Flying Blind: Why do we keep blaming the victims of medical errors?
March 20, 2017
Most coverage of Prince’s death assumed he was an addict who had tempted fate. The role played by mislabeled fentanyl pills was largely overlooked.
A patient dies in the operating suite, and a counter narrative begins to unfold. The patient was old and frail. They failed to tell the doctor about a medication they were taking. They did not follow the pre-operative protocol.
The list goes on.
Dr. Kevin Kavanagh from Health Watch USA wrote an article for the Journal of Patient Safety recently that compared the way we approach medical errors to the way we approach plane crashes. Kavanagh wrote me to underscore what he thought were the main points of the piece:
The most important message is that the errors and preventable deaths are far too common and the patient context (age, illness, life choices) must be dissociated from medical errors and not used to mitigate their occurrence.
I have experienced this first-hand in writing about medical errors. Hospital executives and physicians have pointed to other issues patients had to explain the deaths. They were smokers. They were obese. They had a chronic illness.
Yes, these all are risk factors. But whether an obese smoker with diabetes dies today or 20 years from today may be entirely because of a preventable medical error.
Take the example of Prince, who died from taking too many painkillers. A lot of coverage of Prince’s death, while acknowledging that he was one of the world’s great musicians, also took the tack that he was an addict who had been playing with fire. I applaud Stephen Montemayor at the Minneapolis Star Tribune for pushing to get access to records about Prince’s death and reporting in August that the fentanyl pills found in Prince’s system may have been mislabeled as hydrocodone, something that could have led to him taking too many of them. Danny Cevallos at CNN wrote:
If a corporation mislabeled or manufactured the pills, the Federal Food Drug and Cosmetic Act outlaws engaging in interstate commerce with adulterated or misbranded drugs. Penalties include imprisonment and sanctions like seizures, injunctions and fines.
Here’s how Kavanagh and his co-authors respond to patient blaming, using the National Transportation Safety Board as a contrast.
When reporting airline crash deaths, the NTSB reports the total deaths. If 350 people die, the NTSB reports that the crash caused the death in 350 people, not 348 because two of them had terminal disease and would have died anyways.
The “would have died anyway” assumption is often present in the way reporters cover the deaths of someone over 70 who dies from a health care-related complication. Essentially, if someone is older, there are fewer questions about why they died. I wrote about this when Andy Rooney died, noting how there was a decided lack of interest in the fact that he apparently had a minor medical procedure and died from complications related to it.
If we had better information about these medical procedures, those types of claims would be much harder to make. Having better information would allow us to better assess causality. Kavanagh and his co-authors wrote:
A single causative event is often difficult to define. For example, if a patient dies of an acute myocardial infarction, was this the cause of death? Or was it high cholesterol, obesity, diabetes, or smoking? Or perhaps was it because the patient waited in emergency triage for two hours and did not receive thrombolytic agent in time. One could make a case that any one of these could be the cause of death.
The authors recommend better and more regular reporting of health care-related incidents to federal agencies, including more thorough reporting of health care-acquired infections. They also make the point that we can’t afford to wait for perfect data. Multiple studies have placed the estimate of annual hospital-related deaths in the United States at more than 160,000 and possibly as high as 440,000 (although that last number does seem staggeringly high given that there are about 2.6 million deaths all told in the U.S. every year.)
I agree. We will never have perfect data on every death in the country, regardless of whether it happened in a health care setting. We need better tracking of the contributing factors to a health care-related error. We need better synthesis and analysis of that data. And we need to stop pointing the finger at patients to avoid taking a harder look at all the other pieces of the health care puzzle.
[Photo: Andrew Caballero-Reynolds/Getty Images]
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Comments
Recordings needed!
