What option should my friend take in dealing with a hospital mix up?
November 3, 2010 8:09 PM   Subscribe

My friend was in the hospital and a surgeon delivered the wrong (and devastating news to the family). How should we handle the situation?

(Spoiler: everyone is fine now) The other day a friend had a seizure. Upon learning that he was in the hospital and due for surgery that night I left to be helpful and support any way I could. When I got there he was doing much better; he was talking and totally cognizant of his surroundings. He still needed emergency surgery to fix what had caused the episode in the first place, but he was doing well and doctors said that everything should be fine. Despite sounding scary the surgery was going to be minor and should fix the problem without complications.

Everything was set for him to have surgery when another person came in the same problem and needed the same surgery. My friend got bumped. Both surgeries went though that night. After much waiting the surgeon finally came out to tell the family the prognosis. He told us that the surgery did not go well, that in fact my friend not responsive and still unconscious. The problem was much worse the expected and that he was not going to make it. This took about 5 minutes to do and was absolutely devastating to the family (it sucked more because it was so out of the blue). As he was explaining what had happened one of the details was slightly off, a family member corrected the surgeon on his small mistake.

That is when it clicked for the surgeon; he had given this awful news to the wrong family. His words were “OH Sorry! Wrong person, your friend is doing fine.” It was one of the worst misunderstandings I have witnessed. Being told that a loved one is going to die is one of the worst moments on earth. Having it happen by an avoidable mistake was rough. Besides the “ Oh sorry", he was not sympathetic to the pain that he caused.

Here is the tl;dr, What should I suggest to the family when someone in a hospital makes a large mistake that has no physical damages? A legal action seems silly, there are no real damages to speak of and the operation was a success. It seems like it would be a lot of time for nothing. Not to mention it’s not what the family wants to do.
But what should they do, write a letter to hospital admin and hope he never messes up again?

Talk or write to the surgeon himself and hope he learns to double check names?

There is no need to try and trash his career or name; he just needs to know that news like that should be triple checked. So should push them do something or leave it and be grateful that his work saved my friend’s life? Has anyone ever experienced the similar and how did you handle it?
posted by Felex to Health & Fitness (43 answers total)
My guess would be that the doctor is replaying this scenario in his head and will never make this mistake again.

Doctors are human and make mistakes.

Some of them, like this one, are benign. Others kill their patients.
posted by dfriedman at 8:15 PM on November 3, 2010 [39 favorites]

Dude, not your family, your doctor, or your responsibility. It was a horrible accident, horrible accidents happen and it doesn't have to be anyone's fault. Let it be.
posted by smoke at 8:15 PM on November 3, 2010 [15 favorites]

I would stick with being grateful that his work saved your friend's life.
posted by amicamentis at 8:17 PM on November 3, 2010 [90 favorites]

Legally, there is no recourse as it was a simple mistake about the news that was verbally delivered, there was no harm inflicted to the patient him/herself. Yes, it was a shitty five minutes for the family and no doubt it was an emotional rollercoaster, but it's over now. If the family wishes to write the provider a letter indicating their disappointment with this mistake and to convey the fact that they wish this not to happen to another family, that is well within their rights to do. Frankly, based on the high number of medication errors and procedural errors that happen within the inpatient setting, I'd welcome this type of error over any of the others that would actually cause harm to the patient.
posted by Asherah at 8:18 PM on November 3, 2010

What should I suggest to the family.

You should suggest that they be happy they are not the other family.
posted by milarepa at 8:19 PM on November 3, 2010 [64 favorites]

The doctor was probably thinking "Oh #@#$, did I tell the other family their kid was ok?"
posted by WowLookStars at 8:20 PM on November 3, 2010 [15 favorites]

So he had just done two surgeries in a row, and he'd lost a patient. It really sucks, but he had a rough night and made a mistake.
posted by Nothing at 8:21 PM on November 3, 2010 [10 favorites]

The hospital has a department for this kind of thing. If you look on the hospital's website for contact information, there will almost certainly be info for contacting "Patient Relations" or "Complaints" or something like that. I'd guess that the hospital will be interested in meeting with the family to apologize for the mistake (and having the surgeon apologize).
posted by Salvor Hardin at 8:24 PM on November 3, 2010 [2 favorites]

He was either playing it off light in the HOPES that the family would avoid, you know, suing the pants off the hospital for emotional damage, or, more likely, he was in shock himself about what he had done and just fumbling for words. Hell, I can't express myself clearly sometimes when dealing with the stress related to getting the right imprint on the right rush order for beer can holders and t-shirts I'm working on. I would imagine that's 10)X after you've been trying to keep people alive for a few hours, and have just gotten out of an OR where there has been a bad outcome (which, fortunately for you, was not your friends, but the other persons).

Also, don't forget that unfortunately, medicine is done on an assembly line. It may seem ludicrous to you that this doctor could make this mistake, but he had no personal knowledge of your friend or the other person before he worked on them, and if he met the families at all, it would still be easy to mix them up, especially if the cases were similar (other than the outcome).

