When we experience an unexpected adverse event in health care, we are now smart enough to look at it objectively and try to figure out what went wrong.
The “big” medical mistakes make the public news: wrong site surgery, transplants from incompatible types, and so on. The “little” medical mistakes are sometimes just as bad, and sometimes there are “near-misses,” where we avoid the mistake and hopefully learn from the experience.
Here is a scenario to consider: a 95-year-old patient, resident of a nursing facility, with end stage dementia and multiple other medical problems, has a Living Will, and a Power of Attorney for Healthcare (POA) designated. He has previously expressed (when he was still lucid and able to make his own decisions) his wishes to be kept comfortable, and to not be hospitalized.
His POA, a granddaughter, is a nurse. He has a Do-Not-Resuscitate (DNR) order. One night, the patient develops trouble breathing. He is uncomfortable, and the nurse at the facility calls the emergency medical system (EMS). EMS finds the patient in distress, intubates and transports him to a hospital emergency department.
The facility did not mention his POA, preferences, or DNR order to EMS. In the emergency room, the patient is placed on a ventilator and sent to the Intensive Care Unit (ICU). The emergency physician did not have the name of the POA, and writes orders for Full Code status “for now.”
My question is this: Doesn’t that seem to be as much a “big” medical mistake as the ones listed above? Why don’t we (yet) treat such stories as events worthy of the same responses as wrong site surgery?
Food for thought and hopefully some discussion as well. I’d love to hear what you have to say in the comments below.
Last Updated: November 5, 2018