Thank you for this article and thank you to Dr. Kavanagh for recognizing that patients get blamed, data is flawed, & better & more regular reporting of health care-related incidents to federal agencies is needed. Dr. Makary (Johns Hopkins) and Dr. Aaning (Health Watch USA presentation-2016) have both identified recordings as way to improve patient safety & help good physicians too. Enough with the high error rate & harm. Let's try recordings as a way to improve safety. It worked for the aviation, transportation, banking and food service industries. Software exists to distort voices and faces. It's affordable, easy and benefits everyone. Let's improve the system. As the mom of a child who experienced a preventable adverse outcome, this is an important topic.
Great work!
Great work!
Since deaths from medical
Since deaths from medical errors, mistakes, and accidents are almost never documented on death certificates, federal and state authorities have no clue as to exactly how many deaths result from medical complications. This explains the wide range of estimates of such deaths, contrasted with the precise number of people dying in airplane accidents...
Blame the patient
After my 19-year old son died, his medical records were falsified to suggest that he had been offered a pacemaker. In fact, he was offered only a loop monitor, which he did refuse. Records of that offer and a letter from the "expert" cardiologists, as well as my witness prove this. When I asked those doctors who had falsified records to correct the record based on clear records that I sent them, they ignored me or refused. I had a heated discussion with the pathologist that examined my son's heart. He refused to change his records. A pacemaker might have saved my son's life, a loop monitor would not have done this. Blame the patient does not get much dirtier than this.
No corrections
John James, I am so sorry about your son. Code of silence & deny and defend hurt too many. Thank you for bravely telling your story.
Blame the patient
"They," (The Medical Cartel), took everything away from us that ever meant anything. Health, loved ones, quality of life, and financial resources. When these things are taken away from people, then people have nothing to lose. What can anyone sue us for or publicly chastise us, when we no longer give a s**t and all we have left is the truth? Can they threaten us with law suits? I say "bring it on." Can they threaten us with public humiliation? I say we are already humiliated when we are treated like the lepers who are ostracized from families, friends, neighbors and the medical cartel. Truth is all we have, and as long as it is available and we can bring it out in the open to warn others. Our lives were never the same after the "event." Our lives changed forever the instant we were maimed, harmed or lost our loved ones. I can see this in the way I act, respond, and no longer enjoy the things I used to participate in. I find I have a short fuse, the inability to be in a room when I find there are idiots who irritate me with their misinformation or lack of information, or just do not want to hear the truth in any subject matter. I find my tolerance is at an all time zero when I see self centered adults who do not even know basic history but they are busy taking selfies. I have never seen so many narcissistic and disrespectful people in my life and their lack of common sense and inability to problem solve is amazing. I find I spend less time with people and more and more time reading and communicating with people I never physically met, like fellow advocates who have been through the same nightmare. . All of us changed after we were damaged or lost our loved ones. In many respects, we are psychologically damaged, much like veterans returning from a war with PTSD. Many vets could never adjust to civilian life after they return from combat. In many respects, neither could we.
Many of us are treated like the enemy by the medical cartel, the misinformed public, our families and mainstream media. When people are treated like the enemy, they become the enemy. We become the public's worse nightmare because we have nothing to lose.
Examining blame
Patients often die because they deteriorate in the hospital an no one notices. It is a nurse's job to notice, but if you've got a patient load that is 2 or 3 times a safe load, patients deteriorate unnoticed. If there are hospital managers who think replacing RNs with techs is a good idea, patients deteriorate unnoticed because though techs may dress like nurses, call themselves nurses (sometimes), and give patients the illusion they are getting nursing care, techs do not have a nursing education and cannot detect subtle symptoms that signal deterioration. An obvious solution is to hire actual nurses to do the nursing work--and plenty of them. But media stereotypes and long standing assumptions about who nurses are and what they do have led hospital managers to replace nurses with techs. So dangerous symptoms go unnoticed and patients needlessly die. If we want to stop errors as the third leading cause of death, we should start following nurses and learning about the valuable work that they do as happens in this program https://www.uchealth.org/today/2017/03/14/a-morning-in-their-shoes/ If people knew what nurses really do to save lives, they would start valuing it and then funding it.