There are doctors who are asshats and/or screw up patient care. Be glad your friend is okay and save the indignation for something else.
posted by randomkeystrike at 8:27 PM on November 3, 2010

Yeah, the surgeon is a human being, and he made a human error. It was horrific, but there are no material consequences. He wasn't as empathetic as you'd have liked, but. . . he's a surgeon, empathy is not high on their list of job qualifications. (They choose a specialty in which their patient is asleep for a reason, after all.)

If you're going to do anything at all, don't go any further than dropping a letter to the hospital ombudsman, thanking them for saving your friend's life and including the surgeon's lack of empathy as a codicil. Because one of two things is true: either the surgeon had an off night as a result of losing the patient, in which case he already feels worse than you can ever make him feel about his error, or he's just not that empathetic of a guy, in which case there's nothing you can do to make him become one.
posted by KathrynT at 8:27 PM on November 3, 2010 [2 favorites]

Best answer: Why would anyone want to revisit that conversation for a nano-second? Rejoice that your friend is fine, and quit picking at the scab. Forget it. Never refer to it ever again, except maybe at the friend's 100th birthday party, when everyone can have a good laugh.
posted by Ideefixe at 8:27 PM on November 3, 2010 [22 favorites]

If you REALLY feel that you need to pursue this, the person you're looking for is the patient advocate.
posted by elsietheeel at 8:38 PM on November 3, 2010

Response by poster: The only outcome we would seek is the surgeon being more careful in the future. But from the tone here it looks like we are better off letting it go.
posted by Felex at 8:43 PM on November 3, 2010 [1 favorite]

Awful, horrible, nasty. Sure. But the doctor also successfully performed surgery on your friend. Let me repeat: He cut your friend open, moved some stuff around, then put him back together. He did his job.

I can guarantee you that he was as mortified about his mistake as you were terrified of it. He's already going to check the chart twice next time. Leave it alone, your doctor has other things to think about.
posted by GilloD at 8:48 PM on November 3, 2010 [4 favorites]

What should I suggest to the family when someone in a hospital makes a large mistake that has no physical damages?

All kinds of things, assuming they are cretins and cannot think for themselves.

It doesn't concern you. You might feel like it does, but it doesn't. It's the family's concern.
posted by docpops at 9:35 PM on November 3, 2010 [1 favorite]

Imagine how exhausted the surgeon was after that much work. People make mistakes. Let it go.
posted by effluvia at 9:50 PM on November 3, 2010

I'm having trouble finding room to imagine how exhausted the surgeon was because my imagination is filled with imagining how emotionally exhausting those few minutes were for the family being told their loved one was suddenly dying. If it was my family, I absolutely would ask to meet the doctor and describe for him in a polite way how devastating that kind of error was to us and encourage him to be more careful in the future, while making sure to first thank him for the successful operation.

I also think a letter to the patient advocate, cc'd to the doctor and hospital administrators, could be done in a polite, appropriate way. This might not be the first time this doctor has made this kind of error, and it's not necessarily being mean-spirited to alert his superiors to a potential problem. And if this *has* happened with this doctor before, the next family he does it to will be grateful for the letter on file somewhere. Doctors are human, yes - which means they may respond better if consequences for mistakes are made just a little more clear and direct.

That said, it's not your place to do anything other than suggest it if you see the family is still upset. If you don't see that, let it go. It's their call, not yours.
posted by mediareport at 10:09 PM on November 3, 2010 [2 favorites]

The only outcome we would seek is the surgeon being more careful in the future.

I want surgeons to be careful when they're cutting people open, and if that means living up to all the worst stereotypes of the profession as a counterbalance ('God doesn't think he's a surgeon') then so be it.
posted by holgate at 11:12 PM on November 3, 2010 [1 favorite]

Take a lead from the Bluth family. Could be worse.
posted by ecmendenhall at 11:30 PM on November 3, 2010

Response by poster: Thank you all for the advice. I should say that I do know my place in all of this, I was asking largely because I had no idea how other people would respond. I would never overstep my bounds and do anything other then give advice if I was asked. I did want to hear what others had to say before I came off the cuff and sounded like a jerk.
posted by Felex at 12:28 AM on November 4, 2010

I think your friend's family has been put through a very difficult situation that must be raised with the hospital. Do not feel like it is inappropriate to register your unhappiness.

I can completely understand why the doctor would make this mistake, as he is only human. But then, all doctors are human, and always have been. That's why there are (or at least, should be) processes and checks in place for every aspect of what medical practitioners do.

So the hospital should have a procedure in place to ensure that the right news is only ever given to the right person. I think you can write a balanced letter to the hospital and to the surgeon, saying that you do not want to blame him personally or start a legal action against the hospital, but this was a very serious lapse on their part and you would like to know what they are doing to stop something like this from happening again. This would not have to be complicated: from now on, before they give news to a family, they must confirm name and date of birth, as well as the procedure the patient had (or similar).

