Hiding a medical error

By  |  September 3, 2019 | 

The NYT walked into a gold mine recently–and the timing could not have been better, given the fiftieth anniversary of the moon landing. The trove of anonymously sent documents to the staff there revealed the last days of Neil Armstrong, in a small Ohio community hospital, s/p a CABG.

Armstrong, as you can read, had the procedure for dubious indications, and to add to that suffered a nasty complication staff may have mishandled.

But as it relates to what I wish to convey, the hospital in question engaged in what most of us would characterize as a defensive action.

For over a decade now, I have been collecting valuable snippets of wisdom, insights, pearls of wisdom, call them what you wish, that now comprise a sizable repository of information I could probably publish as a short book. One of the pearls I have in my archive is this and I never forget it:

Risk = hazard + outrage

Risk is not just the probability of a bad outcome and expected repercussions. It’s also the ill will and negative light you cannot predict dropped in the laps of the party’s in question from the sky. There are communication specialists out there who have made a career out of handling the blowback their clients could never have predicted.

The hospital, knowing something awful happened to one of America’s heroes, looked to cover it up with a confidential payment to the family. The family, not so innocent either, went along with the multi-million-dollar settlement.

In this instance, we as clinicians are left to judge. What is the proper action and how do we manage the trust bestowed upon us as healers? On one hand, the hospital recognized their error, sought to make it disappear, and in their own mind perhaps, wished to carry on what was likely perfectly good community work. Why tarnish a reputation and hurt innocent staff? On the other hand, they now have 2019 to deal with (“outrage”). Their next year may be a heck of a lot more expensive and emotionally trying than the one they lived through ten years ago.

Leaders at the time of the episode may be gone, but the team there now must deal with the aftershock. It’s a story worth reading and there are lessons in the account we all can absorb to our betterment. I should add, it’s easy to judge all the participants in hindsight. Put yourself in their shoes and ask yourself, however, “what would have done.”

As a follow up to the piece, the journalists sought out opinions from various cardiovascular specialists for their takes. It’s HERE.

And to give you an idea of what happens, see this public comment. This is the overall theme of what folks had to say, btw:

Golflaw
Columbus, Ohio July 23 Times Pick

Was a poorly kept secret in the local medical/legal community at the time. Now that it is in the public, it makes me sad and furious all over again that one of the world’s great heroes died needlessly. He could be enjoying the 50th anniversary of his remarkable achievement but for incompetence and negligence. that was covered up.

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About the Author: Bradley Flansbaum

Bradley Flansbaum
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education. Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates. Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University. He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.

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