Module II

This week I reviewed the section on medical errors. This case really reminded me of the Dana-Farber Cancer Institute. It was also a highly regarded research hospital that came under much public scrutiny after a lack of communication led to medical errors and consequently a patient death. Within a Capstone assignment we were instructed to come up with a plan on how we would deal with it as an administrator. As any health care lawyer will tell you a physician's relationship with the patient often determines whether litigation will follow. Also by example of John Hopkins, it is always best to have open communication with the family when medical errors occur.

In one instance a family whose daughter died at Johns Hopkins from a medical error teamed up with the hospital to develop medical prevention techniques. Although this may sound unusual the family, instead of blaming the hospital for the error and harboring ill will, worked together with Johns Hopkins and quietly settled out of court due to the hospital's open demeanor in explaining the cause of their daughter's death. So with open communication the hospital turned a liability into a strength.

Below is an article that shows how having open communication about medical errors can actually be a risk management technique. http://web.ebscohost.com.ucfproxy.fcla.edu/ehost/detail?vid=12&hid=106&sid=399d8d56-acf8-4345-a595-7f1a5042c695%40sessionmgr108
Here David Studdert Melio, M., Gawande, A., Brennan, T.A., and Wang, C.Y. also state that such communication is the only way effective preventive strategies can take place or be constructed in the first place.

Getting back to the case in the Perry book, this question definitely has legal implications. I would consider withholding information about medical treatment they are receiving a definite violation of informed consent. This is due to the fact that chemo is not one isolated incident but an on-going treatment lasting over years so shouldn't the patient have a right to informed consent for each and every treatment? Physicians should always note that patients may not always be giving the full details about how they are coping with the chemo from treatment to treatment. Thus they cannot rely on themselves to catch something adverse reactions to overdoses. One main lesson from the Dana Farber case is that even the most gifted and close group of physicians and nurses cannot be trusted to catch everything.

In my opinion in cases like these..."the truth will set you free". This is a great burden for staff and physicians to carry by keeping secrets and definitely does not set the correct tone and culture for the organization. If incidents like these are let slip by the organization as a whole will simply keep spiraling down until something devastating happens. If some of the best hospitals in the country are able to step up and admit mistakes and actually benefit from it, open communication should not be a scary proposition for health care administrators. Trust is something one can rarely win back especially when it regards one's health.

I will end with an example from my life. This Thursday, we had a home health nurse inform us that her client was not in her room and other staff had commented that the last time she was seen was outside in the garden close to the exit. This resident is also under watch for having dementia problems and administrators feared that she had wandered out into the city's downtown streets. If the company had done what those in the case had done they would have had followed procedures and searched for 15 minutes and then called the police. However by calling the family first they were able to find out that the granddaughter had taken the resident to another floor to visit friends. Open communication about possible errors can often be the key to the error's solution.