Friday, May 2, 2008


From time to time, we will be featuring guest bloggers – doctors, nurses, pharmacists, and other healthcare providers who have graciously agreed to share their stories and insights in the hopes of supporting one another.

Dr. John Fromson, Chairman of the Department of Psychiatry at MetroWest Medical Center and also a MITSS Board member, writes…

Not long ago, while attending a medical society continuing medical education conference, a resident physician in internal medicine, who I had known as a student, asked if she could have a confidential talk with me. Initially, I assumed this was for a "curbside" consultation about a patient she had taken care of who was having some sort of psychiatric problem. It soon became apparent that the problem was not that of a patient, but of an entire culture of medicine that was in desperate need of repair. Here's what happened. The resident had mistakenly ordered and was administered the incorrect dose of insulin for a diabetic patient. The dose was double what it should have been for this particular type of relatively short acting drug that helps to control blood sugar levels in patients with diabetes. Minutes later, after having had a chance to review her orders, the resident realized what had happened. Instead of letting a medical colleague, nurse, or hospital pharmacist know about this medication error, she kept it a secret. Concerned about the patient, but not telling him what had happened, she supervised and encouraged him to drink and eat foods that contained high levels of sugar so his blood sugar levels would not drop dangerously low. She also checked in with him every few minutes and monitored his vital signs until the insulin's effects wore off and she was sure he was no longer in physical danger.

Having had some exposure to patient safety education, the resident physician intellectually knew that a very faulty system contributed to this medication error. She was able to rationalize that if a root cause analysis had been performed by the patient safety officer at the hospital, multiple causes or failures in the drug delivery system would have been identified and corrected, preventing this type of error from happening again. Specifically, the nurse who took the order for the insulin should have questioned the unusual dose, so too should have the pharmacist who sent the drug from the pharmacy to the patient's unit, as well as the nurse who administered the drug to the patient. But emotionally, the resident could not forgive herself for not letting the patient and other health care professionals know what had happened. When asked why she could not share this information, even if it meant preventing future reoccurrences, she replied, "Fear, fear that I would be punished, perhaps lose my job, and perhaps lose everything I had spent years working toward, my professional career." She had witnessed public retaliatory, blaming, and shaming behavior on the part of the senior medical leadership toward another resident who had made a drug dose miscalculation that was reported by nursing staff. She feared experiencing similar humiliation and the subsequent bout of depression that her colleague experienced. While the resident was relieved that her patient fortunately was not injured during this event, it became apparent that she was still experiencing severe emotional distress, in fact she was profoundly depressed. The fear of being blamed turned out to be just as debilitating as actually being publicly blamed. Caregivers can bear the emotional scars of an adverse medical event even when their patients may escape injury. The culture of medicine must change from one of shame and blame to a culture of safety.

John A. Fromson, M.D.


ejnodonnell said...

Wow. What a touching and poignant illustration. Thank you for sharing this story. I hope it resonates with others, as it did with me.

patientsafety said...

Unfortunately, everyone who works at the bedside has their own "five minutes they would like to have back". That said, each "five minute episode" has been treated as a one off by the profession rather than a typical and usual occurrence created by the imperfect systems in which we all work. Recognizing the normalcy of error by normal people doing normal work in normal organizations is the first and necessary step in establishing a culture of safety.

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