“Humility leads to strength and not to weakness. It is the highest form of self-respect to admit mistakes and to make amends for them”. -John Jay McCloy
It takes a strong person to review the facts and to admit that they have made an error. Unfortunately, in the field of medicine, it is not always our personal mistakes which lead to error, but those which we delegate. Yet we are still culpable. It is one thing to make an error about a flight departure or arrival, or a week of vacation (all human disasters) – but mistakes which lead to the loss of life are tragic, preventable, and must be avoided at all costs. We invest so much time in the care of our patients, yet it has become normal for clinicians to delegate follow-up responsibilities to nurses and other staff. But this is fraught with potential disaster. Untrained assistants cannot appreciate the magnitude of a laboratory finding or radiological result; they may lack the passion to be certain that the patient understands. It is difficult, if not impossible, to make amends for an unavoidable loss of life.
Ineffective communication among healthcare professionals is one of the leading causes of medical errors and patient harm. Delays can be deadly, such as when the clinician is not forwarding results promptly to a patient with an ongoing DVT, which, without anticoagulation can become a pulmonary embolism. Ann Lanter, JD, posted this scenario on her blog this past month, but I have personally observed this in the death of one of my friends. He had three clinicians caring for him within a large HMO. He spent three days in pain with several returning visits. His twelve-year-old son returned home from school to find his dad lying face-up on his bedroom floor with a blue pallor. This was a life-changer for the young son, his four siblings, as well as my friend’s wife. How do we healthcare professionals make amends for or more importantly – avoid situations like this?
Communication errors were implicated as the root of over 70% of sentinel events. With statistics this significant, why are poor communications such an issue in the United States? Where is the fault? What is the most common problem? Patient callbacks for labs and other studies are often not timely and this can result in a disaster. A patient’s phone calls that are annoyingly repetitive can make even the most stalwart of clinicians upset. But what if that patient has now sustained a change in symptoms? How might their prognosis have changed? I had a friend experience this after he performed a liposuction procedure. The patient ultimately went to an ER, and a general surgeon examined and elected to operate. He discovered three perforations of her bowel. The practice of medicine is fraught with potential dangers and our mandate has never changed: Do No Harm.
In conclusion, it is possible for the very best providers to make medical errors or to have issues with communication in their practice. With concentrated effort and tremendous focus communications can improve, but the chances remain that you might still be the focus of an error and a malpractice suit. Are you prepared? Are you comfortable and secure that you have the best personal liability coverage for you, your family’s future and your career? If you are a PA, your professional organization has vetted all of the country’s best providers and has chosen one who continues to offer stable, comprehensive coverage with the highest insurance ratings for decades – at affordable rates. Don’t be caught without this critical career-saving security. Membership has its rewards and your career’s protection remains the most important!
Robert M. Blumm, DFAAPA, PA-C Emeritus
PA Advisor to CM&F