Grand Rounds: “When Things go Wrong”

December 26, 2007

Bellevue AmphitheaterCommentary by Rosemary Adamson MD, PGY-2

Medical error, the most formidable of topics, was under discussion at ground rounds this past week. Dr. Tom Delbanco visited us from Boston to show his movie about patients’ and their families’ experiences of medical errors. Dr. Delbanco graduated from Columbia Medical School and did his residency at the Columbia Medical Division at Bellevue Hospital. He then moved to Harvard where he created one of the first primary care practice and teaching programs at an academic medical center; he was a founding member of the Society of General Internal Medicine and a council member of the American Public Health Association. He now holds the position of the Richard and Florence Koplow – James Tullis Professor of General Medicine and Primary Care at Harvard Medical School and is co-editor for the JAMA monthly series of case studies “Clinical Crossroads.” Dr. Delbanco started his talk with reminiscences from early in his career at Bellevue: His second patient actually died as the result of an anesthesia error.

Dr. Delbanco’s movie featured five patients and their families who had experienced significant medical errors. A bowel perforation after surgery for colon cancer; a child with leukemia who had died after being given Benadryl, to which she was known to be allergic; missed raised intracranial pressure leading to dementia and paraplegia. Each family expressed frustration about the lack of communication they had received from their doctors, frustration that they had not received an apology and frustration that their doctors had not tried to empathize with their experiences.

Dr. Delbanco emphasized 3 main themes: guilt, fear & isolation. It is not only doctors who feel guilty about mistakes made in the care of patients – the patient’s family members also feel guilty. Patients and their families have a fear of mistreatment if they voice concerns about their care. Patients and their families feel isolated when mistakes occur as doctors are apt to spend less time with them.

The movie and talk highlighted the importance of communication. Good communication is essential at all times between doctors and their patients but particularly at times of high stress, when misunderstandings can easily occur. Good communication is the key to the maintenance of trust and empathy is central to this. During the small group session after grand rounds, Dr. Delbanco explained the key components of communication after a mistake: an explanation of what happened, a sincere apology and a plan for how to avoid this mistake in the future. The group session also highlighted the idea that this process of explaining, apologizing and preventing future mistakes is helpful also for the physicians involved: closure is necessary for patients, their families and healthcare professionals.

The patients and their families featured in this movie expressed their knowledge that doctors are human and their wish to be treated as human by their doctors. A first step would be to remember that if, after a mistake, healthcare professionals feel guilty, scared and isolated, how much worse must these feelings be for those to whom the mistake happened. If we need support after a mistake, how much more do our patients?

Dr. Delbanco recently had a perspective piece on this topic published in the New England Journal of Medicine. He mentioned that this simple 2-page perspective has generated tremendous discussion from health-care professionals and the public at large.

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