Atlanta, Ga. – Dr, John Banja points to his desk, and a just-released study published in the Journal of the American Medical Association.
It's about patients' and physicians' attitudes, regarding the disclosure of medical errors.
The clinical ethicist in Emory's Center for Ethics says it re-confirms what he and his colleagues have concluded, from a decade of medical malpractice research.
“When persons are seriously harmed by a medical error,” he says, “When persons are seriously harmed by a medical error, they absolutely want the truth - they want to hear the words error' and mistake'.
They absolutely want an apology from the health care provider. Moreover, they want some conversation about, or better, an indication about what the hospital or the doctor has done, so that this error is not going to happen again.”
Banja says Duke officials did the right thing, to confess their error and apologize.
“The case, however, is a complex one,”, he notes, “as all these catastrophic error cases are. There are multiple areas, wherein apparently mistakes were made. And in some of the reading that I've done, Duke has been criticized - that had the error been made known to the public sooner, that had Duke confessed this to the public, that possibly a second set of organs could have been found faster.”
The case also points up that even a first-rate medical school such as Duke can fall prey to such a serious error.
“You basically had three groups of health care professionals,” he says, “each one assuing that the other two were checking for the appropriate blood type. You had the North Carolina donor services, you had the Duke procurement team that went in to get the organs, and then you had the Duke transplant team. And each one was anticipating or assuming that the other two were making sure that there would be no incompatibilities, regarding blood. And that's where it happened.”
“By the way, errors like this are so rare that it's easy to see how a hospital as good as a Duke might get a little lackadaisical and just assume that somebody else is taking care of this. Because in the reading that I've done, there have only been two documented cases, where an incompatible match or a mismatch has occurred over the tens of thousands of transplants that happened in the United States. I mean, these are incredibly rare.”
“What we know is that usually for a catastrophe, such as what Jesica experience at Duke Hospital, it takes multiple people making multiple mistakes, and a certain amount of time that passes by - so that these errors that are made kind of exploit the system. In other words, the system doesn't have adequate defense mechanisms built into the system - to catch an error when it's made and then to stop what is called the trajectory of the error', the progress of the error from culminating in a harm.”
Banja has some thoughts on how to reconcile such an emotionally-charged situation - where there are no winners.
“It seems to me that all one can ultimately do, in a case like this, is to keep lines of communication open, to try one's best to listen very, very compassionately to what is going on, on both sides. For each side to try very, very hard - and this is hard to do - but for each side to try to imagine what it is like to be on the other side of the desk, or the other side of the table, and to work from that empathic sort of dimension. To try and understand the anxiety and the fear and the anger and the wretchedness that the other individuals are feeling, and really hopefully just to be with one another. The more the two sides are with one another, the more humanized I believe the situation will become.”