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CASE 13
The Silence of the Hospital: Lessons on Supporting
Patients and Staff After an Adverse Event
The Story of Linda Kenney (United States)
Linda Ken ney
Editors’ Note Linda Kenncç considered herself nearly a profi’ssional patient. Born with bilateral cliii, feet, she had undergone 19 eor tee/tEe sulgeries oz-er the Lou;3e other li/e. In addition, her job was in health ca;: she worked as an administrati-;’e assistant I!? iii? operating rooni in a large medical center am/flit confident that she understood the system well. “1 was an administrative worker not a clinician, “she says, “but Igot to see amazing things.
In 1999, Linda was scheduledJbr her twentieth surgery, a right ankle replacement. An educated hea/theare consume,; she went to the hospital with a list oJthings she wanted This included a requestjbr an attending physician as h’, anesthesiologist. Linda a mid the surgeon had decided that he, anecthesia would be z poplitealfosca block, in which the numbing agent hupivacaine would he injected into a nerve in the ha-k o/J.’er knee to numb the lower leg and ankle. Linda did not want a resident doing this procedure. A hoard— certfled anesthesiologist named Rick van Pelt was scheduled to handle her nerve block. On the day of the operation, Linda told her husband to go on to work until the surgery Was over Bnt th urge;) d,d not go Jo; aaid am planned AJte; th an cth siologut administered the pop/iteal facsa block, Linda had a seizure,Jollowed by cardiac arrest.
163
Ihe an
e.th esio
lo ç’i.v
t h ad
,n j’,e
i/ tI,e
iierz’e (i/uiaccul’ntaIiv
n iect’d
the bupie
7/cal/Ic itito
the blood
vessel i,itec,c(
I,a.iiiin’ ihe
w as
in a
la r g
e teaching
hospital w
ith im
m ediate
access to
specialized k
n o
w l
edge ‘m
d e q u ip
m e n t,
L in
d a
su rv
iv ed
her cardiac
arrest, h at
she suffired
lingering phi,si—
cal e //c
t a n d
o n g o in
g em
otional trau
m a
M ost
disturbing o f
all she
Jilt, w
as the
h o sp
itaR fàilare
to provide
support either
to her
an d
h erJàm
ily or
to D
r v
an P
elt an
d
the other
clinicians involved.
L inda
tells the
story o f her
brush w
ith death
in the
hospital an
d h
ersu h
seq aen
t/b u
n d
in g
o fthe
nonprofit organization
M IT
S S
— M
edicully Induced
7}aunia S
upport S
ervices— w
hose m
ission i.c
“To S
upport H
ealin g
an d
R ejb
r, H
ope’to
patients, hint ilies
an d
cliii iciansf& llow
inç’ adverse
m edical events.
L E
A R
N IN
G O
B JE
C T
IV E
S
A fter
com pleting
this c a s e
study, you
w ill
he able
to:
1. D
escribe the
potential efficrs
o f
a m
edical error
or adverse
m edical
event on
patients, fam
ilies, and
health profrssionals.
2. D
iscuss elem
ents o f
a strategy
for disclosing
adverse events
and m
edical errors,
3. C
reate a
strategy for
supporting m
edically harm
ed patients
and their
fam ilies.
4 .
C reate
a strategy
for supporting
health professionals
w ho
have been
involved in
harm ing
a patient.
A N
ear-D eath
E xperience
I rem
em ber
everything th
at happened
th at
day before
the surgery
w as
supposed to
take place.
I rem
em ber
rolling into
the p reh
o ld
in g
area. I
rem em
ber telling
the anesthesiologist
th at
I w
as very
u n c o m
fortable about
the block,
lie told
m e
n o t
to w
orry, th
at he
had done
it a
h u n d red
tim es,
H e
w ill
tell you
now th
at he
has never
said th
at again.
In fact,
he w
ill tell
you th
at w
hen he
saw the
list o f
things I
w anted,
his im
m ediate
reaction w
as, “S
he is
going to
he a
pain.” T
oday, his
th in
k in
g has
changed to,“T
his is
a p atien
t w
ho has
som e
experience and
w e
need to
have a
conversation before
the surgery.”