Better reporting
Over a period of years thousands of injured patients called me just trying to figure out how to get iatrogenic injuries treated, because they couldn't. No one was going to create a diagnosis, let along a report, that suggested that they had iatrogenic injuries. The first thing I would tell them to do was get their records. Almost universally they were shocked to find that there was nothing in the original record to suggest they had been injured.
I'm not sure what could be more naive than to call for more and better reporting. A thousand years from now people still will have faith that it is possible for something good to result from asking for more and better reporting. But there still won't be any if it is left up to health care professionals to do the reporting. When things go wrong in medicine, the people who don't report it don't think they are failing to report something, rationalization is so strong. There are things you cannot understand about medicine until you have watched your primary care physician rearrange his beliefs to secure his own comfort at the expense of your physical well-being. It is the routine when things go wrong, and so is being in denial deeply enough to imagine that it is not the routine. If you are in medicine and you imagine it is not, you are a member of the club.
Medical records
As long as the medical industry enjoy the luxury of exploiting the exception to the hear say rule (manipulating material facts, omitting material facts) in medical records, there can, will NEVER be improved outcomes or improved work enviorment for providers.
Period.
Yes, the victims are blamed
Thank you for your article. You are all too right that the victim is often blamed for the error - the victim's so called 'non-compliance' or risk factors.
To truly understand what happened, we need professional investigators, who are schooled in safety science and human factors, and can understand medical records, to evaluate what went on. Most physicians are not trained to do this.
After losing my sister to a significant delay in diagnosis of cardiac chest pain, I am less tolerant of the blase' approach to concerns that I bring up regarding health care. I am certain I am often labeled as a 'difficult patient'. Which misses the point completely...those of us who are looking out to improve the system should be welcomed, not shunned.
Thank you for writing about this.
JodI Mahle
Joedi Mahle died this weekend. She never made it to that detox bed in Ernie Turner. ANMC treated my sister like crap. These addicts truly wanting change need to be given that med that could make the difference between life or death. So far ANMC hasnt given these addicts a fighting chance and here there is a med that takes detox symptoms and makes them non existence. ARe they giving it away...ohh but theyll give free needles!!! RIP Baby sister "JODI MAHLE" you are not alone baby....YOu were loved ny JUlie Jason Gerald SR Anthony Wesley Austin Dakota AiyaNA aCHILLES Brianna Heaven Alice JR Henry and Robert
Jodi
Hi Julie, this is Kyle Hopkins in Anchorage, the reporter who interviewed Jodi in 2014.
I'm so sorry for you loss.
If you would like to connect to talk, I am still interested in writing about addiction and problems with the public health safety net in Anchorage and Alaska and would like to hear your thoughts. I can be reached at (907) 854-8540 or by email at khopkins@ktuu.com. Or if you prefer Facebook, I can be reached here: https://www.facebook.com/KyleDHopkins
Kyle
Blame the patient
I was castrated in 2015, at 50 years old, against my recorded wishes, because my surgeon decided, because the average woman reaches menopause at 51 and the average woman has a 1% lifetime risk of developing and dying from ovarian cancer, that the only way he would perform a hysterectomy for benign reasons (fibroids causing heavy bleeding and anemia) was to remove my ovaries, regardless of the health of my ovaries. Although my request to keep my ovaries, if they were healthy (normal), was documented in my medical records by the Ob-Gyn who referred me to his partner the surgeon, the surgeon stated he was never told I wanted to keep them, and that if he had known, he would have cancelled my surgery. The surgeon said I should have known he was going to remove them, regardless of health, because the removal was in his treatment plan. The surgeon never documented discussing removing my ovaries in any of the exam notes, and he never documented my agreement to the removal. The surgery scheduled was TAHBS according the surgical scheduling form and the medical file cover page, but he performed TAHBSO.
Very good article. I enjoyed
Very good article. I enjoyed the post and discussion in the comment section.