Four years ago, I made an error

College of Physicians and Surgeons of Alberta CPSA, Messenger

It could have happened to anyone, but I hope talking about it now and sharing my experience will help other physicians

Foreword

Through a complaint directed to the College, I realized that some four years earlier, I missed a very significant, unexpected abdominal finding on a cardiac ultrasound report. This experience will always remind me how easy it is for any front-line, practicing doctor to add to the thousands of medical errors occurring annually across North America.

Thankfully, the patient (who learned of this finding directly from an ultrasound technician, rather than a physician), has apparently done well after the mass was resected. However, following my recent disciplinary hearing, I welcome the chance to share my experience in hopes that others can avoid a similar one.

As medical professionals, obsessive attention to detail in all that we do becomes second nature to us: from conducting a proper clinical examination, to performing complex procedures, through to reviewing the dozens of test results that we deal with every single day. How did I miss this significant finding and, more importantly, what can we all learn from this experience?

Four years ago, I saw the patient on a referral at my hospital-based clinic in St. Albert.

After consultation, the patient was referred for a cardiac exercise stress test and an echocardiogram. Like many of us, I work at several different facilities, each with a different routine for evaluating tests and following up (as a result of varying degrees of staff support). While the patient was seen in my hospital clinic in St. Albert, at his request he was referred for stress testing to another facility in Edmonton and was followed up with at my own practice. Medical care is becoming increasingly patient-centred. In trying to accommodate my patient’s wishes and schedule, I believe that this shift in my regular routine contributed to the oversight. As more and more factors play into how we manage care (different locations, different procedures, varying staff support), I learned that we need to doubly on guard.

"It would be naïve to imagine mistakes do not happen in the world of healthcare delivery. Doctors need mechanisms to be able to admit to genuine errors."

We need to continue to encourage patients to feel more empowered to ask questions about their care. Perhaps if my patient specifically asked about the outcome of his cardiac ultrasound, it would have been an incentive to review the report with him.  Instead, I had concerns from his cardiac stress test and sent him for a nuclear stress test. The latter assured me his heart size, cardiac function and perfusion were all normal. At his follow-up, I basically reassured him that I was unable to find issues with his heart. All the while, the finding of concern—an abdominal mass—was tucked away at the bottom of an echocardiogram report in his file at my office.

Supporting your healthcare colleagues

"Shouldn’t a referring doctor be alerted about a potentially sinister abdominal finding? I think so—especially one on an ultrasound requested for another organ system. There is a difference between “doing things right” and “doing the right thing” and the consequences of such a finding not being flagged can be very serious."

While the cardiac findings in the patient’s echocardiogram were completely unremarkable, in the final paragraphs of the report there was a reference to what the reading radiologist felt could be a phaeochromocytoma. Four years ago, findings like this were at the bottom of a report, where the chances of being overlooked are considerably higher. Today, most labs would highlight these findings at the top of a report.

The patient’s report was faxed back without a phone call to alert anyone in my office and the family doctor didn’t get a copy of the report. As professionals, we need to work together in a supportive environment to prevent potential catastrophes. The better we are at sharing information the lower the risk of errors being made. I am called regularly about electrolyte values that are noticeably out of range. Shouldn’t a referring doctor be alerted about a potentially sinister abdominal finding? I think so—especially one on an ultrasound requested for another organ system. There is a difference between “doing things right” and “doing the right thing” and the consequences of such a finding not being flagged can be very serious. Had this mass been a renal cell malignancy, the lesion would have long since metastasized over the four year duration and the system would have essentially failed the patient.

While I must shoulder the full blame for having missed this finding on the report, there are gaps in the system that we all need to watch for. The findings of the ultrasound were posted on Netcare, yet no other healthcare professional reviewed the report during the four years that it has been available, despite his many visits for health care support. Hopefully in the future, when patients have full access to their own reports on Connect Care, these occurrences will be rarer.

Is there room for error in our profession?

Few of us, whatever our calling in life, can say we have never made an honest and unintended error. Sadly, the consequences of mistakes that doctors make are always more serious. My first impulse on learning of this serious oversight was to request an opportunity to call the patient and sincerely apologize. However I received legal counsel advising otherwise.

It would be naïve to imagine mistakes do not happen in the world of healthcare delivery. Doctors need mechanisms to be able to admit to genuine errors. We need an opportunity to apologize when we have unintentionally let a patient down. Despite the College’s efforts to facilitate an informal resolution, we ended up at a hearing. The College should, however, have other ways for patients to raise concerns other than through a complaint. A more informal process would help us learn from such genuinely unintended errors and arguably benefit both the profession and the patients.

"A more informal process like mediation or alternate dispute resolution would help us learn from such genuinely unintended errors and arguably benefit both the profession and the patients."

"We try daily to be the best we can at what we are trained to do. I hope we can all accept our rare unintended shortcomings for the human oversights they truly are."

Our College has the role of assuring that the public is safe through the regulation of medicine. Sometimes that means the disciplining of our errant colleagues by their peers. However, the process can be very adversarial. I don’t think it moves us forward to label somebody with “unprofessional conduct” for a genuine unintended error. The category is shared by extremes of deliberate unethical behaviour.  Such adversarial processes make a stressful career even more so.

With burnout among medical professionals growing into a more serious issue by the day, this is something we need to reconsider as a society, so that we continue to see every patient as someone with a problem we have the expertise and privilege to help and not as a potential adversary in a litigious system. We try daily to be the best we can at what we are trained to do. I hope we can all accept our rare unintended shortcomings for the human oversights they truly are.

Humbly submitted,

Zaheer Lakhani, CM FRCP FRCPC FACC
Consultant Cardiologist/Clinical Professor