So his
practice has
changed because
o f
w h at
happened th
at day.
F rom
the beginning,
I had
a bad
feeling about
this surgery.
I had
signed m
any consent
form s,
but this
w as
the first
tim e
I had
looked
at a
form and
had the
w ord
death pop
out at
m e.
I don’t
know w
hy I
felt th
at w
ay, but
w hen
1 th
in k
back I
w ould
say to
any patient,
“If you
have a
bad feeling,
honor th
at feeling.
It does
not m
atter how
crazy you
feel, h o n o r
th at
had feeling.
‘The last
th in
g I
rem em
ber is
saying goodbye
to m
y husband.
‘T hen
w e
w en
t into
the preoperative
holding area, and
th at
w as
w here
they injected
the block.
T he
procedure consisted
o f
going in
past the
blood vessels
into the
nerve. T
b do
thi.s they
have to
pull back
on the
needle; if
there is
no blood
then they
are sure
they are
into the
nerve. B
ut w
hen the
anesthesiologist pulled
back on
the needle
there w
as no
blood, so
he p t
the m
edication in.
and apparently’
it w
ent into
the blood
vessel anyw
ay. W
h at
they th
in k
happened w
as th
at he
did n o t
get any
blood because
it w
as a
b ro
k en
-d o w
n vessel.
I3tipivacaine is
a cardiotoxic
drug and
w ith
in a
m inute
I had
a grand
m al
seizure follow
ed by
a full
cardiac arrest.
‘They called
a cardiac
code and
started advanced
cardiac life
su p p o rt
rig h t
aw a;
but after
15 m
inutes I
w as
still unresponsive.
L uckily
for m
e, there
just happened
to be
a doctor
there w
ho had
experience w
ith this.
H e
knew th
at the
only’ w
ay to
save m
y life
w ould
he to
get m
e onto
cardiac bypass
rig h t
aw ay.
A gain,
things w
ere in
m y
fhvor th
at day:
there w
asa cardiac
suite already
prepared for
an o th
er p atien
t, w ith
a cardiopulm
onary bypass
m achine
prim ed
and ready.
T hey
b u m
p ed
the o th
er p
atien t
and w
ith in
35 m
inutes they’
had opened
m y
chest and
had m
e hooked
up to
a cardiopul—
m onary’
bypass m
achine so
th at
the m
edication could
be flushed
out o f
nn’ system
.
M v
husband w
as not
even out
o f
the m
ain lobby’
before I
had the
cardiac arrest.
H e
got a
phone call
from the
o rth
o p ed
ic surgeon
w ho
had stood
by’ in
horror w
atching the
w hole
in cid
en t
unfold. T
he surgeon
said, “i\Ir.
K enney,
there has
been a
problem w
ith the
a n
e s
thesia. \V
e had
to crack
your w
ife’s chest;
you need
to com
e iii.”
M v
husband ju
st dropped
the phone
and im
m ediately
returned. M
y husband
didn’t know
w here
to go,
but a
w om
an from
ad m
ittin g
16.
recognized him
and b ro
u g h t
him into
a room
. H
e w
as left
alone in
a sm
all room
until som
ebody’ cam
e to
get him
. I
th in
k about
th at
now .
S om
ebody should
have been
w ith
m y
husband.
T he
anesthesiologist and
o rth
o p ed
ic surgeon
w aited
for a
w hile
before they
cam e
to talk
to him
. A
s soon
as they
opened the
door m
y husband
physically w
ent after
them .
H e
said, “‘W
hat have
you done
to m
y beautiful
w ife?!”’T
he o rth
o p ed
ic surgeon’s
reply w
as, “It
doesn’t look
good. W
e don’t
know w
hat the
outcom e
is going
to be.”
W h
en I
w oke
up I
w as
on a
ventilator in
the intensive
care unit.
N o
one w
an ted
to talk
ab o
u t
w h
at had
happened. S
om eone
told m
e I
had had
an allergic
reaction to
the anesthesia.
I knew
intuitively th
at w
as w
rong, so
rig h t
aw ay,
as I
lay there
in the
hospital, I
felt unsafe
and u n tru
stin g .T
hat w
as n o t
a good
m ental
state to
be in
after w
hat I
had been
th ro
u g h .
