Silence Around Surgical Errors Is Jeopardizing Patients, Experts Say

Both problems undermine a patient-focused environment and stifle error reporting that could reduce medical mistakes.

The thought of medical errors isn’t likely to be on patients' minds as they’re wheeled into an operating room, according to research by the Institute for Healthcare Improvement and National Patient Safety Foundation.

In fact, these watchdog groups discovered in their poll of 2,536 adults that nearly two-thirds of Americans don’t believe medical errors are likely to happen to them. The harsh reality is that 21 percent have experienced at least one.

Patient advocacy groups are convinced that speaking up about errors can actually make a difference in lowering systemic risks for everyone who needs surgery. However, many patients don't report mistakes even when they become aware that an error is responsible for their present suffering.

A 2016 study found about 250,000 deaths annually are due to medical error, making it the third leading cause of death in the United States, where it’s more problematic than other developed countries.

Louise Aron was injured during surgery—her small intestine was nicked during a liver stent procedure—and she died shortly afterward. Though she had stage 4 colon cancer, the surgery wasn't considered high-risk. The mistake prompted the surgical team to suture her and transfer her to immediate hospice care.

Her daughter, Dr. Rosia Parrish, told The Epoch Times that she’s still overwhelmed with regret and sorrow and has yet to review the medical records to understand how the situation was handled.

“The sudden shift to hospice was heartbreaking, as the surgery was initially expected to be life-saving or at least life-extending, but it did not achieve either of these outcomes,” she said. “In hindsight, I wish we had chosen a top-tier hospital, even if it meant traveling farther.”

Not all errors result in tragedy. Most surgical errors are “near misses,” events that could have harmed a patient but by chance or mitigation did not. Surgery accounts for about a quarter of medical errors, but others might involve care received before or after an operation. For instance, medication, communication, and infection are common sources of mistakes outside a surgeon’s purview.

A great deal of research shows that patients who are told about mistakes are more likely to follow medical advice, and continue with care while being less likely to seek malpractice lawsuits, according to “Patient Safety and Quality: An Evidence-Based Handbook for Nurses.”

“Patients have the right to know; patients and the public strongly desire disclosure. Failure to disclose mistakes and unanticipated outcomes limits opportunities for evaluation of systems and processes, and for sharing knowledge gained by publishing safety alerts across organizations, conducting educational sessions, modifying practice, and offering opportunities for improved performance,” the book states.

Dr. Parrish found herself once again facing the horrors of surgical complications a year after her mother’s death when she had an emergency cesarean birth.

In this case, the staff didn’t thoroughly review her medical history. Dr. Parrish experienced cardiomegaly (enlarged heart), postpartum hypertension, and nocturnal hypoxia—a condition characterized by low nighttime oxygen levels.

She used an oxygen tank for more than a month, had a series of pulmonology and cardiology appointments for several years, and continues to have no nerve sensation above and below her c-section scar.

In stark contrast to her mother’s death after which there were no apologies, Dr. Parrish’s hospital provided exceptional postoperative care with additional visits and even provided her with internal medical records that were not part of her file. Apologies facilitated healing.

However, the American Medical Association Journal of Ethics said they don’t go far enough. For instance, few states have laws protecting expressions both of sympathy and of fault from being entered into medical malpractice lawsuit evidence. This puts an unofficial gag on doctors, it said.

On the other hand, only 10 states even require physicians to disclose an error to the patient. Some doctors hide behind the fact that the definition of “medical error” is vague.

Adverse events are a type of injury that often happens in surgical treatment that isn’t really caused by the underlying medical issue of the patient. Adverse events are preventable, but not all are the result of an error, according to medical error and prevention training for clinicians. Preventable adverse events occur when there is a “failure to follow accepted practices.”

In such situations, the only witnesses to errors are the health care team. Fear of negative consequences—retribution, job security, malpractice lawsuits, and reputation damage—might mean providers only report those errors associated with harm or those that can't be “covered up,” according to “Patient Safety and Quality.”

Earlier this year, Ms. Kehart woke up in an intensive care unit unable to get answers for why she was there after a standard stent procedure.

She was told she needed a longer hospital stay. She thought she overheard someone mention that she had coded—medical language for a cardiac arrest. There was also talk amid staff of contrast dye allergy listed on her chart that she repeatedly told them was an error. Despite large teams of clinicians going in and out of her room, nobody seemed interested in anything she asked.

“This nurse gets three inches from my face and says, ‘Mrs. Kehart, I want you to listen to us, be quiet, and do what we say.’ I said, ‘Excuse me. I may be old but I’m not stupid. Let’s talk about what’s happening.’ And they wouldn’t. They said I had to stay but they wouldn’t tell me why,” Ms. Kehart recalled.

Frustrated by the lack of transparency, she demanded to be discharged. The hospital refused to let her leave in a wheelchair and made her sign paperwork, which later disappeared, on which she wrote that nobody would answer her questions about what transpired during her surgery.

“I appreciated that attitude. I still have a lot of stress,” Ms. Kehart said. “I’ve had a lot of surgeries, but I’ve never had any worries before. It’s scary now.”

Most patients don’t believe filing reports will make a difference. Four in 10 of those who didn’t report medical errors in the Institute for Healthcare Improvement (IHI) poll said they didn’t know how to.

Confusion is understandable. There is no universal system that patients can use for reporting errors. Most states have few guidelines, and the burden of creating a system for reporting errors falls on each individual hospital or health system.

Errors can be reported to the state public health department and the state medical licensing board to make a complaint about a physician, as well as to the Joint Safety Commission, a nonprofit organization that accredits hospitals and is responsible for patient safety.

Patients are perhaps the less obvious stakeholder, but Dr. Stahel and patient safety groups agree that not speaking up about medical mistakes is a contributing factor to the proliferation of errors.

Research has found that patients who are involved in their care, ask questions, and speak up—having high “health literacy”—can help minimize errors.

However, recognizing when an error has occurred can be challenging. Only one-third of patients have been told that a mistake occurred to them, according to IHI data.

And nearly half of American adults have trouble understanding or using health care information, according to an Institute of Medicine report. This becomes a stumbling block to improving care quality and reducing health costs.