Jul-Aug 2002 Table of Contents

BALANCING ACT

When Medical Errors Hit Home



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Her father’s illness brought this FP face-to-face with the potential price of medical mistakes.

Fam Pract Manag. 2002 Jul-Aug;9(7):66.

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Last August I began a journey through the health care system from the perspective of a daughter who also happens to be a doctor. My father, who lives 500 miles away, was having some chest discomfort and shortness of breath. A 59-year-old man who viewed himself as relatively healthy, he’d never considered cardiac disease. Yet after an angiogram revealed almost total occlusion of the high left anterior descending artery as well as serious involvement of two other coronary arteries, he faced surgery for three-vessel bypass.

In the two months that followed, I became keenly aware of how unsafe our medical environment can be for patients. My father’s providers were all well educated, caring and competent. The institutions were clean and offered state-of-the-art diagnostic and treatment modalities. Yet our experience was fraught with errors – some minor, some potentially fatal. According to the Institute of Medicine, “a major force for improving patient safety is the intrinsic motivation of healthcare providers, shaped by professional ethics, norms and expectations.”1 To that I would add three personal lessons I learned while trying to help my father navigate the system:

Listen carefully

After listening to the preop informed consent and signing the appropriate forms, my father felt prepared for his surgery. But he seemed a little too calm. I asked him if he understood that he could die as a result of the procedure. He did not. Trust in the surgeon and respect for the surgeon’s busy schedule stopped him from seeking clarification. His experience taught me to listen carefully to what patients and their family members say and, just as important, to what they don’t say. I have also learned to seek clarification so I can differentiate between what may be said to meet my expectations and what may be closer to the truth.

Be clear about follow-up

Following discharge, my father began having some shortness of breath. My family reported it to the visiting nurse, who reassured them that some dyspnea and fatigue were normal after surgery. His strength, they were told, would gradually return. When I called home that evening I realized his dyspnea was profound. My father had great difficulty speaking just a few words. When he finally went to the emergency department at my urging, he was diagnosed with bilateral multiple pulmonary emboli. His oxygen saturation was 82 percent on six liters of oxygen. Without extraordinary persistence, the diagnosis might have been made upon autopsy.

As a result of my father’s experience, I have begun to “shop” my office to assess the care my patients receive. Are they able to understand the instructions we give them about serious symptoms? Can they negotiate our office systems to receive the level of attention they require? Asking these questions has uncovered areas in my office where more education and system changes are needed.

Make sure patients understand prescriptions

Following my father’s third hospital admission in less than two months, I learned he had filled several hundred dollars worth of prescriptions and was now confused about the directions he’d been given. He’d tried to call the hospitalist but hadn’t received a response in more than 24 hours. I asked him to line up the containers and read the labels to me: “warfarin, 5 mg, take one tablet daily”; “atenolol, 50 mg, take one tablet each morning”; “Coumadin, 2.5 mg, take one tablet daily”; “Tenormin, 50 mg, take one tablet daily.” It was immediately obvious to me that he’d received brand name medications, duplicating the generics he already had. Fortunately, by this time, he’d learned to question his care and averted the danger caused by a simple communication failure.

My father is recovering nicely, having graduated from cardiac rehab to regular follow-up with his family physician. Each time I tell his story I gain greater perspective, some clarity and the ability to expand my thinking to larger issues and themes. As family physicians, we must lead in the coordination of our patients’ care by recognizing their needs, their level of understanding and identifying and correcting the flaws in our complex delivery systems. Above all we must listen to understand, communicate with clarity and get to know our patients and their families as well as we know their diseases.

Dr. McPherson is the assistant director of the AAFP’s division of medical education.

Conflicts of interest: none reported.

1. Committee on Quality of Health Care in America. Institute of Medicine. To Err is Human: Building a Safer Health Care System. Washington, DC: National Academy Press; 2000.

Copyright © 2002 by the American Academy of Family Physicians.
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