M y
husband did
not w
ant to
leave m
y side
and did
not w
an t
anybody near
m e;
I’m sure
he w
as m
arked by
the staff
as a
difficult fam
ily m
em ber.
I found
out years
later th
at they
did not
ever ask
him to
leave. T
hey actually
changed th
eir practice
because they
saw th
at m
y husband’s
voice helped
calm m
e dow
n. I
w as
the first
p atien
t to
change this
practice.
I rem
em ber
w orrying
about m
y children.
T here
w as
no su
p p o rt
for any
o f
m y
fam ily
m em
bers. Y
ou could
see th
at the
staff felt
had for
m e,
hut nobody
w as
talking. M
y o rth
o p ed
ic surgeon
could barely
look at
m e.
I rem
em ber
w ritin
g a
note asking
if he
had replaced
m y
ankle. I-Ic
shook his
head and
looked dow
n. It
took m
e a
good w
eek to
grasp th
at m
y ankle
had not
been replaced.
I felt
ab an
d o n ed
. I
had a
rew ired
chest, broken
ribs, and
I looked
as th
o u
g h
I had
been beaten
up. I
rem em
ber tak
in g
th at
first show
er and
having som
ebody w
ash m
e because
I could
not do
it an
d fe
e l
ing the
m ost
vulnerable I
had ever
felt in
m y
life. I
g o t
m y
ch art
before I
left the
h o sp
ital and
it said
rig h t
on the
fro n t,
“A llergy
to P
E N
IC IL
L IN
and B
U P
IV A
C A
IN E
.” T
h at
w as
the route
they w
ere going.
A lone
a t
H o
m e
W h
en I
left the
hospital, I
received instructions
on caring
for m
y
incision and
in fb
rm atio
n about
a visiting
nurse. T hat
w as
all. I
never
got a
phone call.
A ll
I got
w as
a bill.
I had
had m
any day
surgeries
w hen
th e’
w ould
call m
e the
next day
and ask
how I
w as
doing.
T his
tim e
they alm
ost killed
m e
and I
didn’t even
get a
call.
A w
eek after
I got
hom e
I received
a letter
from the
anesthesiologist,
D r.
van P
elt. I
did not
know th
at he
had tried
to see
m e
several
tim es
in the
hospital, but
th at
m ultiple
things had
stopped th
at from
happening. In
the letter
he said
he w
as sorry
for w
h at
had happened
and th
at he
believed in
open and
h o n est
com m
unication. lie
gave
m e
his hom
e telephone
num ber
and cell
num ber.
I had
no idea
th at
w hat
he w
as doing
w as
so ahead
o f
the tim
e. M
y feelings
at the
tim e
w ere
th at
this w
as d am
ag e
co n tro
l. I
filed th
e letter,
an d
did n
o t
th in
k about
it for
a long
tim e.
W h
en I
got hom
e, C
h ristm
as w
as com
ing. M
y kids
w ere
all still
reacting to
w h at
had happened.
I w
as trying
to take
care o f
their
needs, and
I w
as physically
very lim
ited. It
w as
a slow
recovery. A
t
the tim
e, I
coped by
focusing on
being thankful
to be
alive and
ta k
ing care
o f
m y
fam ilyc
A couple
o f
m o n th
s later
I w
as feeling
b etter
physically. M
y fam
ily
and frien
d s
th o
u g
h t
I had
m oved
on, b u t
I k n
o w
today th
at I
h ad
not yet
processed m
y em
o tio
n s.T
h en
, w hile
at a
w ake
for a
14-year-
old child,
I began
to feel
guilty. I
felt guilty
th at
I got
to live
and
this child
had died.
It w
as like
the floodgate
opened, and
every
feeling I
h ad
b een
pushing dow
n ju
st cam
e out.
I began
crying and
felt as
th o u g h
I w
as never
going to
stop. I
rem em
ber crying
over
fo ld
in g
tow els.
I lu
st felt
iso lated
and alone
fir m
o n th
s.
