|
|
|
Disclosure success stories are becoming more abundant - and more public too. See below for a memo that was publicly released two weeks ago by Park Nicollet Hospital in Minnesota after surgery to remove a cancerous kidney resulted in the wrong kidney being removed. We applaud this hospital for sharing their honesty and candor with the world. Notice...there are no weasel words in the memo - only truth telling words like "medical error," "accepting full responsibility," and "apologized to the family" in the first paragraph of the memo. Bravo!
TO: All Employees
FROM: David Wessner, President and Chief Executive Officer
David Abelson, Executive Vice President, Chief Clinical Officer
RE: Tragic Medical Error at Park Nicollet
SUMMARY:We are saddened to tell you that Park Nicollet has made a tragic medical error for which we accept full responsibility. We have apologized to the family and are doing everything we can to support them. We also are supporting our involved staff. The family has reviewed this communication and asks that no further information be released. We expect significant media coverage.
DETAILS:On Tuesday, March 11th, a patient with presumed cancer of the kidney had their healthy kidney removed, leaving the affected kidney inside their body.
This is a tragic error and Park Nicollet assumes full responsibility. We have apologized to the patient and to the family. We are working closely with them to support them in every way we can during this difficult and challenging time in their lives.
The error occurred in diagnosis before the surgery took place. The surgery staff followed all appropriate safety protocols, including marking the surgical site and pausing before surgery to confirm the final details. Unfortunately, the side of the affected kidney was incorrectly identified in the medical chart several weeks before the surgery took place.
This event will be reported as required under the Adverse Health Event laws.
This is a devastating tragedy for the family. It is also a tragedy for all of us at Park Nicollet. We know we can say that everyone at Park Nicollet feels this error personally and we offer our thoughts, prayers and support to the patient and family.
The surgeon that performed the procedure has voluntarily ceased surgical and clinical care and will not see patients until a complete Root Cause Analysis has been performed and reviewed. During that time, Park Nicollet's other urologists will assume care of this physician's patients. We will use the Root Cause Analysis to determine how we can prevent this error from ever occurring again, and we will share our findings with other hospitals so they can also learn from this experience.
Those of us privileged to work in health care know that there are many opportunities to do great good for patients. Unfortunately, in the course of providing care, there are also opportunities to make errors. We work continuously to eliminate errors and will not rest until we reduce them to zero. Internally, we encourage you to talk in your teams about our opportunities to do great good and how we can avoid and entirely eliminate medical errors. Every employee at Park Nicollet has a stake in this, and we will only succeed with the support of everyone.
The patient and family have chosen to remain at Methodist Hospital for their recovery. We have discussed this communication with them and they know that we are sharing this information with Park Nicollet employees. They do not want any additional information released and do not want to speak publicly at this time. They also asked us to share this message with you: "Please respect our privacy and confidentiality during this difficult time." We ask you to respect their wishes.
QUESTION:Do you want your hospital or medical practice to be able to embrace disclosure like Park Nicollet Hospital? If so, the Sorry Works! Book - the how-to manual on disclosure and apology - can be your guide. At 103 pages it's a quick, informative read that is priced right: $21.95 per copy. To order your copy today, click on this link:.<
MEDIA COVERAGE ON PARK NICOLLET DISCLOSURE
Below is a story that ran in Sunday's Star Tribune newspaper about Park Nicollet Hospital. Not only does the story go into greater detail about Park Nicollet, it also discusses other disclosure success stories.
Hospitals learn to say sorry
By MAURA LERNER
Star Tribune
March 29, 200
Brock Nelson remembers the final time he stonewalled a family about a hospital error.
Almost ten years ago, a teenage boy had died after doctors misdiagnosed his cancer. The boy's grief-stricken parents asked to meet with Nelson, then CEO of Children's Hospitals and Clinics of Minnesota.
"I was advised 'don't volunteer information, and don't admit or say that we made a mistake,'" he recalled. After the emotional meeting, he walked out shaking, turned to his lawyer and "vowed we're never going to do that again." Weeks later, he met with the parents again, apologized, and "shared everything we knew."
That was, by all accounts, the start of a sea change in Minnesota hospitals, which have been quietly challenging the code of silence surrounding medical mistakes.
