We don't deserve tort reform

A physician discovers a possibly fatal blunder in his own mother's treatment.

By Michael S. Smith, MD

Despite my chosen profession, my mother always hated physicians and medical tests. When she fell last year and was taken to the ED at a Tucson hospital, she didn't want much done. Facial X-rays were normal. But she refused a CT head scan, a fact duly noted in the record. Unfortunately, nobody told my father of her refusal, certainly not my mother who had incipient dementia. Instead, the floor staff told him the CT was "normal."

The next day, my mother was discharged. Shortly afterward, my father received a copy of the attending cardiologist's discharge summary, which read: "CT head scan was performed and normal." Two months later, after another fall, my mother saw a neurologist, who accepted the report of a normal CT scan without question. Concerned about possible cervical spondylosis, that doctor ordered an MRI of her neck, which was also normal.

Assured by the results of those tests, my parents spent that summer in Oregon. In July, my mother fell again, breaking her hip. She was never the same. Her dementia slowly progressed, and she worsened dramatically after the stress of surgery and anesthesia. Physical rehabilitation was partially successful, but her dementia never cleared. Late that August, I flew to Oregon to bring both my parents home to Tucson.

The truth about Mom's CT scan

We took my mother back to the same hospital for another CT scan. Imagine our surprise when the radiology technologist remembered her as "the lady who refused the scan."

When we looked at the record, we saw the original ED note documenting her refusal of the CT scan. But we also found that the report of the X-rays she did have wasn't filed in her chart. In other words, her record contained reports of studies not done, but no reports of the studies that had been done.

This time the CT scan showed that my mother had a small subdural hematoma. Unfortunately, her pronounced left frontal-temporal atrophy could not be compared with prior studies. Her condition continued to worsen, and she died soon afterwards.

Some time later, when we looked again at my mother's discharge summary, it included an undated addendum handwritten by the cardiologist: "Patient did not have a CT scan."

My father and I were both furious: not only about the altered record, but about the entire course of my mother's treatment at the hospital. My father would never have taken her to Oregon if he'd known the CT scan hadn't been performed. At first he wanted to sue the hospital, but I talked him out of it, knowing it couldn't bring my mother back. For the first time in my life, I understood the trial lawyers' side of the tort reform issue. Why in the world would they agree to limit malpractice damages when errors such as the one that happened to my mother still occur, and are covered up by the physicians involved?

Cold comfort from a 99.9 percent success rate

A few months later, my father and I met with the hospital's CEO to discuss my mother's treatment. He readily agreed with the facts of the case, including the mistaken report of the unperformed head scan. But he insisted that, "99.9 percent of the time we have no problems of this kind."

Based on what data, I wondered? I would question whether this hospital or most others systematically review their records to measure the frequency of medical errors. Besides, that 99.9 percent means that an error occurs once every 1,000 cases. In a busy hospital, that's a lot. And should we feel comforted by the assurance that 99.9999 percent of airline flights weren't hijacked in 2001?

I didn't want to file a lawsuit, but I did want to make sure such an error wouldn't happen again. I wanted the hospital to fix a system that could allow a physician to report that a scan was normal when it hadn't even been done. I wanted the hospital to develop a way of ensuring that when a patient refuses a major test, both the attending physician and the family are made aware of the refusal.

It's ironic that this tragedy occurred with my mother, since I'd been studying medical errors for several years. In fact, I've developed a confidential, voluntary, protected system for reporting medical errors, similar to the FAA's Aviation Safety Action Program. I've sent my proposal to dozens of medical organizations, but I've received very little support for them. The reason, I suspect, is not only because of legal fears about revealing medical errors, which I can understand, but also because of a feeling in the medical community that the problem really isn't that serious.

But it is. Several studies have reported that thousands of hospital patients die each year as a result of medical errors and system failures. In fact, even conservative estimates suggest that far more people die each year from such causes than the number who died in the terrorist attacks of Sept. 11. Let's face it: everyone makes mistakes—even doctors. We desperately need a good faith system for tracking medical errors that protects those who confess or report them. Physicians and other health care workers need a safe way to tell somebody "I screwed up," and be thanked for their honesty, not sued or otherwise sanctioned.

Those reports should go to a neutral body that can publicize the causes of medical errors so that we can start learning from each other's mistakes. We need to develop such a system and get it running soon. Otherwise, doctors and others will continue to hide their errors, shift blame, and hurt patients, families, and themselves.

From my mother's experience and from my own years of research, the major lesson I've learned is not to trust the health care system: The problem isn't that the people in the system are bad, or that there are staffing shortages. It's that process improvement simply isn't one of health care's strong suits. We don't do a good job of counting things other than dollars, least of all our mistakes.

So what can individual doctors do? Here are some simple recommendations: If a family member is hospitalized, check carefully on her care, and her test results. If you don't get the information you need, insist on it. Be a pain. In your practice, don't take your patient's word on what his test results showed. Look at the lab or radiology reports yourself. It takes time, but it's worth it. Your patient's life could be at stake.

Michael Smith, a former neurologist, is now a consultant in medical statistics and quality improvement in Tucson.

 

Michael Smith. We don't deserve tort reform. Medical Economics Oct. 10, 2003;80:71.