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Sorry Works! Blog

Making Disclosure A Reality For Healthcare Organizations 

Doc Waits Four Months to Hear About Mom's Death from Medical Errors

There is a very important essay in the December edition of Health Affairs written by Dr. Jonathan R. Welch.  In the essay, Dr. Welch describes how his mother died from medical errors in a Wisconsin hospital.  Dr. Welch's mother died from a sepsis infection, and the errors that killed her can be best described as a failure to rescue.

Dr. Welch, like many patients and families, wasn't comfortable with the idea of a lawsuit ---even though his medical colleagues suggested he pursue litigation!  Also, just like many patients and families, Dr. Welch and his own family were/are very angry and felt abandoned by the doctors, nurses, and hospital.   They wanted an explanation, an apology, and a fixes so future patients and families wouldn't suffer.  Sound familiar?

So, Dr. Welch decided to write a letter to the hospital asking for a chance to discuss his mom's care, and how the hospital can improve.  He quickly got a call - a voicemail - to which he replied with a voicemail...but then the hospital didn't return his call for four months!! Dr. Welch and his family became very angry, began reconsidering litigation, and Dr. Welch decided to call back one more time and left a message. This time a top administrator called back, saying they waited for four months to respond to thoroughly review the case, look at possible safety fixes, etc, etc.  How maddening!    Yet hospitals and insurers all across the country follow the very same procedure.

This has been a big theme for us at Sorry Works! this year...don't wait for "new information" to stay in touch with your patient or family.  We suggest contacting them at least once per week during the review or investigation....maybe more, maybe a little less if the patient/family needs space.  Also, very clearly set reasonable expectations up front by saying the review may take weeks or even months.   But, don't ever lose contact with your patient or family.  Because when you don't talk, patients and families get very anxious and start to wonder...and start to find alternative paths such as litigation, the media, the medical board, etc.  Stay involved in the relationship with your patients and families....communicate and finds ways to help, even if you are still waiting for the review to be complete.

Dr. Welch said the hospital sort-of apologized and discussed some safety fixes but not in a satisfactory manner for the Welch family.  Now the case is "closed" for the hospital and doctor, but not emotionally closed for Dr. Welch and his family.   Sound familiar?  I would add one thing...the case is probably not emotionally closed for the doctors and nurses either.  Remember the second victims!

Sorry guys....but after doing this work for seven+ years I'm amazed how hospitals and healthcare professionals can still drop the ball so badly after adverse events!   Waiting four months to reach out to a grieving family?   Come on.  But this happens in hospitals and practices all the time.  We need to do much, much better.  We need better communication plans, better outreach to patients and families, more training for leadership and staff, and more pro-active behavior post-event...or we shouldn't be surprised when patients and families act on their anger and frustration and seek revenge.

Dr. Welch provided some additional suggestions in his article, including a Sorry Works! favorite of interviewing the patient or family post-event.  Really good article, and many of the themes covered in Dr. Welch's article are covered indepth in the new Sorry Works! UP Book.  Through Monday we are offering 20% off the UP Book -- order today.  The UP Book is a great resource of stories, questions, and challenges about disclosure from the United States.

Here is a link for Dr. Welch's article.

This is the last Sorry Works! e-blast for 2012 --- going to take a holiday over next two weeks to spend time with my with seven-year old son (Will), three-year old daughter (Claire), and wife of eight+ years (Jeanne).  From the Wojcieszak family to your family, have a blessed and safe holiday season!  All the best!

See you in 2013!

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