I needed
a cortisone
shot in
m y
right ankle
due to
severe pain
because I
had not
had the
ankle replaced.
I m
ade an
ap p o
in tm
en t
to see
m y
o rth
o p ed
ic surgeon.
I w
ent in
and told
him th
at I
th o
u g
h t
16
w e
should talk
about w
hat had
happened. F
lis entourage
left the
room and
he told
m e
w hat
the (lay
w as
like fbr
him .
lie said,
“T hat
day is
burned in
m y
m em
ory like
the b irth
o f
m y
children, although
those w
ere joyful
occasions and
this w
as not.
L inda,
you are
a m
iracle.” B
y th
at tim
e everybody
w as
telling m
e I
w as
a m
iracle and
I (lid
not believe
it. H
e said,
“N o,
L inda,
you are
a m
iracle from
G od,”
and he
began to
cry
M y
first reaction
w as,“W
h at?
W h at
are you
doing?” B
u t
th en
c o m
passion cam
e over
m e
and I
looked at
him in
a different
light. I
felt bad
for him
. It
w as
the first
tim e
th at
anybody had
show ed
m e
th at
they cared
and th
at this
had had
an effect
on them
, too.
A s
the patient,
I needed
this. It
really m
ade m
e feel
b etter
to see
this reac
tion, h u t
alm ost
at once
lie stopped
the story
and w
ould not
finish. H
e got
up, w
alked to
the door,
and left.
A few
days after
this m
eetin g
1 called
the hospital
to ask
if there
w ere
o th
er patients
I could
talk to
w ho
had gone
th ro
u g h
this sam
e thing.
I knew
I could
not be
the only
one and
I needed
others to
talk to.‘They
never called
m e
back. M
o n
th s
later I
called m
y o
rth o
pedic surgeon
again and
asked w
h eth
er he
th o
u g h t
it w
ould he
reasonable for
m e
to invite
D r.
van P
elt for
coffee. T
hat w
as w
hen I
found out
th at
D r.
van P
elt w
as no
longer in
I3oston. I
felt as
th o u g h
the floor
had dropped
out from
u n d er
m e.
I th
o u
g h
t 1
had m
issed the
o p p o rtu
n ity
to ever
hear the
anesthesiologist’s perspective
and get
closure on
our shared
event.
I.uckily for
m e,the
orthopedic surgeon
w as
very’proactive.H e
reached out
to the
head o f
anesthesia departm
ent,w ho
contacted D
r.van P
elt. T
his ultim
ately led
to m
y phone
conversation w
ith D
r.van P
elt,w hich
w as
w onderful
for m
e because
I got
to hear
how affected
he w
as. I
felt as
though I
finally had
gotten to
hear the
tru th
from som
ebody.
I w
as the
first person
w ho
had asked
him liw
lie w
as doing.
T his
struck m
eas so
odd. E
ventually I
m et
o th
er people
w ho
had been
on the
code team
and all
they could
do w
as cry.
I rem
em ber
m eeting
a nursing
supervisor w
ho had
been tak
in g
care o f
the p atien
t next
to m
e and
I told
her I
often w
ondered how
the o
th er
patients going
into surgery
dealt w
ith seeing
this scene
unfold rig
h t
in front
o f
th eir
eyes. S
he said
th at
for the
peopl.e w
ho stayed
overnight, she
w ent
up to
see them
in th
eir room
s. S
he to
o k
it upon
h erself
to do
this all
on her
ow n.
I called
the hospital
and told
th em
th at
I could
not read
the w
ritin g
in the
chart, b u t
th at
I w
ould like
to know
w ho
everybody w
as on
m y
code team
because I
w anted
to w
rite th
em a
letter. It
w as
com ing
up on
m y
1-year anniversary
and I
really w
anted to
th an
k them
for doing
th eir
job. I
knew th
at for
th em
it w
as ju
st their
job, h u t
I
w an
ted to
articulate how
this had
affected m
y fam
ily and
m e
and
w h at
it m
ean t
to us.
I never
got a
phone call
back. I
have been
told
th at
they w
ere ju
st w
aiting for
the law
suit. tlhe
culture at
the tim
e w
as not
to speak
to anybody
involved in
a serious
adverse event,
but
I did
not know
this.
