We fouled up, and a patient passed away.
I felt a shiver when some fellow specialists asked me about a particular patient in my ward as we all sat down for a cuppa yesterday before starting the day’s work.
That patient was admitted the day before yesterday and was seen by the on-call team. When I saw him in the morning along with my team, we disagreed with some of the management and made the necessary changes. Just before I moved on to another patient, this patient’s apparently elevated potassium level was highlighted to me by the MO.
My orders were to repeat the ECG (the first ECG was not recent and not indicative) and the renal profile stat and that they should be reviewed immediately and action taken. I also ordered measures be taken to bring down the level.
And that was that. I didn’t see the patient again until I heard the bad news the next morning. Apparently the patient passed away sometime in the night and the on-call team believed the cause of death could have been the high potassium level, or at least it played a major role in the patient’s demise.
Later on as I walked into my ward, the MO-in-charge of that patient’s face was decidedly ashen and she had fear and distress in her eyes. She quickly explained that she had ‘forgotten’ to review the ECG and check on the patient. She said she was very tired after a particularly bad on-call the day before and couldn’t think straight. The HO beside the MO hastily made a similar confession.
Now both of them fear “being singled out in the mortality meeting and blamed”.
She asked me this: “What excuse should I give? How will I answer if they ask me to explain myself?”
I answered her “None, just tell the truth, be honest about it. We are not perfect. We will admit our mistakes, learn from it and promise not to repeat it.”
That, in my opinion, is the best thing to do. Mistakes cannot be undone but it can be a tool for learning. There is no need to cover up.
Today, the MO was a lot more cheerful. Apparently the repeat renal profile, though still showing a raised potassium level, was a ‘grossly hemolysed’ specimen rendering the level inaccurate. Another repeat showed a normal potassium level. The repeat ECG was not suggestive of raised potassium level.
Whatever it was, I hope the lesson has been learnt.
AM, yeah, but I bet taking care of Abby is a greater responsibility. Sometimes when I look at my kids, I feel like I have shortchanged them. Sigh.
Thanks Fibrate for your feedback. I have bad feelings about this. I shall blog about this some time soon. Yes we are always wiser (but useless) in retrospect and passing judgement helps nothing.
**shiver**
close call, brings back some hair-raising memories…
y’know, sometimes i’m glad i’m not doing medicine for awhile. the responsibility that one had to bear is so awesomely huge.
I believe our intentions are always good (well, for most of us anyway). It’s always easier to take a retrospective look and pass comments.
deMoon, I agree with you. And the answer was ‘no, no and no’. The HO didn’t (I don’t know her reason, after all she only has 7 patients under her!), the MO was too tired according to her, and I also did not. I think my fault is I trust them too much. Won’t happen again. However, if I have to go over every single patient that are entrusted to them, what is the point of the hierachy? Still, as the person-in-charge, I am still responsible, hence, I said ‘we fouled up’ and not ‘they’.
Honesty is the best policy and as a physician treat all ur patient as thought they are ur own family.
The MO & HO in this aspect should learned from this incidence as well as the specialist in-charge. When the first 2 tier of care eg MO & HO have failed to follow up this patient, did the specialist in-charge oversee or review the patient?
If we care and treat them like our own family, such incidence will less likely happen. Would u imagining urself forgetting to trace a result if ur own father had a high level of pottasium ?
Any doctor who has not made a single mistake which affected his or her patient in a detrimental fashion has obviously not practiced medicine long enough.
Is Mortality meeting conducted for every death in the ward?
Never heard of that b4.
Tell us more =)
scary…hope the lesson learnt can be used to save more lifes…not to be repeated again.