I have already opined on the ‘never events’ reform where hospitals would not be compensated for certain medical catastrophes that should never occur. We all agree that performing surgery on the wrong organ, or the wrong patient, should never happen. My fear is that the list of events will metastasize and will include many unfortunate medical outcomes that cannot be avoided by even the most diligent physicians and institutions, a point echoed at The Covert Rationing Blog, and elsewhere. Dr. Val, in a guest post at Health Care Law Blog argues that patient falls in the hospital, while regrettable, should not be a 'never event'. Dr. Wes, a cardiologist, irreverently suggests that the common cold may be added to the 'never events' list!
We bloggers know how easy it is to hurl opinions from our safe sanctuaries. I learned this when I wrote a post about excessive emergency room care. Folks who had never heard of me, an obscure gastroenterologist from Cleveland, were leaving comments on various websites that I hope my mother never saw. While I stand by the post, I realize now that I didn’t sufficiently consider the issue from the emergency room physicians’ vantage point.
Recently, I experienced a ‘never event’ in my own practice. I am no longer a smug blogger who is pontificating from a distance, but I am now a physician who has to explain to a real human being why something happened that never should have occurred.
Was it my fault? I don’t think so. Was I responsible? Of course. I’m the doctor.
Two months ago, an elderly man was referred to me with suspected silent internal bleeding, a medical issue that gastroenterologists commonly address. He was in his 80s and had many medical conditions. He was a very reluctant patient. To the surprise of the referring physician, he actually showed up. I gave him his options:
- Scope examinations of the large intestine (colonoscopy) and the stomach (EGD) to search for a source of the presumed bleeding. These tests are the most accurate, but have risk. He would be advised to stop his blood thinner several days before the test. He was anxious about stopping this medication, even though the risks of briefly interrupting a blood thinner in his case are extremely low.
- Radiographic tests of the colon and stomach. No risk, but less accurate. He could continue the blood thinner. These tests require the same cruel, but not unusual, laxative purge as required in colonsocopy. However, if a lesion is discovered on these noninvasive tests, then he may need a colonoscopy and an EGD on another day to remove it. This option is safer, but may result in the fun and excitement of a 2nd colonic cleansing.
- Do nothing and take your chances.
He agreed to contact me in a few days with his decision. While I would have wagered handsomely that he would have selected option #3, he surprised me. He chose option #2, so I scheduled him for a virtual ‘colonoscopy’, which examines the colon with a CAT scan. He preferred this over colonsocopy because it was safer and he could continue his blood thinner. He understood that if the CAT scan showed an abnormal finding, or wasn’t a high quality study, that he would be offered the ‘enlightening’ experience of a traditional colonoscopy.
Of course, the CAT scan showed a large growth high up in the colon. I related the news to him and then offered a colonoscopy. Now that he knew for certain that he harbored an unwelcome stowaway in his large intestine, this was an offer he could not refuse. For the second time in a month, he endured the liquid-dynamite cleansing agents that we gastroenterologists casually prescribe every day. I performed the colonoscopy and removed the large lesion and submitted it to the pathologist for analysis. The patient was to see me in 2 weeks.
Days later, in advance of his appointment, our office was called as the specimen was not received by the pathology department. No need to panic yet. This was likely a clerical oversight that would soon be rectified. Not quite. After several more phone calls, I learned the truth. The nurse had discarded the specimen. Let me restate this in more familiar language. She threw it in the garbage. Why? I’m still not sure. The nurse maintains that she asked what I wanted done with the specimen and she heard me reply, “I didn't need it.” So, she obediently complied and discarded the specimen.
There have been very rare instances when a specimen has been lost, but never has this been a deliberate act. What a colossal misunderstanding! Though I cannot recall my precise words to the nurse, I am sure that I wasn't talking trash.
I was shocked at this occurrence, which should have never occurred. I have removed thousands of colon polyps and every single one of them has been sent for analysis. We never discard a specimen. The nurse should not have deviated from an unbroken pattern of medical practice. Clearly, there was a complete disconnect between her inquiry and my response. I should be relieved that she didn’t ask if we should amputate his left leg. What if I nodded ‘yes’? Would she have taken out a chainsaw?
The patient and his wife returned and I disclosed what occurred. I apologized for the event and told him that the hospital was thoroughly investigating the event to assure that such an error will never happen again. I told him that the lesion appeared benign to my eye, but I couldn’t guarantee this, or that it was completely excised. I told him that another colonoscopy in a few months was advisable. He agreed to return to see me in the office 2 months later.
I saw him last week and scheduled him for another colonoscopy. As a precaution, I will be accompanied by a retinue of trained SWAT personnel to secure the site and guarantee that the chain of polyp custody will be seamless. Should I hire a Brink's truck?