Medical errors book off base

OB/GYN News, May 15, 2004 by Reinhold H. Hinz

After reading about Dr. Robert M. Wachter and Dr. Kaveh G. Shojania in the excitingly titled article "Physician Authors Take On Medical Mistakes" (April 1, 2004, p. 25), I do not feel encouraged to read their book.

The doctors described several case reports of medical errors, with accompanying comments. Dr. Wachter's case is not a good one for any reader interested in learning more about the new push for "reducing avoidable medical errors," because after discovering his "mistake"--he should not have transported his patient in an ambulance without appropriate monitoring equipment--he played "the blame game" by blaming himself (and the nurse, as well as the emergency room clerk) for not requesting the correct ambulance, which is certainly not helpful.

The accompanying story of Joe Silber is likewise not well suited for a discussion of medical misadventures (a 12-hour emergency room work-up for chest pain in a 43-year-old man?) since the patient's regular physician had nothing to do with this case ("Fumbling the Handoff," p. 25).

Dr. Wachter and Dr. Shojania should have indicated that the physician who ordered the chest x-ray was responsible for dealing with the results even when he turned out--no surprise in modern ER work--not to be the one who discharged the patient. The patient deserved to be contacted and personally told by the ER physician (on the phone and in writing) that he had an abnormal chest x-ray. This physician is liable since his name is on the x-ray report as the requesting physician.

Fancy talk about error reduction approaches used in aviation is not helpful in seeing how a case such as this could have had a better outcome. Even the radiologist, who probably had only minimal or no meaningful clinical information on the case but also probably did not read the films until after the patient had left the ER, had a responsibility to contact the patient instead of "dumping" the case on the so-called primary physician.

Most physicians are, unfortunately, brought up in a hierarchical culture in which no one would dare to suggest that a radiologist (who supposedly "sees" most patients only as a consultant) contact the patient. A hospital interested in having good and meaningful relationships with patients would perhaps see nothing wrong with such a contact between radiologist and patient.

Reinhold H. Hinz, M.D.

Strawn, Tex.