Dr. Decipher: Should Doctors and Hospitals Apologize?

By Dr. John Janousek, M.D. Monday, August 23, 2010

The Wall Street Journal recently reported the story of 18-month-old Kaelyn. She fell at home, which caused a swelling to appear on her head, so her mother took her to the ER at a children's hospital in Miami.

While at the hospital, she apparently had a seizure and was sedated, then intubated. A CT scan was done, which showed an abnormality, so an emergent MRI was then performed. As a nurse wheeled Kaelyn out of the MRI room, she noticed that her chest was not rising and falling with ventilations. A terrible error had occurred: the endotracheal tube had become dislodged, depriving her of needed oxygen. Kaelyn barely survived, and was left with permanent mental and physical disabilities.

So what do you think should happen after this mistake? The usual scenario is the physician and hospitals contact their insurance companies, and lawyers are consulted. Communication between the patient, the family, and the hospital ceases. Hospitals providers are counseled not to contact or say anything to the family; a provider commented that she was told not to attend the funeral of a patient she lost. One small exception is a recent Virginia state law exempting "expressions of sympathy" from being used against providers at trial.

But something surprising and refreshing occurred in this case. Hospital administrators analyzed the case to find the contributing factors to the error. It is rarely a single event which causes an injury, but a series of mistakes which line up - the "Swiss cheese effect." The hospital engaged the child's parents and apologized to them. They adopted a "full disclosure policy" and honestly told Kaelyn's parents what had happened and why it occurred as soon as the investigation was finished.

Several studies show that adopting a disclosure policy after mistakes occur and apologizing to patients and families lowers overall costs for malpractice. The number of suits may actually increase but the amounts paid out are less, and may be settlements as opposed to court judgments. Also the hospital and providers can deal directly with the patient and family.

More importantly, the patient and families can understand how the event occurred. Everyone makes mistakes - nurses, doctors, lab techs, administrators, etc. (To Err is Human). The challenge in medicine is building checks and error prevention into the system.

This is just in its infancy in medicine, unlike the airline industry which does a good job of error analysis and checklist use. The culture of medicine is also rather toxic with mortality and morbidity conferences where providers are grilled about bad cases. The natural tendency to keep mistakes "under the radar" to avoid lawsuits, hospital "lack of standard of care" files, even damaging newspaper columns. When a bad outcome occurs, finger pointing and the blame game begins.

So what happened with Kaelyn's family? An out-of-court mediated agreement was reached where she receives free medical care for life in addition to an undisclosed settlement amount. Her parents helped the hospital make a video that they are using to educate their employees about events that led to the injury. They are very satisfied with the result and said, "no one woke up that morning and said we are going to mess up your little girl."

Hospitals and medicine in general need a lot of improvement in processes, and we need to move beyond the current medico-legal climate such as this Miami hospital has done. It takes courage and faith on the part of hospital administrators, physicians, nurses, and especially patients and their families but this is not only therapeutic for the injured parties, but helps prevent avoidable errors in the future.

I have never felt comfortable not talking to a grieving patient or family, and have been torn apart by these situations. Providers hurt also after a bad case, and need resolution besides legal battles. A tragedy for Kaelyn and her family was turned into changes for the better; let's work to make this the norm.