M o
v in
g F
o rw
ard A
fter a
year I
w rote
a letter
to the
ad m
in istratio
n .I
said th
at patients
left th
eir facilities
all the
tim e
after so
m eth
in g
had gone
w rong
and
asked w
hy w
e w
ere n o t
su p p o rtin
g them
. I
offered to
help them
m ake
the change.
I received
a letter
back a
couple o f
m o n th
s later.
It w
as very
cold and
w ritten
in legal
term s.
It m
ade m
e so
angry, I
w an
ted to
lash out
and h u
rt them
back. I
rem em
ber th
in k in
g , “N
ow
I know
w hy
patients sue!”
T hen,
finally, nearly
2 years
after the
event, D
r. van
P elt
and I
m et.
I w
as finally
able to
p u t
a face
to the
m an
w ho
w as
p art
o f
an event
th at
had such
an im
pact on
m y
life. W
e had
shared this
extrem ely
em o tio
n al
event and
I didn’t
even know
w h at
he looked
like. B
y this
tim e
I had
m et
a n u m
b er
o f
clinicians and
I believed
the system
had failed
us both.
I w
an ted
to change
that. I
rem em
ber telling
him I
w an
ted to
start an
organization, although
at the
tim e
I had
no idea
16
w hat
it w
oul.d look
like. M
IT S
S —
M ed
ically In
d u ced
T rau
m a
S u p
p o rt
S ervices—
bad a
b rain
sto rm
in g
brunch in
A pril
o f
2002, and
D r.
van P
elt w
as one
o f
the m
any invited
guests.‘This w
as w
here w
e developed
the m
ission o f
M IT
S S
and ideas
for how
w e
w ould
carry it
out. D
r. van
P elt
w as
one o f
the first
board m
em bers
o f
M IT
S S
.
I w
as so
naïve; I
really th
o u
g h
t th
at if
I started
this organization
all the
hospitals w
ould send
us the
people w
ho needed
our support.
I w
as so
w rong.’T
hree years
to the
day after
m y
adverse event,
I sc
h e d
uled an
ap p
o in
tm en
t w
ith the
risk m
anager o f
the hospital.
I had
M JT
S S
brochures and
I w
as going
there to
see if
she w
ould give
them to
all her
patients and
fam ily
m em
bers. I
left early,
all ready
for the
m eeting,
and after
I left
she called
the house
canceling the
ap p o in
tm en
t. So
can you
im agine
the look
on her
face w
hen I
show ed
up? B
ut w
e have
becom e
good friends,
and she
tells m
e now
th at
they did
not know
w h at
to do.
T hey
did not
know w
h at
I w
anted. T
he assum
ed I
w anted
som ething,
but all
I w
anted w
as to
he p art
o f
a solution.
‘They could
not co
m p reh
en d
that. It
has taken
years for
m e
to build
credibility w
ith this
hospital. W
h at
struck m
e w
as th
at if
w e
are not
acknow ledging
th at
these events
happen, not
doing disclosure
or apology,
then how
can w
e get
to the
su p p o rt
piece? It
has been
a journey.
I am
now startin
g to
see som
e progress,
h u t
it has
been slow
.
T he
in stitu
tio n
finally m
ade changes
and prom
ised to
p u t
our b ro
chures th
ro u
g h
o u
t the
hospital. B
ut w
hen I
w ould
go in,
I w
ould find
our brochures
on the
shelves in
the closets.
‘T hen
D r.
van P
elt and
I had
our pictures
on the
front page
o f
the W
all S
treetJo u
rn al
and suddenly
it w
as a
different gam
e. A
fter this
publication, I
had the
o p p o rtu
n ity
to m
eet w
ith the
hospital, and
w e
w ere
given office
space at
the hospital.
O n ce
I began
to learn
w h at
the challenges
w ere
for the
m edical
co m
m u n ity
w e
could look
for solutions
together, because
som etim
es they
just didn’t
see them
. T
hey needed
the patient’s
perspective. It
has been
a rew
arding partnership.
