD

You are on the Endocrine surgery service and have been involved in the care of a 58-year-old woman who had an enucleation of an insulinoma from the head of her pancreas a week ago. At the time of that procedure, 1 drain was left anterior to the head of the pancreas and one drain was left posterior to the head of the pancreas. One of those drains, the posterior one, has actually had very little output over the last 48 hours and your chief resident has asked that you go pull that drain. You have been appropriately instructed in how to remove an abdominal drain, and you proceed to remove the drain. However, after doing so, much to your horror, you realize that although you were asked to remove the posterior drain, in fact, because of some confusion on your part as to which drain was which, you have removed the anterior drain. You realize this after the patient began complaining of abdominal discomfort and spiked a fever 12 hours after the drain removal. The attending and senior surgical residents are in the operating room and you have discussed this with them and they have explained that it is now necessary for this patient to have a CT scan.

1.
Should the patient be told that an error occurred?

2.
How would you address this error with the patient?

3.
How might a resident contend emotionally with having made an error?

4.
How might you address an error made by a colleague?

ERRORS

Answers

1.
According to the Institute of Medicine’s
To Error is Human
report, an error is defined as either the failure of a planned action to be completed as intended (ie, an error of execution) or the use of a wrong plan to achieve an aim (ie, error of planning). As noted in the report, medical errors are one of the leading causes of death in the United States. Medical errors may rank as high as the fifth leading cause of overall death in the United States, exceeding the number of deaths that occur from motor vehicle accidents, breast cancer, and AIDS combined. In the years since the IOM report was published, research has revealed that errors are a growing problem. Since all medical and surgical care is provided by humans and humans are fallible, we know that errors will occur. Patients also know that errors can occur even with the best of intentions to avoid them. An honest
discussion of what happened and how it happened is essential. Years ago, many physicians felt that to admit an error would be tantamount to inviting a lawsuit. In fact, the preponderance of data suggests that honest and prompt disclosure of errors is an important factor in reducing malpractice suits. More importantly, however, honest and prompt disclosure of errors is essential for the honest and ethical relationship between a patient and his or her physicians.

2.
As noted above, prompt and frank disclosure of errors is essential. The resident should decide with the attending surgeon if the resident should go alone to discuss this with the patient (if the attending surgeon will be unavailable for a prolonged period of time) or whether the attending and resident should go together. A quiet setting is important for such communication. The resident and/or attending should sit down with the patient to apologize and frankly explain what happened, why it happened, and what impact it will have on the patient’s future condition. The patient should be given the opportunity to ask questions and get the level of detail of information that he or she feels is needed and is comfortable with. The resident and/or attending should also be prepared to offer to the patient what will be done in the future to prevent the same error from happening to another patient.

Most hospitals have a Risk Management office or division with representatives skilled in helping physicians and surgeons communicate with patients about errors. There may be policies and procedures in place to ensure that error disclosure and corresponding apologies are communicated appropriately and completely to the patient.

3.
It can be difficult for residents or any health care providers knowing they harmed a patient. Individuals may respond differently and have various approaches for how to come to terms with having compromised a patient’s outcome, even with the best of intentions. Common emotions include guilt, fear, anger, loss of self-confidence, shame, and embarrassment. Wu and colleagues identified two ways to cope with errors: a problem-focused and an emotion-focused approach. The former involves coping through a focus on the situation or variables that led to the error. The outcome is to promote change to prevent it from happening again. The latter is focusing on emotional distress with the aim to achieve psychological well-being through either formal counseling or dialoguing with mature minds who have “been there” and who can help a resident see different perspectives on the problem. The aim is to not push the feelings aside or internalize them to the degree that they are not dealt with at all. Those who cope by accepting responsibility for their mistakes are more likely to reflect on how to make constructive changes to their practices.

4.
Should a fellow resident open up to you about having made a mistake, it is important to encourage a description of what happened, and to begin by accepting this assessment and not minimizing the importance of the mistake. Disclosing one’s own experience of mistakes or “near misses” can reduce the
peer’s sense of isolation. It is helpful to ask about and acknowledge the emotional impact of the mistake and discuss how the colleague is coping. Residents should make it feel safe to talk about mistakes as it is critical to creating a culture of mutual support and an environment with a patient safety focus.

TIPS TO REMEMBER

Studies show that disclosure may help patients get treatment to offset the results of an error, may award them fair compensation, and may help restore trust in the health care provider. Thus, the honest, forthright disclosure of an error, including an apology, is an important component of an ethically attuned patient safety agenda.

Residents should consult with their attendings or senior residents once an error is made or noticed. The attending may call for a consult with the Risk Management unit within the hospital. Your hospital may have policies and procedures in place for disclosing error information to patients.

It is natural to have some emotional distress or reaction when dealing with an error. Coping mechanisms vary by individual, but honest and direct communication may be the best antidote.

COMPREHENSION QUESTIONS

1.
Not disclosing an error to a patient can result in which of the following?

A. Possible litigation

B. Limiting opportunities for systems and process improvement

C. Distrustful relationship between patient and provider

D. All of the above

2.
There is a difference between error “reporting” and error “disclosure.”

A. True

B. False

3.
What barriers exist that thwart error reporting and disclosure?

A. Fear of blame

B. Confusion as to what really “counts” as an error

C. Poor match of administrative response to errors with severity of errors

D. Burden of effort (paperwork, time, etc)

E. All of the above

Answers

1.
D
. All of the above. Any of these and other ethical consequences can occur when physicians choose not to report or disclose errors.

2
.
A
. True. A
report
of a health care error is an account of the mistake that conveys details of the occurrence, at times implicating health care providers, patients, or family members in error events. Both clinicians and patients can detect and report errors. Each report of a health care error can be communicated through established and informal systems existing in hospitals (internal) and outside organizations (external), and may be written (eg, electronic or paper) or verbal, voluntary or mandatory (policy driven). The core value supporting reporting is nonmaleficence: do no harm, or prevent the recurrence of errors. Error
disclosure
occurs when a health care provider shares with patients and significant others the actual error. Both provide opportunities to reduce the effects of errors and prevent the likelihood of future errors by, in effect, warning others about the potential risk of harm.

3.
E
. All of the above. Research as to why health care providers do not report or disclose errors includes fear, misunderstanding, administrative/organizational report process burdens, and the response anticipated from hospital leadership.

A Resident Who Is Unsure About How to Remove a Chest Tube

Peter Angelos, MD, PhD, FACS and Debra A. DaRosa, PhD

It is early July. As the first-year surgical resident on the thoracic surgery service, you are asked by the senior resident to remove the chest tube on a patient who recently had a pulmonary resection. You have been on the service for a few days and you have seen the problems that can occur if a chest tube is pulled without appropriate management—namely, the patient may have an air leak into the pleural space requiring replacement of another chest tube. Although you have seen one chest tube removed, you are uncertain of the appropriate steps to take to ensure that the patient does not have a pneumothorax as a result of the chest tube removal.