A Case of Disclosure

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From 1987 to early 2003, while I was chief of staff at the Lexington, KY VA Medical Center, we instituted a policy of full disclosure and fair negotiated compensation to anyone who had been injured by a medical error. No discretion was allowed and no case was too big or too small. It started without advance planning or training. We just did what was right and kept the patient at the center and didn’t stop until the patient was made whole (to the extent possible). Although I retired from the VA in 2003 (practicing now at the University of Kentucky) please don’t conclude that the VA policy ended then. It’s just that I can only vouch for what happened during the years mentioned above. We have previously described this program < http://annals.org/article.aspx?articleid=713181 >. In this short blog, I’d like to give a previously unpublished example illustrating how we operated. This was not a typical case and some readers might ask why we didn’t just let it alone. I will leave some clinical facts vague to avoid identification of the involved parties.

A man was admitted overnight for an oral surgery procedure. The surgery went well and the patient was discharged to the care of a relative the following day. He and his relative were instructed verbally and in writing how to care for the surgical site and what to do, and avoid doing, in the days following the operation. Within hours of discharge, the patient visited a bar and became drunk. The surgical site began bleeding profusely and he was returned emergently to the hospital having lost significant blood. Despite the efforts of the clinical staff, the patient died of complications a few days later.

On the surface, we first saw this as a case of extreme carelessness on the part of the patient who, by knowingly ignoring his post-operative instructions, caused his own death. However, we found evidence in his medical record that his alcoholism was known as was a past history of non-compliance. So, we assembled all the clinical staff involved in his case and asked whether they thought his care was appropriate or could have been handled better. I was somewhat anxious before this meeting, anticipating that the clinicians who had tried their best to treat this patient only to have it fall apart because of his irresponsible actions would perceive that they were being somehow blamed for the whole thing. Nevertheless, by the end of the meeting, the clinicians had acknowledged that they had known that the patient was poorly compliant and had an alcohol problem but they had nevertheless treated him as though he were an ordinary patient. They agreed that there had been other options and, on hindsight, could have declined to perform the procedure at all (it was elective) or could have done it and kept him hospitalized through the immediate postoperative period. Without letting the patient off the hook, they took some of the responsibility for the awful result that left a widow without a source of income.

Subsequent to this meeting, we contacted the widow, disclosed our findings and arranged to meet and negotiate a compensation amount based on the estimated monetary loss without losing sight of the patient’s shared responsibility. We believed that it was fair and a court would likely have seen it in a similar way.

It would have been so easy to let this thing lie. After all, it wasn’t really a medical error. The operation was indicated; there was no wrong site surgery, retained sponge or incorrect medication. The surgeons were qualified, skilled, and the trainees were well-supervised. But there was an error in judgement in that the staff hadn’t considered the patient’s known unreliability regarding his own care. Looking back at this, they recognized the lapse.

Medicine is hard and a doctor can feel like a juggler having to keep anything thrown at him in the air; balls, knives, water balloons; no errors allowed. But errors do happen inevitably and when they do, we mustn’t give ourselves a pass but instead admit the error, take care of the patient, cooperate in trying to make the patient or surviving relative whole, correct the systems or practices that contributed to the error and then move on without beating ourselves up. Hospital administrators and risk managers should take the lead to assure that communication is honest and complete and that everyone, including the clinicians, are cared for.

Steve Kraman, M.D.

4 thoughts on “A Case of Disclosure

  1. Actually what Dr. Karman describes is now known as a medical error of context, although a subtle one. Discharge of a patient into a situation that he is unlikely to be able to handle safely because of his limitations is an error of context. Perhaps these days a social worker would have caught this error before the patient’s discharge.

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  2. Dr. Kraman, thank you for this article. I also admired your interview in the Disclosure movie via SorryWorks! At the May 12th “Safe Staffing” DC healthcare rally, there were plenty of healthcare professionals discussing juggling & errors. Meanwhile, patients are on sites comparing stories, medical records & writing reviews. Risk managers, hospital administrators and politicians don’t seem to realize that “deny&defend” is actually bringing groups of harmed patients and good providers together for change.

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  3. I had the privilege of working with Dr. Kraman for many years in several different capacities. He and a few other people were key in changing the way medical errors are treated, not just in the Lexington VA, but in many, many hospitals. He sat the bar for how patients, families and clinicians should be treated in the event of a medical error. People tend to forget that clinicians are just people doing the best they can everyday to meet the medical needs of the patients under their care. It should be recognized that Dr. Kraman recognized this fact and nurtured and promoted an environment where mistakes could be admitted and brought forward without fear.

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