Sunday, November 15, 2009

A ‘Never Event’ In My Own Practice!

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?


  1. Those things happen, but often the analysis stops early, before identifying procedural changes that absolutely forestall the error. An example that I recall for the anesthesiologists' attack upon errors in their arena: sometimes---rarely---the wrong gas bottle would be attached to a line. As the anesthesiologists looked at the error to find fail-safe preventives (not relying on the alertness or infallibility of anesthesiologists or their minions), they came up with the idea of gas-specific attachment hardware, so that it would be impossible to attach the wrong gas tank. (This is based upon my memory, so it may be an incorrect account.)

    At any rate, the anesthesiologists were in a major battle to reduce their malpractice insurance rates, and they made the change. As a result of that and many other changes (perhaps even including the tremendous step of policing their profession and disqualifying those members who consistently made errors), their malpractice rates dropped.

    Because we're human, we will be making errors from time to time. But because we're intelligent, we can construct systems that disallow most errors. (Think of the checklist proposal that was profiled in the New Yorker not long ago: not adopted because doctors resented being asked to use a checklist: things like that are behind the malpractice insurance rates.)

    Just a thought. Props to you for acknowledging the error instead of burying it. I read recently (in I think) that when doctors acknowledge and apologize, the lawsuit rates drop dramatically.

  2. Please tell me you are not going to charge this unfortunate gentleman for a second colonoscopy.

  3. What else could you do? Someone makes a mistake. The person is informed. You rectify it, 'scuse the pun, and move on.

    LG is right, but the role model for this is often our politicians, on both sides of the border! Deny, deny, deny.

    I have pet peeves about people who cover up, deny culpability, and blame someone else.
    Excellent post. Have you heard of our White Coat, Black Art shows on CBC? He is fabulous, and an emergency room doctor. Some issues can cross the border.

  4. You should deal with this the way an airline crash is dealt with, no blame, investigate and correct. What have you done to find out how your error occured and how you'll prevent this in the future?

  5. I come to this post late (just found your blog) but as a pathologist I find this an extremely interesting case. For one thing, you were performing the colonoscopy for a KNOWN mass. Therefore, I would assume it should have been posted as "colonoscopy with removal of mass" or something similar. This should have alerted the operative staff to pre-prepare a specimen bottle, and there should have been no question that a specimen would be forthcoming and would be sent to pathology. Also, I wonder frankly how dumb the nurse had to be, since I have never heard of a colonoscopy in which tissue was taken and then is not needed. (e.g. any tissue removed during colonoscopy is by definition a biopsy).
    Seriously, I hope you pursued this with not only the operative staff but the administration of your hospital. This problem clearly indicates a system problem in the OR which may lead to a far more serious error in the future.
    And BTW, the worst one I ever experienced was a mastectomy for cancer in which the nurse threw the lymph node dissection in the trash.


  6. To retiredpath, my forlorn polypoid mass tale pales next to your vignette. In my situation, there was not a systemic defect, but a judgment lapse restricted to a single individual. The policies and procedures were in place. No system is airtight.

  7. Three items: 1) was the individual who threw the specimen away a Registered Nurse? A lot of females in scrubs are unaccurately called "nurse"; 2) are you using the AHRQ's Team STEPPS in your procedures and 3) in Belgium physicians are no longer using irritating purgatives
    Nshort DrPH, RN

  8. Yes, she is an R.N. There is no 'quality program' that would have prevented this event. It was complete human error and a violation of bedrock medical practice.

  9. I can't help but notice that you are blaming the RN for this mistake in a veiled way. You start off by taking responsibility since you are in charge, and then you conclude by saying, "The nurse should not have deviated from an unbroken pattern of medical practice." The truth of the matter is that you did not make it clear what you were doing, and you left the specimen in a place that created doubt in a trained medical professional's mind, someone who has never made this mistake in your presence before. You are the one that deviated in some way, and until you accept this, you'll make the same mistake in the future. You're joke about the Brinks truck is irresponsible as well. THis is not a joking matter. I hope that man gets a good lawyer and takes your insurance carrier to the cleaners. You deserve it for your smugness alone.

  10. To the anonymous commenter: Respectfully, I disagree with you. While the physician is ultimately responsible, as I have already stated, the nurse in this instance was at fault. I still work with her. I assume that she agrees that she committed an error, since she apologized to me for what occurred. Every human errs. In this vignette, it was the nurse who made a mistake. Fortunately, the patient was not angry and decided not to pursue the remedy you suggested.

  11. I have my second colonscopy with Dr. Kirsch scheduled soon and reading this only increases my confidence in his procedures! Bravo for admitting that an error occurred. P.S. don't toss my polyps!