I w
ish people
w ould
take the
o p p o rtu
n ity
to em
brace th
eir patients
w hen
things go
w rong
because am
azing things
can happen.
C onclusion
S even
years after
the incident
described in
this chapter.
L inda
K en—
had her
long— postponed
ankle replacem
ent surgery.W
h ile
every
effbrr w
as m
ade to
allay her
and her
fam ily’s
fears before
surgery,
p o sto
p cratn
clv she
dcvclopcd i.surgical
site infection
th at
rcquircd
rehospitalization and
intravenous vancom
ycin antibiotics.
A fter
m ore
‘ears o f
acute isstes
Sand breakdow
n in
the replaced
ankle,
L inda
finall’ had
the ankle
replacem ent
rem oved
and a
total ankle
fusion in
2014. H
er nonprofit
organization, M
IT S
S ,
has continued
to grow
d u rin
g this
tim c
It is
now cn
tird v
consum cr-lcd
and is
i
leading source
o f
inffirm ation
on su
p p o rtin
g patients
and healthcare
professionals follow
ing m
edical harm
.
C ’ase
D iscussion
L inda
K enne
relates the
silence o f
the hospital
follow ing
her near—
death experience
from m
edical error
and the
reluctance o f
the hospital
to help
her anesthesiologist
reach out
to her
follow ing
her injunc
T ier
story illustrates
the w
ays in
w hich
the difficulties
o f
com m
unication
m agnify
the psychological
harm o f
an already
traum ati.c
event. T
he
silence th
at L
inda encountered
w as
the traditional
response to
harm
o f
m any
healthcare in
stin itio
n s,w
h ich
included severing
co m
m u n ica
tion w
ith injured
patients and
taking actions
aim ed
at reducing
legal
liability rathcr
than prom
oting hc
ding T
his response
c in
leavc both
patients and
healthcare professionals
w ith
a sense
o f
abandonm ent,
loss, and
uncertainty (M
IT S
S &
C art,
2009). S
urveys have
show n
th at
the m
ain things
m ost
patients and
fam ilies
w ant
after m
edical
harm are
an apologc
an explanation
o f w
hat happened,
and assurance
th it
steps irc
being takcn
to bring
m caning
from their
cxpcriencc h
prcvcntm g
its rccurrencc
A nccdotal
accounts also
indicate th
at m
any
healthcare providers
rem ain
troubled by
adverse events
th ro
u g h o u t
their careers
(C onw
ay, P
ederico, S
tew art,
& C
am pbell.
2011).
‘The m
ovem ent
tow ard
m ore
openness in
dealing w
ith adverse
events
in the
U n ited
S tates
began in
the 1990s
w ith
D r.
S teven
K ram
an
70 1
at the
l.ex in
g to
n ,
K entucky,
V eterans
A ffairs
hospital (K
ram an
& H
am m
, 1999).
It spread
to the
U niversity
o f
M ich
ig an
in 2001,
w here
attorney R
ichard B
o o th
m an
w as
a leader
in developing
a system
atic program
o f
disclosure, com
pensation, and
p atien
t safety
im provem
ent. B
o o th
m an
also reported
substantially reduced
legal and
insurance costs
(B o o th
m an
, lm
hofT &
C am
pbell, 2012).
T his
m odel
has been
described as
em phasizfingJ
both honest
com m
unication w
ith patients
an d
fhm ilies
an d
a 35/stem
s approach
to errors.
It prom
otes a
p rin
czled in
stitu tio
n al
response to
unanticipated clinical
outcom es
in w
hich health
care organizations
(1) proac—
tively identjfj’
at/verse evenis,
(2) distinguish
betw een
i?ju ries
cau sed
by m
ed i
cal negligence
anti those
arising fro
m com
plications of
disease or
intrinsically hiçrh—
risk m
edicalcare, (3)
of/erpatients fill
disclosure an
d honest
explanations, (4)
encourage legal
representation Jb
r patw
nts antifizm
ilies, an
d (S
, o/ftr
an apology
w ith
rapid a n
d fiir
com pensation
w hen
standards ofcare
w ere
not m
et. (B
ellet at,
2012)
A sim
ilar philosophy
em erged
in M
assachusetts in
2006 w
h en
the H
arvard hospitals
published a
set o f
guiding principles
based on
the view
point o f
the harm
ed p atien
t and
stressing su
p p o rt
o f
the p atien
t (M
assachusetts C
o alitio
n for
the P
revention o f
M edical
E rrors,
2006). in
2012, a
program based
on. these
principles w
as piloted
in six
M assachusetts
hospitals u n d er
the aegis
o f
a consortium
know n
as M
A C
R M
I, o f
w hich
L inda
K enney’s
organization M
IT S
S is
a m
em ber.T
h o
u g
h still
far from
universal, these
principles have
spread to
m any
hospitals in
the U
n ited
S tates.
