Accountability: Patient Safety and Policy Reform

1. Writing/Righting Wrong

C H A P T E R 1 Writing/Righting Wrong S A N D R A M . G I L B E R T More than a decade has now passed since the sunny morning of February 11, 1991, when two orderlies arrived to wheel my husband of thirty-three years into the operating theater where he had a routine prostatectomy from which he never recovered. Though he was in robust health apart from the tumor for which he was being treated, Elliot died some six hours after my children and I were told that his surgeon had successfully removed the malignancy. But to this very moment, no one from the hospital has explained to us how or why he died. “Dad’s had a heart attack.” That was the explanation my husband’s doctor offered us as he strode grimly into the hospital lobby on the night of February 11, 1991. But the next day the medical center released a different story, alleging that the cause of death was “heart failure.” And two weeks later, a death certificate signed by the chief resident who worked with my husband’s physician gave still another account, asserting that death resulted from “liver failure.” Through painful investigation—first with the help of a close friend who was a pathologist, then with the aid of an attorney—we discovered that my husband had suffered a massive postoperative internal hemorrhage. In fact, he evidently bled to death because someone in the recovery room failed to get the results of a hematocrit that would have easily detected the problem. Eventually, we filed suit for negligence—and our lawyer won a settlement just two days after he deposed the attending surgeon. Although, as in most settlements , the hospital admits no guilt, my husband had clearly been the victim of a “negligent adverse event”: an event defined by one writer as “an injury caused by the failure to meet standards reasonably expected of the average physician, other provider, or institution” (Hiatt et al. 1989). Eventually, too, I wrote a book titled Wrongful Death (Gilbert [1995a] 1997), along with a collection of poems titled Ghost Volcano (Gilbert 1995b), each focusing in its own way on the disturbing story I’ve just told. In doing so, I understood that I was writing (recording) as well as seeking to right (to rectify) wrong, and now, as I retell the tale, I realize that I am still writing and seeking to right a terrible wrong. 27 c01 sharpe pp27-42 08/05/2004 16:44 Page 27 Many writers and speakers on the subject of medical error have considered the frightening prevalence of mistakes like the one that killed my husband: they have discussed the statistics showing that “[a]s many as 98,000 Americans die unnecessarily every year” from such calamities, more “than from breast cancer, highway accidents, or AIDS” and have considered the recommendations made by the Institute of Medicine’s report To Err Is Human (Kohn, Corrigan, and Donaldson 2000, 31). Some have evaluated the preventive measures proposed by systems analysts, health care providers, and physicians themselves. Some have examined the deeply conscientious efforts many doctors have made to analyze and (sometimes) expiate their own errors (Hilfiker 1984; Fonseka 1996; Gawande 1999; Drayer 1999). Some have considered ways of guaranteeing accountability. Most address these issues, as is appropriate in this context, from the perspective of their own professional involvement, though some have begun to speculate on strategies for moving the patient from the periphery to the center of the “mistakes” dilemma. I have a different mission: I write as both a witness—to testify to the experience of the patient who has endured the consequences of a catastrophic mistake —and as an informant—to help illuminate the complex sorrow that inevitably enshrouds such an experience. I speak as and for the one who is inexorably trapped at the center of the web of medical error, the unprofessional, often ignorant, and almost always innocent one who suffers the error—the patient who is the object of the mistake or mistakes. Following several other writers on this topic, I use the word “patient” to signify not only the person who has been the direct recipient of medical treatment but also those associated with him or her who have also been profoundly affected by such treatment (Crawley, Shultz, and Weinberg 2000). It’s interesting , in this connection, that my dictionary gives two meanings for the noun “patient”: first, “one under...