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Making Disclosure A Reality For Healthcare Organizations 

Nurse Educator Shares Personal Story of Medical Error, No Disclosure

Today, I am turning the floor over to Linda Snell, DNS, RN.   Linda is a Sorry Works! Board member and Associate Professor, Department of Nursing at the College of Brockport (NY).  Linda is passionate about Sorry Works! and disclosure because of her own experiences with medical errors.  In my travels, I have seen --- sadly --- that some of the worst cases of cover up involve clinicians (or their family members) who received bad care. Not only does the medical system refused to communicate with their injured colleagues, they sometimes professionally ostracize these folks, further injuring these poor souls.  I always tell doctors and nurses who experienced cover ups that they are our “aces in the hole.”   They can speak with credibility to their fellow physicians and nurses and say, “I know how it feels to not receive the truth after something goes wrong…it happened to me.  Here’s my story….we should never cover up an error from one of our patients.”
Linda Snell truly is an “ace in the hole” and has a powerful story for physicians, nurses, and future clinicians. 
In April 2003, I slipped on a patch of ice and injured my right knee.  Freezing rain that morning had caused multiple accidents, and the emergency room was overflowing with other injured patients.  I had dislocated that knee as a child, and was certain it was again dislocated.  But the x-ray report came back negative and the exhausted MD did not do a thorough exam.  I believe the chaos of that day provided the backdrop for the unbelievable scenario of discharging a patient with a severely dislocated knee with the diagnosis of sprain. I saw an orthopedist the next day.  He also pronounced my x-rays as normal.  Many months later, I would learn that the x-rays taken the day of my fall did show the dislocation.  I believe the orthopedist saw x-rays taken several years before my fall.  Because of the missed diagnosis, I lived in agony for 33 days before my knee was surgically reconstructed.  By that time, my knee was pink and warm from inflammation.  After the surgery, the inflammation led to extreme scarring and the knee joint basically turned to bone.  I had to wait over a year for the inflammation to calm down before I had a knee replacement at the Mayo Clinic.  This was no routine knee replacement – while I am grateful for the improvement after the surgery, I still have significant, permanent disabilities from my ordeal. 
After my life changing injury from medical mistakes, I felt strongly that I could provide perspectives/suggestions that would help prevent further cases such as mine.  To my utter frustration, no one wanted to hear it!   In fact, the doctors all insisted that the delay in treatment had not caused my problem…they seemed to think I would believe that the only person who ever waited 33 days for the repair of a dislocated knee just by coincidence ended up with a knee that turned to bone! 
The more my doctors denied the delay of diagnosis contributed to my problems, the angrier I became.  As a nurse who has great respect for the physicians I have worked with over the years, it was a difficult decision to file a lawsuit against the doctors who missed my diagnosis and delayed appropriate treatment.  Eventually, my lawyer decided not to go forward with the case.  Even though my lawsuit would not go forward, I was still obsessed with the injustice – I was dealing with disability every day, while my doctors and lawyer just walked away.  How I wished I could walk away! 
I made a report to the Medical Licensing Board of New York State about the poor care I received.  After at least a year of waiting, I received a letter that no discipline was recommended for my physicians.  If a pet owner forced their injured pet to suffer for a month that left them crippled, they would be arrested for cruelty to animals.  Yet I was a person who had literally begged for help, was ignored for weeks, was crippled for life – yet my physicians didn’t even get a reprimand.  It was very difficult to accept.
The only communication I received from the hospital was a letter saying that they had corrected the report on my x-rays from the day of my fall – it was basically a form letter that included “We are sorry we did not meet your expectations.”  That phrase infuriated me.  After all, I didn’t receive a cold breakfast – I had been crippled for life by mistakes made in their institution.  It made the whole situation even more difficult to bear.  As a nurse, it left me feeling disenfranchised from the health care system and from some people I had respected and considered colleagues.  It took a lot of emotional energy to pick myself up from all the disappointments and resume my career as a nurse educator. 
While there is much more to my story, I think there is enough written here to demonstrate why I am so passionate about Sorry Works!  Mistakes do happen.  When they are denied and minimized, I know firsthand that the person and family involved hurt even more.  I am very encouraged by signs that the culture of denying errors may be changing.
After thoughts…
Linda sent me her piece to review, and then I sent her my intro to review, and here is her reaction which I think is very valuable for our readers:
Thanks Doug – I really liked your introduction.  The betrayal I felt from colleagues was just one more difficult thing to deal with.  It was like I was a limping reminder of mistakes no one wanted to remember.  Or they no doubt felt protective of my providers.  People I had known for years would avoid me at conferences – at least it seemed like that to me.
Another piece of my story that I never go into – my husband is a chaplain at the hospital where this happened.  Chaplains there are not employees – they are independent “vendors.”  And he was very worried that if administration connected my complaints to him they would let him go…he felt he had no protection at all such as most of the “employees” who were unionized.  He loved his position and this concern was a huge stressor for both of us.
Even colleagues not associated with the hospital avoided the topic.  Some criticized me for not being aggressive enough to get care earlier…both my husband and I were already beating ourselves up over that – so comments about that were definitely not helpful.
I have had conversations with others who have endured much worse than I.  I had some level of protection since I could not do clinical after my injury – healthcare workers who are still full time at the institution where they were injured are in a much worse position.
Sorry for an “earful” this early in the morning!  This topic is one that is not often mentioned – I appreciate the fact that it is on Sorry Works! radar!  

Doug WojcieszakComment