Medicine’s Code of Silence About Mistakes

Have you ever heard the phrase “see no evil, hear no evil, speak no evil”? Wonder where it comes from? This proverb about three monkeys is often used to refer to people who deal with bad behavior by pretending it hasn’t happened. In other words, when a mistake happens or someone screws up, the solution is to look the other way rather than to acknowledge the problem and try to fix it.
This happens far too often in health care. Medicine has developed a code of silence when it comes to mistakes that harm patients. Although almost every hospital has clear guidelines on reporting errors, a new report from the Office of the Inspector General of Health and Human Services suggests that problems are often ignored or swept under the rug.
The study focused on Medicare patients and estimated that more than 130,000 experience accidental harm in the hospital each month. An in-depth analysis of 293 instances in which patients suffered revealed that only one in seven problems (40) were reported to hospital administrators. Even fewer of these cases (28) were thoroughly investigated and a tiny fraction (5) led the hospital to change its standard practice or policy to ensure that the error would not be repeated.
The Inspector General, Daniel Levinson, pointed out that hospitals are required to track such events as a condition of being reimbursed by Medicare. The study found, however, that many hospital employees do not recognize situations that result in patient harm, or they may assume that the problem is so common it does not need to be reported. In other cases, employees may worry about being blamed for the error and fear repercussions.
The trouble is that the system can’t fix a problem it doesn’t detect or acknowledge. The Inspector General’s report is not the first one to show that serious events are underreported, only the latest. A study published last year in the policy journal Health Affairs (April, 2011) showed that only 4 major injuries out of 354 events detected through a careful analysis of records had been reported to hospital management. That’s just a bit more than 1 percent. And if you think these stats apply only to older people, think again. Health care harm is just as likely to go unreported for everyone else as well.
No other professional could ignore so many mistakes or mishaps. Pilots must report close calls. Airplane accidents are investigated thoroughly by the National Transportation Safety Board. No such entity exists to track health care harm in hospitals, nursing homes, outpatient surgical centers or doctors’ offices.
When patients suffer a medical mishap they want an acknowledgment that something bad happened. They appreciate an apology from the health care provider and hope for a promise that changes will be made to protect others from experiencing the same complication. They also may want the institution to pay their medical bills for the damages that occurred. There is no greater insult than to be charged thousands of dollars for care resulting from a series of mistakes. Yet that happens every day in this country.
We have all heard how important it is for patients to take personal responsibility for their lifestyle choices. We think it is also critical for providers and institutions to be accountable for their mistakes.
Our new book, Top Screwups Doctors Make and How to Avoid Them, reveals the healthcare cover-up in much greater detail. You will learn how to protect yourself or a loved one from misdiagnosis, medication mistakes and drug interactions. You will learn about the most common screwups that are made for conditions like:
• Alzheimer’s disease
• Arthritis
• Asthma
• Attention Deficit Disorder
• Back Pain
• Breast Cancer
• Celiac Disease
• Deep Vein Thrombosis (DVT)
• Depression
• Diabetes
• Fibromyalgia
• Heartburn
• Hypothyroidism
• Migraines
• Osteoporosis
• Prostate Problems
• Tick Borne Diseases
Should you wish to share your story below in the comment section, we would like to learn about your experience with the healthcare system, positive or negative. Here are just a few medical screwups that we have recently heard about after our radio show on the Inspector General’s report:
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STORIES FROM LISTENERS:
In Sept. 2007, was hospitalized for a mitral valve repair. I was in excellent health except for the mitral valve prolapse, and my doctors told me, “You’ll be in and out in 5 days.”
I flat-lined three times during the operation and was on life support for a week. I spent a month in the hospital ICCU for a month. When I returned home I saw a physical therapist, occupational therapist and nurse for a month.
I had been given a 20% chance to live the first week. The surgeon told my husband, “Shit happens.”
My chart was stamped: “angry spouse.” He was supposed to be happy? But he told the surgeon that if I were brought back to health, there would be no lawsuit because we are not litigious people.
When I went back for my final checkup and release letter for work, I asked the surgeon, since he had had a couple months to investigate, why was it that I had all these problems?
He said…exact words…”I’ll tell ya what, you’re going to die before me, so when you get to heaven, you ask God what happened, and when I get up there, you can tell me.” Yes, he was a cocky, relatively young surgeon, who would have had a broken nose if I had had my strength back. And if I didn’t want to sue before, I did after that comment.
No one ever spoke of any problems, and to date, the hospital refuses to send me my entire record.
V. P., Jan 7, 2012
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I was listening to your radio program this morning and I heard you talking about wanting to hear of narrowly missed disasters in health care. On Dec. 6th, I had what felt like a very large and painful gas bubble in my abdomen that also seemed to be causing reflux. I was in severe pain but drove myself to the ER closest to home.
When I arrived they gave me nothing for pain relief for nearly three hours because, I was told by an ER physician, “If you need surgery the doctor will want to examine you before you are medicated.” Not knowing any better, I reluctantly went along with the plan.
Meanwhile, they did x-ray, blood work, and urine sample, but found nothing. So the ER physician chalked it up to a bad case of constipation and gave me something for the pain. Minutes after taking it, I began dry heaves. When the ER physician returned, he was suprised I was throwing up, but without any further investigation decided I was having a nausea reaction to the pain medication and sent me home. After I quit the dry heaves I began to feel better and didn’t think any more of it.
Four days later, my wife and I went to join friends for an early Christmas get-together. We stopped along the way to gas up the vehicle and pick up a pastry and drink for each of us. Mine was on the rich side and 20 minutes later the severe pain in my abdomen returned. This time it snowballed to such pressure that I had all I could do to breathe. My wife exited the freeway to the closest hospital and right away they gave me something for the pain. In addition to the other tests they re-ran like the previous hospital had, they also called for an ultra-sound. That’s how they discovered a huge stone in my gallbladder.
When they did surgery that evening, they began the laparoscopic procedure only to find my gallbladder had swollen to four times its normal size, with one wall so decrepit that it was clear it could burst at any time and cause peritonitis. What would have normally been a 45-minute procedure took nearly three hours as they debated several times whether or not to open me up full-bore. Eventually they widened the incision at my belly button by three times the usual and slipped a bag around my gallbladder in case it burst while removing it.
After they finally got it out, the doctor inspected it and found that not only did it have the one large stone, but also “thousands of little ones.” He said I won the prize for the most difficult gallbladder surgery he had ever performed.
Now I am only a layman, but it seems to me that if they had run an ultra-sound test at the first ER visit this could have avoided a bunch of trouble. We complained to the first hospital, but 27 days later we still haven’t heard anything definitive regarding an investigation. It seems like they are dragging their feet on this. Talk about frustrating!
It sure was scary that Saturday morning when I couldn’t catch my breath and didn’t know what was going on. My health and my life were at risk from the danger of peritonitis due to the possibility of my gallbladder rupturing — all for a lack of curiosity and concern.
Steve from Wisconsin, Jan. 7, 2012
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We welcome comments below from others who may have experienced health care harm. We also want to remind you that we wrote our latest book to try to protect you and those you care about from just these kinds of terrible events:
Top Screwups Doctors Make and How to Avoid Them