Lessons Learned from a Botched Transplant

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Lessons Learned from a Botched Transplant

• James Jaggers MD
• Pediatric Cardiac Surgery
• Duke University Medical Center

3rd Annual Betsy Lehman Center Patient Safety
Conference
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Botched To ruin through clumsiness. To make or
perform clumsily bungle. To repair or mend
clumsily
Thesaurus words for "botched" blighted,
bungled, bungling, butchered, clumsy, deficient,
destroyed, fumbled, half-assed, haphazard,
hit-and-miss, hit-or-miss, ill-advised,
ill-considered, ill-contrived, ill-devised,
ill-done, ill-executed, ill-managed, impolitic,
marred, messy, misconducted, misdirected,
misguided, mismanaged, muffed, murdered,
negligent, promiscuous, ruined, slipshod,
slipshoddy, sloppy, slovenly, sluttish, spoiled,
spoilt, untidy, wrecked
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What Happened?
7 PM
Recipient Name Offered to CDS
Contributing Time Restraints
Discussion between CDS and UNOS
MN
Ischemic Time
Ischemic Limit
Weather Delays
CDS Organ Offer for JS
Harvest Team Departs Duke
Recipient admitted
Four Separate Attempts By Duke to Contact CDS
Over 19 different communications
Noon
Implant Operation Start
Heart Lung Arrives, donor blood to Lab
ABO Incompatibility Determined
7 PM
Fax from CDS with donor info
JS Operation End
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How could this happen?
How lazy can he be to not check the blood type?
Its just like a blood transfusion, dont they
check the blood type before they put it in?
He should resign and lose his license!
Duke was trying to cover up
They rigged the system to get another set of
organs
How come the organ procurement agency gave them
the wrong organs?
Why were we transplanting an illegal aliens in
the first place?
They should have never given her a second
transplant
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Just When you think it cant get any worse
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Medical Errors Tip of the Iceberg

• Australia 18,000 annual deaths from Medical
  errors, 1995.
• U.S 44- 98,000 Deaths/year (IOM, 1998)
• United Kingdom 850,000 incidents/year, 2000.
• Canada Adverse events in 7 of Admissions
  9-24,000 deaths/year. 2004.
• Health Care may be the 3rd Leading cause of Death
  
• Contributed to by
• Changes in technology
• Changes in procedures
• Economic pressure
• Health care is more successful than ever and now
  more vulnerable than ever

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Mediagenic Medical Errors

• 1984 Libby Zion Fatal Drug Interaction
  Resident Fatigue
• 1987 Andy Warhol Death from Inadequate post op
  monitoring
• 1994 Betsy Lehman Death after Chemo Overdose
• 1995 Willy King Wrong site Surgery
• 1998 Dana Carvey Wrong Vessel CABG
• 2002 Michael Hurwitz Liver Donor Death
  Inadequate Resident Supervision
• 2003 Jesica Santillon Death after Botched
  Transplant Inadequate redundancy in organ
  allocation protocols

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What do these have in Common?

• Most Involve Surgery
• Most involve Major Teaching Institution
• Very famous or sympathetic patients
• Typically East coast phenomenon
• Distrust of major hospital systems
• Encouraged by Local health care politics

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Response to the Press

• Press is driven by the 24/365 cable news machine
• Conflict adequately inform public and yet
  maintain patient confidentiality
• Duke was slow to get out in front of the story
• Foster good relations with media

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Human Error

• "Human Error An inappropriate action, or
  intention to act, given a goal and the context in
  which one is trying to reach that goal." Ramon,
  1995

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Medical Errors

• Human factors
• Variations in provider training and experience
• Diverse patients, unfamiliar settings, Time
  pressures
• Medical Complexity
• New technologies
• Expanded pharmaceuticals
• System Failures
• Poor communication, misalignments,
• Bad hand-offs
• Lack of systemic error reporting
• Administrative Understaffing, cost-control

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Transplant error
New England Donor agency
Faulty Organ Allocation System
Retrieval team
UNOS
CDS
Implant Team
Duke System
Botched transplant
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Findings of Root Cause Analysis

• Lack of redundancy in transplant processes
• Practice Differences between Adult and Pediatric
  Services
• Quasi-normative error
• Confusion regarding usual practices
• High Volume vs. Low Volume
• Surgeon as one man army is at risk
• Misalignments of Institutional resources
• Compassionate and Financial motivation to place
  organs
• Deficiency in UNOS and CDS practices

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Communication

• Failure of Hierarchal communication
• Vertically integrated silos

Organ Procurement Agency
Adult TX Service
Pediatric TX Service
UNOS
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Institutional failures

• Organizational silence
• One cannot address what one does not acknowledge
• Quick fixes and Work arounds delay
  recognition of problems from institutions

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Surgical Team Practices to Promote Safety

• Shared participation and responsibility
• Encourage communication
• No hostile behavior (raised voice, insults,
  public reprimands)
• No humiliation of residents and nurses
• No derogatory comments about colleagues
• Accept challenges to the authority
• Promote redundancy of safety measures
• Group time-outs
• Multi-level communications and checkouts

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Truth telling

• Everybody believes in Transparency
• The Devil is in the details

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Patients Favor Complete disclosure

• Disclose
• What Happened
• Why it happened
• Who is accountable
• How to prevent errors

• What Patients Want
• Correct the Error
• Investigate the Error
• Achieve Justice
• Receive Apology

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Effects on Patients and Families

• A form of PTSD
• Harmed by their healers
• Patients usually frightened, angry, distrustful,
  isolated and helpless
• If death results, Families have difficulty coping
  with guilt