Few go as far as the Park Nicollet Health System, which publicly admitted March 17 that the wrong kidney had been removed from a cancer patient at Methodist Hospital in St. Louis Park.
But many of Minnesota's largest hospitals are embracing the idea of fessing up to their mistakes, at least to patients and families, and trying to make amends.
That includes Regions Hospital in St. Paul, where Nelson is now CEO.
"As a whole state, I think the culture has shifted," said Dr. Phil Kibort, vice president and chief medical officer at Children's Hospitals. "In the last five, six years, we've been telling the truth."
Nationally, hospitals that admit mistakes "are definitely a minority," said Douglas Wojcieszak (pronounced wo-Chez-ik), who lost a brother to medical errors at a Cincinnati hospital.
Three years ago, Wojcieszak founded the Sorry Works Coalition (sorryworks.net) in Glen Carbon, Ill., to promote the idea that hospitals have a financial incentive to apologize and admit errors: They're less likely to get sued.
"For years they've covered this up," he said. "It's been a horrible strategy....It's the reason we have so many lawsuits."
Privately, he said, many hospital officials will admit as much. "They know why patients sue. Because no one will level with them."
'Don't say a word'
It's no secret that, for decades, doctors were warned to keep their mouths shut when something went wrong.
When Dr. Gary Brandeland lost a patient to an anesthesia error in 1986, he remembers, the hospital's medical director told him: "Don't say a word to anyone, not even your wife."
That was, he says, "the most unhealthy advice I have ever received."
Now an emergency=room doctor in St. Peter, Minn., he still bears the scars of that experience, which he shared in a moving essay in the journal Medical Economics in 2006.
His patient, Joy, a "beautiful, healthy 21-year-old," was about to give birth by C-section when the anesthesia was connected improperly, he wrote. By the time it was over, Joy was brain-dead and her baby was brain-damaged. Although he didn't make the mistake, he was the only one willing to meet with the family. "I apologized right away," he recalled last week. But the hospital, in Wisconsin, closed ranks.
"I just felt like I was thrown to the lions," he said, especially when the story made the evening news. "I assumed I would get sued. I thought the only dignity I have left now is to support the family." In fact, when the woman's relatives filed suit, they specifically instructed their lawyer not to go after him.
"I think they felt abandoned by everybody else," Brandeland said.
'They're rightly angry'
In 1999, Minnesota's two children's hospitals started disclosing errors to patients and families as a matter of policy. Even if it's a near miss, hospital officials meet with the family, apologize and explain what happened, Kibort said.
"Every time I do it, it just kills me," he said. "They're rightly angry. They put their trust in you to take care of their child, and they get upset."
At the same time, he said, the staff will talk about what they learned from the mistake, and what they plan to do about it.
"Parents all say the same thing: 'I just don't want this to happen to another child,'" he said.
Sometimes, it costs money. Several weeks ago, Kibort said, a baby received the wrong dose of a medication and suffered seizures, which resulted in a longer stay at the hospital. As a result, Children's covered all the extra medical costs, and offered to pay the parents' lost wages and expenses while they stayed at the hospital, he said.
It's hard to say if it's made a difference in legal costs, he said, because Children's has always had a low incidence of malpractice cases.
But the numbers have been more dramatic elsewhere. At the University of Michigan Health System, lawsuits dropped in half after it started admitting mistakes, saving nearly $2 million a year in legal costs, according to the Sorry Works Coalition.
The Luther Midelfort hospital and clinic in Eau Claire, Wis., also saw a drop in lawsuits after it started disclosing errors about eight years ago, said Dr. Terrance Borman, the medical director. "There was certainly, initially, some concern on the part of physicians: 'Gee, are you going to get me sued?'" Borman said. "I think the truth is just the opposite." Now the Mayo Clinic, which owns Luther Midelfort, is drafting a similar policy.
That is becoming common practice throughout the state, according to the Minnesota Hospital Association. "We take the position that the hospital has an obligation to share this information," said Bruce Rueben, the group's president.
Yet there's still a long way to go, says Wojcieszak, of the Sorry Works Coalition. "Three years ago, disclosure was a four-letter word," he said. When his brother was misdiagnosed and died of a heart attack in 1998, his parents felt a lawsuit was the only way to get answers. "We never got an apology," he said. "If someone had said sorry, and just dealt with them fairly, it would have made all the difference."
|
|
|
