Dr. Jonathan Welch’s Narrative Matters essay in the December, 2012 edition of Health Affairs, regarding the cascade of errors and omissions he witnessed in connection with the care provided to his mother, should raise profound questions about how the hospital allowed those failures of care to happen. Dr. Welch, an emergency medicine physician, watched helplessly as his mother received indifferent care from various nurses and doctors and ultimately died. Despite having classic signs of evolving sepsis, she was not closely monitored by the nursing staff which ignored alarming signs, was not put on a sepsis treatment protocol by her oncologist, and was not put in an intensive care unit where she could receive more intense monitoring and aggressive treatment from specialists.
While it is tempting to blame the nurse (for not taking vital signs frequently enough and not reacting to abnormal vital signs) and the oncologist (for not following the patient closely enough, not initiating appropriate treatment, and not involving other specialists), Dr. Welch’s story suggests that there were more deeply rooted systemic problems at the hospital that went beyond the shortcomings of the individuals involved in his mother’s care.
As health care attorneys who represent hospitals and physicians, we believe there are some fundamental questions which should be asked by this hospital’s administration, medical staff leadership and governing body to ensure Dr. Welch’s experience is not repeated. Those questions, which the leaders in all hospitals should consider, include the following:
1. Does the hospital have political or cultural barriers that would interfere with a patient’s receiving appropriate care, such as being transferred to a higher level of care (e.g. ICU) and receiving treatment from an appropriate specialist (e.g. intensivist)?
As the practice of medicine becomes more specialized, it is not uncommon for there to be “political” barriers to improving patient care. Internal medicine physicians and pulmonologists who have traditionally followed patients on intensive care units by visiting the patients once or twice a day are often resistant to being replaced by full-time, specialty-trained intensivists who are present in the ICU 24 hours a day, 7 days a week and continuously monitor patients. Internists and family practitioners who have made a significant portion of their income from following patients in the hospital often oppose the hospital hiring hospitalists who are always in the hospital and available to provide continuous care to patients. It is incumbent on hospital leaders to understand whether such barriers exist and, if so, address them. The economic interests of a few physicians must not interfere with the delivery of the best possible care.
2. Do nurses feel they are able to discuss concerns about patient care with attending physicians?
Whether it is due to a culture of deference to the physician or the personality of an individual doctor, nurses frequently are reluctant to call a physician at 2 a.m. regarding a patient’s worsening condition, or to confront a physician who is indifferent to a patient’s needs. Nurses are the health care providers who are most in touch with the patient’s condition and hospital leaders need to empower them to speak out whenever they feel that a patient’s needs are being neglected. Moreover, if nurses do not get satisfactory responses from a physician, they should know how to go “up the chain of command” and have no reluctance to do so.
3. Would nurse managers have been aware of and acted on this situation as it developed?
Conspicuously absent from Dr. Welch’s story is any discussion of whether the hospital’s nursing managers were aware of the unfolding events and attempted to intervene. If the bedside nurse had concerns about the patient’s not being placed on a sepsis protocol or being too sick to be on a regular medical/surgical unit, those concerns should have been discussed with the nursing managers who could assist the nurse in mobilizing the appropriate resources. However, nurse managers should not only be responsive to issues that are brought to them by the bedside nurses. They should also have systems in place to flag situations that require attention, even if not recognized by the nurse providing the hands-on care. A crucial question for hospital leaders is whether the nursing managers knew about the events involving Dr. Welch’s mother as they occurred. If they did, why didn’t they intervene, and if they didn’t know, why?
4. Would this kind of event have been identified and investigated to determine the root cause of the failure of care and implement remedial measures?
One of the essential hallmarks of a viable quality assessment and improvement program is a vigorous monitoring and reporting program that picks up on the kinds of events that were observed by Dr. Welch. Members of hospital governing bodies should be assured that when untoward events occur, they are detected and addressed to identify the cause and fix the problems. Moreover, it is essential that appropriate investigations and actions take place, even absent a complaint from the patient or family members. If appropriate quality monitoring systems are in place, hospital leaders should never have to learn about a situation such as Dr. Welch encountered from the family or the press.
5. Would the medical staff be willing to initiate peer review and appropriate action regarding a physician who did not appropriately handle a patient’s care such as in this case?
The hospital’s medical staff must have peer review processes which identify inappropriate care provided by physicians, as well as procedures to address such conduct. Corrective action could range from simple discussions with a physician to terminating a physician’s medical staff membership and clinical privileges. But galvanizing medical staffs into taking action against their colleagues is often difficult, and as a result marginal or underperforming physicians continue to practice in hospitals.
6. Is there an established process for reaching out to patients and families who have experienced adverse outcomes, answering their questions and dealing openly and honestly with mistakes that have been made?
All hospitals are expected to have policies and procedures for dealing with “unanticipated outcomes.” Those policies generally provide for adverse events to be openly and candidly discussed with patients and family members, and disclosed to patients and families even in situations where the patient or family may not know that something went wrong. Dr. Welch should not have had to initiate contact with the hospital leadership; however, once he did he should have been engaged in a meaningful dialogue that frankly recognized what went wrong and gave Dr. Welch assurance that at the very least his mother’s death would serve as a learning experience that would avoid such unnecessary deaths in the future. Not only is accepting responsibility for mistakes the right thing to do, both for the patient and the culture of the hospital, studies have shown that a proactive approach to untoward events often avoids or minimizes malpractice claims.
Dr. Welch’s story highlights a series of systemic failures where the health care system did not perform as it should have on multiple levels. Hospitals have for years been using a tool know as a “root cause analysis” (affectionately known by some as a “root canalysis” because of the sometimes painful information it produces), which is designed to ferret out the real reasons behind a failure to deliver quality health care. A root cause analysis in this case might answer many questions about why events unfolded as they did, such as:
- Did the nursing staff not take vital signs frequently enough, or not recognize the significance of abnormal signs, because they were poorly trained, understaffed or overworked, or for some other reason?
- Did the nurses not call the oncologist in the middle of the night to suggest to him that a sepsis protocol should be implemented, or that the patient should be transferred to the ICU, because the oncologist was known to berate and humiliate nurses who bothered him at night or dared to challenge his care?
- Were standard protocols for treating conditions such as sepsis, stroke, and heart attacks not used because they were poorly designed or because physicians were resistant to what they considered (erroneously) to be “cookbook” medicine?
- Was the involvement of appropriate specialists delayed or avoided because the attending physician was more interested in being able to continue to provide (and bill for) care than he was in the patient’s receiving the best available care?
Hopefully, Dr. Welch’s story will lead to continuous quality improvements not only in the hospital where his mother was treated but in hospitals across the country. Hopefully, members of hospital governing bodies and administrative and medical staff leaders will read his story and begin asking questions about whether such a sequence of events could occur in their hospital. Hospital board members should ask themselves, “If I were asked by a friend or colleague whether this could happen in my hospital, would I be able to answer ‘no?’ More importantly, would I be able to answer the follow up question: ‘How do you know?’”