Medical errors: A Harsh reality Description: During my last NCU shift, I was assigned to a patient who was fairly young in comparison to the others. He had spent almost a month in the ICU and was recently brought to the NCU due to the Acinetobacter outbreak. "He is a 51-year-old male with no past medical or surgical history and was admitted to the hospital for a mesenteric mass excision (the pathology showed benign adipose tissue)," I said as everyone, including my preceptor, looked at me with a confused look. I could tell right away what they were all thinking: Why is he here then? And what happened to him? These were also the same thoughts I had at the beginning. As I was very confused about the case myself, I went, previously early on in my shift, to ask the medical student who was assigned to him from the very beginning. I was in utter disbelief when he was trying to explain the reason that my patient suffered from duodenal perforation. He said in a low tone with no expression “to be honest, it must’ve been a medical error, they probably perforated the duodenum as they were trying to remove the mesenteric mass”. This “medical error” led the patient to undergo three life-saving laparotomies, and ended up developing sepsis due to an intra-abdominal infection (Candidemia). Even when he was in the “intensive care unit”, The amount of hospital-acquired infections that he caught there is just ridiculous. He caught Acinetobacter DTA, a ventilation-acquired infection, and Candida Albicans, a central line-associated bloodstream infection, and he also developed cellulitis of the abdominal wall. This led the patient to go into severe septic shock and eventually acute respiratory distress syndrome. Feelings: The first thought that came to me when I first looked at the case through epic was, "Oh!" He is the same age as my father. As I was listening to the medical student talk so nonchalantly about the cause of this case and the medical error, I was utterly dumbfounded. It felt like a flood of emotions submerged me; I was sad, mad, and in disbelief. I was sad because my father is my backbone, and now that I could see my father in that patient, I felt like my world had collapsed because I wouldn’t want something so horrific to happen to him. I was mad at the medical student for brushing it off, but then again, I was conflicted because he was the one who put the patient in this position. I was also in disbelief because, at that moment, it felt like everyone knew but was pretending not to. At the same time, a million thoughts were popping in my head. Who’s more at fault? the surgical team in the operating room? Or the nurses and medical staff who should’ve been more cautious about the patient getting all these hospital-acquired infections? Is the family aware of this? Did they compensate and reach a middle ground or at least apologize to the family? Evaluation: Overall, this experience was pretty bad since everything that happened could’ve been prevented if they were more careful, honest, and thorough. It all went wrong, from the dismissed medical error to the mishandling of infectious precautions on the patient, whether it was from the nursing staff or the medical team since they have a history of getting into a patient’s room who has contact plus precautions, for example, without any PPEs. However, we can’t blame it all on the surgical, surgical, and medical teams since mistakes, unfortunately, do happen, but it is the action that we proceed to take after them that ultimately matters. Currently, they’re trying to do their best and are hoping for the best outcome for the patient. Analysis: It all started with a medical error until the patient developed severe septic shock and ARDS from the multiple hospital-acquired infections, which ultimately significantly increased his mortality rate. Medical errors are not shameful; by the end of the day we are humans, we’re not perfect, and we make mistakes. But not owning up to the mistakes and allowing further damage to occur is what is shameful. A shift away from the current culture of "name, blame, and shame" and toward a "no-blame" scenario in which mistakes can be more openly admitted and discussed is needed. Many errors are built into existing routines and devices, putting the doctor and patient at risk (Tevlin et al., 2013). It felt like in this patient’s case, they weren’t trying to cover up the mistake, but at the same time, no one was talking about or expressing how it was handled, and in my opinion, this is even more shameful. Physicians have an ethical and professional obligation to inform the patient if a medical error occurs. Yet, I can also sense and feel the cultural and occupational pressure put on healthcare providers, whether it be from the overwhelming patient-to-nurse ratio or from the intensive hours of shifts for physicians. We must ensure that the "learning moment" is stressed and that mistakes are learned from rather than simply forgotten. The "name, blame, and shame" culture must be replaced with one that is open, transparent, supportive, and committed to learning (Tevlin et al., 2013). Looking back at this, it also made me wonder: if mistakes are constantly disregarded, then how are we actively learning from them? Although the publication of every medical error has the potential to cause widespread harm and foster mistrust in medicine, This is not to say that serious errors should be routinely and uncritically ignored. However, the first occurrence is probably best viewed as an opportunity for education rather than litigation. By the end of the day, the family and the patient’s health condition should be our main focus. Conclusion: Errors will never disappear from medical practice; hence, our aim should be to ensure that they occur as rarely and as humanly possible. However, if they do happen, it is important to manage and disclose them properly. in order to minimize the harm that was done and to at least prevent further harm. I don’t know what exactly happened in the OR when the medical error occurred, but what I know for sure is I would’ve definitely reported it right away since it is not something we can turn a blind eye to if there’s any. Also, I wouldn’t let such a critical case be handled so loosely to the point where it caught multiple infections that further made his condition deteriorate. Action plan: If I were the nurse taking care of the patient in the NCU again, I would have probably stressed to the medical team to wear the proper PPE. I would’ve started my morning round with this patient if I had another patient who had an infection. I would try to minimize the amounts of time I go in and out of the patient's room as much as possible while still taking care of him properly. I would also limit visitors, be strict with the precautions measures, and also educate them about them, as a lot of them tend to not comply. References: Tevlin, R., Doherty, E., & Traynor, O. (2013). Improving disclosure and management of medical error – an opportunity to transform the surgeons of tomorrow. The Surgeon (Edinburgh), 11(6), 338343. https://doi.org/10.1016/j.surge.2013.07.008 An Ethical Dilemma: Medical Errors And Medical Culture. (2001). BMJ: British Medical Journal, 322(7296), 1236–1237. http://www.jstor.org/stable/25466945