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Patients attitudes and litigation
What was the dominant consequence of the
injury? Serious financial consequences 25 to
40 Physical limitations gt50 Emotional
difficulties 25-35
What were the dominant feelings? Humiliation
40 Betrayal 55 Bitterness 80 Ang
er 90
What could have prevented the Lawsuit? Pay
Compensation 13 Be willing to correct the
error 25 Explain what happened offer
apology gt50
What motivated the lawsuit? Advice from 3rd
person 33 Physician not completely
honest 25 Needed Compensation 25 Only
way to find out what happened 20 Punish the
doctor 20
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Honesty Do we need a policy for truth telling?
Hippocrates advised "concealing most things from
the patient while you are attending to him. Give
necessary orders with cheerfulness and
serenity...revealing nothing of the patient's
future or present condition. For many
patients...have taken a turn for the worse...by
forecast of what is to come
AMA Principles of Medical Ethics 1998 A
physician shall deal honestly with patients and
colleagues and strive to expose those physicians
deficient in character or competence, or those
who engage in fraud or deception AMA code fails
to draw the line when it comes to disclosure of
medical Errors.
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Why physicians conceal the truth about medical
errors

• Misguided Parternalism
• Protection of themselves and institutions from
  reprisal
• Conflict avoidance
• Ignorance of responsibility

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Five Es of Effective Communication with patients

• Engage
• Empathize
• Educate
• Enlist
• Extend

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Disclosure and Litigation
In errors with a severe outcome, an honest,
empathetic and accountable approach to the error
decreases the probability of the participants
support for strong sanctions against the
physician involved by 59. Schwappach, DLB. A
Factorial Survey on the disclosure of Medical
errors. Int Journ for Quality Health Care, 2004
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Error Disclosure Surgeons Deficiency

• Only 57 accurately report the event as an error
  Use words like complication or problem.
• 65 took responsibility for the error
• 47 offered a verbal apology
• 8 offered assurance that future errors will
  avoided
• The vast majority of physicians receive no
  training on how to disclose medical errors
• Chan et. Al. How Surgeons disclose medical errors
  to patients Surgery 2005.

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Surgeon-Patient Communication and Ethics

• Old Paradigm
• Captain of the ship
• Captain goes down with the ship
• Does not require leadership skills
• Paternalism
• Surgeons make decisions for patients based on
  surgeons belief systems
• Non-collaborative care between providers

• New Paradigm
• Surgeon as the quarterback
• No more or less important than other members of
  the team
• Requires leadership skills
• Autonomy vs. Weak Paternalism
• Surgeons may guide therapy in accord with good
  care, but does not impose
• Collaboration and equality with patients
• Requires multidisciplinary care

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Handling the Error with the patient

• Prompt recognition
• Never discount patients or families questions or
  concerns
• Open and honest, explain fully and reassure
• Maintain continuity of care if possible
• Practical and financial help quickly
• Avoid billing errors and aggressive collection
• Transparency within limits

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The second victim

• The physicians and staff can suffer depression,
  guilt, anxiety that will affect job performance
• Psychological support must be made available

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Ethical and Legal Perspectives of Admission of
Medical Errors

• Failure to acknowledge medical errors
• Interferes with educational value of the error
• Interferes with the potential benefit by
  improving care for others
• Interferes with the fiduciary patient physician
  relationship

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Legal Requirement for reporting to patients

• Institutions have a direct legal obligation to
  report significant medical unexpected errors that
  involve death or serious physical or
  psychological injury.
• While it may not be required by law for
  institutions to report these errors to the
  patient, It is seems wise and prudent to do so.
• Even when involved physicians object to reporting
  of the error

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Institutional Impediments to Transparency

• On balance, most hospital leaders believed that
  mandatory non-confidential state reporting
  systems as designed discouraged internal
  reporting of medical errors and led to a greater
  frequency of law suits while failing to provide
  substantial benefit toward patient safety.
• Error reporting and disclosure systems Views
  from hospital leaders. Joel Weissman, et. Al.
  JAMA 2005.
• CMS has proposed diminishing payments to
  hospitals for poor performance including near
  miss events and preventable medical errors.
• Eliminating Serious, Costly and Preventable
  errors. Centers for Medicare and Medicaid
  services. 2006.

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Institutional process for disclosure to patients

• Attending physician should be notified
• Risk management counsels the attending
• Attending physician discloses the error,
  consequences and remediable action to be taken
• If attending physician refuses to disclose,
  another physician appointed by institution should
  disclose. i.e. Chief of Medical staff
• Institution facilitates care by another provider
  if requested or transfer to another facility if
  requested by the patient
• Discussion of fault and causality should be
  avoided
• Institutions should develop Patient Safety
  Organizations to help facilitate this process

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Impediment to Physician Disclosure

• Fear of Litigation
• Fear of Patient Distress
• Fear of Patient Attrition
• Fear of Damage to Reputation
• Fear of Public Humiliation
• Fear of Censorship

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Real Life Consequences of Disclosure The
Inquisition

• Institutional Estrangement
• Object of Media Circus
• Public Scrutiny and Scorn
• Institutional Medical Staff Review
• Proof of no pattern of negligent behavior
• Proof of Surgical Competence
• Letters of support from outside and inside
  Colleagues
• Censorship from Colleagues
• Formal Inquiry by Medical Board
• Formal Inquiry by UNOS
• Eventual Malpractice suit and settlement

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It is unwise to be too sure of one's own wisdom.
It is healthy to be reminded that the strongest
might weaken and the wisest might err. Mahatma
Gandhi (1869 1948)
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