Joe Kita writes at readersdigest.com a remarkable set of interviews of physicians and nurses confessing medical mistakes for the record which either could have or did lead to wrongful death. Among those interviewed was Peter Pronovost, a professor at John’s Hopkins University School of Medicine, who has received considerable notoriety as a patient safety advocate.
Pronovost and his work at Hopkins was the subject of one of my prior posts. In Pronovost’s interview he provides us considerable insight as to how his views concerning patient safety evolved. We learn for example, that his father died because of medical errors at age 50. Also, during his training in critical care medicine, he prematurely removed a breathing tube in a patient recovering from esophageal surgery performed earlier the same day. The patient arrested and though successfully resuscitated, remained unconscious for a time. Pronovost admits that his shame at having made a very serious error prevented him from candidly explaining to the patient’s wife the reason for the arrest.
The medical culture of Pronovost’s early years remains today as a true impediment to patient safety. The widespread refusals of physicians and other health care providers to admit their errors allows the errors to be repeated by others.
Ironically, today as I was writing this post, I visited Kevin MD.com and found a very interesting and compelling article authored by Brian Goldman (an emergency physician) addressing the issue of the culture of patient safety. Goldman agrees that medical errors must be confessed in order for change to occur. He appears to reject the view shared by many advocates of tort reform the Dr.’s will not confess except in secret.
Confession is good for the soul and indispensable if a culture of patient safety is to be established.