By Julie Marshall
One Thursday in August 2005, Leilani Schweitzer brought her sick child into a hospital in Reno, Nevada, where staff diagnosed him with a common stomach flu.
By the following Tuesday, Gabriel—who was just 20 months old—was dead because of a hospital error: A nurse had accidentally shut off the alarm linked to his heart and breathing monitors, so when Gabriel’s heart stopped beating and he ceased breathing, no one knew, including his mom, who had slept in a chair next to his hospital bed.
“I had hoped that I would wake up and find out this was a nightmare,” Schweitzer says, “but this was worse than any nightmare.”
Schweitzer’s experience isn’t unusual. A 2016 Johns Hopkins study estimates that more than 250,000 Americans die each year from medical errors, ranging from post-surgical complications to administering the wrong medications. That puts medical errors among the top three causes of death in the United States, just behind heart disease and cancer, according to the Centers for Disease Control.
When hospital errors occur, it’s vitally important that facilities respond expeditiously, says Schweitzer, who advocates for hospital transparency nationwide through a model program she created at Stanford University Hospital. But it’s still common practice for hospitals to “remain quiet, let the lawyers take over and keep patients in the dark,” she says.
When asked to explain its policies and procedures for when the unexpected happens, University of Colorado Hospital declined an interview. Dan Weaver, senior director of communications, explained in an email: “Our chief quality officer says we have a program … but we’re currently expanding it, so he thinks we’re just not ready yet to discuss it.” Children’s Hospital Colorado also declined an interview, but without explanation.
In contrast, one of Colorado’s largest healthcare providers and several Boulder County hospitals were willing and even enthusiastic to discuss how they support patients and their families, as well as medical staff facing the painful trauma of unforeseen events. Administrators at these facilities believe that honest reporting done with compassion is the best way to prevent future mistakes and to save lives.
The truth and an apology go a long way, Schweitzer says. “When something goes horribly wrong and you don’t know what happened, you tend to blame yourself,” she says. “We all need to know the truth to heal.”
Everyone Makes Mistakes
Everyone makes mistakes, says Dianne McCallister, a physician and chief medical officer at The Medical Center of Aurora. In fact, science shows that the average person makes seven errors each day, but in health care the consequences can be tragic, she says.
When the unexpected happens, McCallister is often the one offering an apology on behalf of the hospital.
“It’s humbling,” she says. “My entire job is about preventing mistakes, but when something does go wrong, we apologize.”
At Boulder Community Health, staff also take the initiative to apologize when it’s the right thing to do, says Jackie Attlesey-Pries, vice president of operations and chief nursing officer. “As soon as we identify something that didn’t go as planned, we apologize to the patient or family members or both.”
An apology is only the first step toward a meaningful culture of transparency, Schweitzer says. Hospitals must further investigate, fix system errors and, finally, offer compensation.
“It’s powerful when hospitals help patients heal from medical errors,” Schweitzer says, “just like they help people heal from illness and disease.”
Free to Speak the Truth
Morally and ethically, we know that (an apology and disclosure) is the right thing to do when medical errors happen, says Shawn Dufford, a physician and chief medical officer for six Colorado hospitals, including Good Samaritan Medical Center in Lafayette.
“Historically, hospitals and providers have been constrained from being forthright with their patients under the direction of insurance companies and attorneys,” he says. “This approach stunted our ability to fix the problems and prevent harm from recurring. It also prevented patients, family members and clinicians from healing after a catastrophic event.”
Over the past decade, dozens of states—including Colorado—have passed “I’m sorry laws” to protect physicians and staff who wish to voluntarily apologize. Colorado’s statute is one of the strongest, stating that a provider’s admission of “fault” to a patient is not admissible in court. Proponents of these laws point out that apologizing decreases lawsuits against hospitals and providers.
With legal protections, hospitals have begun crafting new programs and policies that encourage honesty and transparency, administrators say. For instance, two years ago, Good Samaritan Medical Center in Lafayette created The Bridge, an apology and disclosure program that doesn’t stop after one conversation, Dufford stresses.
“When something goes horribly wrong and you don’t know what happened, you tend to blame yourself,” says Schweitzer. “We all need to know the truth to heal.”
“A key component to The Bridge program is our commitment to follow up with our patients. These are rarely “one and done” conversations. We encourage our patients to be involved in the ‘fix’ of any system issue that led to the error. We reach back out to them regularly.”
This is very important, Schweitzer says, because it can take time for patients to digest what happened to them. “They want information, understanding and the opportunity to have all their questions answered.”
Fixing the System
Even with legal protections, clinicians must feel supported from the top down for transparency to work, says Schweitzer, who has watched top physicians and nurses quit the field because of lack of support.
Providers want to be assured they won’t lose their jobs for speaking candidly, says Beth Fischer Reasoner, a registered nurse and group director of quality resources for Centura Health, which includes both Avista Adventist Hospital in Louisville and Longmont United Hospital.
“Honesty and transparency are only possible when we eliminate the fear within clinicians of being personally blamed or punished for errors that are clearly system or process issues that need to be fixed,” she says. “When fear is successfully eliminated by the efforts of healthcare leaders of an organization … staff will not only come forward with their own errors but will actually start reporting near misses so that problems can be fixed before they touch a patient.”
Room to Improve
Schweitzer receives daily telephone calls and emails from around the country from people wanting her help because they are the victim of a hospital error but have not experienced full disclosure or, in her words, been made whole.
“This tells me there is still a significant need not being met,” she says. “It’s difficult work to sit with people in their pain and to offer amends. But it’s a profound thing to see how healing it can be for everyone on all sides to have an opportunity to understand the truth.”
Julie Marshall is a freelance writer, author and community organizer in Lafayette. Visit her online at www.brainsong.net.