O n e
im petus
for th
eir spread
has been
the ineffectiveness
o f
the legal
system ,
w hich
com pensates
only around
1% o f
m edical
error victim
s. P
ro p o n en
ts o f
the full-
disclosure m
odel cite
the perceived
in h u m
an ity
o f
the court
system tow
ard b o th
p atien
t and
provider and
the im
p ed
im en
t the
tra d
i tional
system poses
to education
and quality
im p ro
v em
en t
because o f
lack o f
learning from
m istakes.
In m
ost in
stitu tio
n s
th at
have adopted
the full—
disclosure m
odel, adverse
events are
assessed using
the “just
culture” approach,
w hich
looks for
the system
ic cause
o f
the event
rath er
th an
penalizing individuals
for m
istakes (B
ell et
al., 2012;
C onw
ay et
al., 2011).
Q uestions
1. H
o w
m uch
o f
a problem
do you
believe the
policy o f
not disclosing
errors to
patients m
ig h t
be? C
an you
envision circum
stances in
w hich
this w
ould create
ongoing problem
s for
patients and
th eir
fam ilies?
2. W
h at
adverse effects
have you
seen on
clinicians w
ho w
ere involved
in a
m edical
error? W
h at
do you
th in
k could
he done
to alleviate
these adverse
effects?
3. R
esearch som
e o f
the full-disclosure
program s
th at
have been
developed and
discuss th
eir m
ajor com
ponents. W
h at
barriers do
you see
to provider
disclosure follow
ing error?
F low
do full—
disclosure program
s overcom
e the
barriers to
transparency th
at exist
on b o
th sides?
4. M
u ch
o f
this story
is a
lack o f
com passion
in health
care. D
o you
th in
k there
are forces
th at
discourage com
passion in
day- to
-d ay
dealings w
ith patients?
If so,
how do
you th
in k
they could
be overcom
e?
5. W
h ich
o f
the core
com petencies
for h ealth
professions do
you th
in k
are m
ost relevant
for this
case? W
hy?
R eferences
B ell,
S. K
., Sm
ulow itz,
P B
.,W oodw
ard, A
. C
., M
ello, M
. M
., D
uva, A
. M
., B
oothm an,
R .
C ,
& Sands,
K .
(2012). D
isclosure, apology,
and offer
program s:
S takeholders’
view s
o f
harriers to
and strategies
for broad
im plem
entation. M
ilbank Q
uarterly, 90(4),
682— 705.
B oothm
an, R
. C
., Im
hoff, S.J.,
& C
am pbell,
D .
A .Jr.
(2012). N
urturing a
culture o
fpatient safety
and achieving
low er
m alpractice
risk through
disclosure: L
essons learned
and future
directions. F
ro n tiers
o f flealth
S erv
ices M
an ag
em en
t, 28(3),
13— 28.
C onw
ay,J., Federico,
F., Stew
art, K
., &
C am
pbell, M
. (2011).
R espectful
m anagem
ent o
f serious
clinical adverse
events (2nd
ed.). IH
I In
n o v a
tion S
eries w
hite paper.
C am
bridge, M
A :
Institute fbr
H ealthcare
Im provem
ent. K
ram an,
S. S.,&
H am
m , 0
. (1999).
R isk
m anagem
ent: E
xtrem e
honesty m
ay he
the best
policy. A
n n a ls
o f
In te
rn a l
M ed
icin e,
131(12), 963—
967.
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