A hurried doctor trying to talk to a grieving family after hours of surgery and with other patients on the go is undoubtedly under pressures and deserves to be cut some slack. But it is because there is so much to think about that medical practitioners have set processes and check lists, to help make sure they don't make simple mistakes that could have serious consequences. Cutting corners should not be an option. For instance, although IANAD, I believe surgeons perform an equipment count after they have closed someone up. A hell of a lot scissors might have been lost in a hell of a lot of people without this seemingly simple check.
posted by marmaduke_yaverland at 12:41 AM on November 4, 2010 [1 favorite]

he just needs to know that news like that should be triple checked

He knows this. He made a mistake. I'm terribly sorry for your friends' momentary emotional pain. Rubbing the doctor's nose in those is not going to get those moments back for them.
posted by pecanpies at 4:05 AM on November 4, 2010 [1 favorite]

the doctor also successfully performed surgery on your friend. Let me repeat: He cut your friend open, moved some stuff around, then put him back together. He did his job.

Talking with families about the outcome of the surgery is part of the surgeon's job. He should have done that part just as correctly and with just as much professionalism as the surgery itself. It is not "rubbing his nose in it" to point that out and hold him accountable for his behavior. A letter or phone call to Patient Relations is completely appropriate.
posted by shiny blue object at 5:07 AM on November 4, 2010 [3 favorites]

I understand that this is extremely hurtful, but I think you're extremely lucky that this was the worst mistake to happen and the worst attitude anybody showed you during the whole incident.
posted by tel3path at 5:19 AM on November 4, 2010

Uh, just drop it.

Everyone was relieved when the doctor realized his mistake. Isn't that enough consolation?

Another family got bad news and the doctor couldn't take it back.
posted by General Tonic at 6:55 AM on November 4, 2010

Let me get this straight - this surgeon spent hours in one surgery, lost a patient (which is a difficult event for a physician who is trying to save a life), went right into surgery for your friend, FIXED YOUR FRIEND, and after that exhausting experience of TWO back-to-back emergency surgeries he comes out of the OR, hazy from the effort of trying to save two lives, and talks to the wrong people. And you think he needs a reminder because he's careless?

That surgeon doesn't need a stern letter. He needs a medal. And you need to be a little embarrassed for even asking this question, because correcting him would be very, very, clearly wrong.

I work tangentially with physicians. I can think of a lot of things that I'd like them to improve. This is not one of them; this is a tiny blip in the grand scheme of things because, well, your friend is healed and you should be praising this guy for his skills as a surgeon. What are you going to say? "When you're done with back-to-back surgeries, can you please not be so exhausted? Maybe pay less attention while cutting so you have more energy to properly deliver the news?" Think about how ridiculous that statement is. It's not that he's a careless individual - careless people don't get to be surgeons - it's that he had lots on his mind and made the kind of goofy-ass mix-up that we all make, only his goofy-ass mix-up offended you.

he was not sympathetic to the pain that he caused. Are you in his head? Did he ever say "it's not a big deal?" He was probably shaken when he realized what he'd said. But physicians learn quickly that they're expected to be in control at all times, and as a result they sometimes have to bottle things up. Frankly, you don't know. Yes, it would have been nice for him to show a little more care and humility. But you're asking this surgeon (who, I remind you, was exhausted by this point) to have the self-awareness that his usual response (remaining stoic) isn't the right response and to perfectly thread the needle of showing the right amount of contrition to you and your friend's family. That's a lot to ask someone who just saved a life. It would have been nice, but it's asking a lot to stop thinking about the patients he was just saving and think really hard about himself, these people who are not his patients, and this awkward social situation. He's probably thinking about the family with a real reason to grieve. So while it would have been nice for him to be more sorry, it's not something worth pointing out.
posted by Tehhund at 7:08 AM on November 4, 2010 [8 favorites]

simple mistakes that could have serious consequences

Those checklists exist to make sure that nobody dies. As soon as the surgeon steps out of the operating room, and away from the patient, it is unlikely that he will do anything that could endanger the lives of one of his patients.

Yeah, it sucks for the family, but on the scale of "bad things that happen in hospitals," this ranks pretty much near the bottom of the list. He's only human, and those checklists are more effective if they only exist in places where they are actually medically necessary.

If somebody skillfully and adeptfully saved the life of one of my family members, I don't think I'd call his boss to complain....under any circumstance.

Drop it and move on.
posted by schmod at 7:13 AM on November 4, 2010

In the OP's position, I would be mildly upset about the emotional damage, but horrified at what it might indicate about the surgeon's general competence:

If the surgeon could have a five minute conversation about the wrong patient, what else might he get wrong?

Probably nothing, but I don't think the family--or any patient or patient's family--should feel the need to overlook incompetence out of gratitude. Maybe this doctor is a hero and a superstar who made a regrettable but honest and never-to-be-repeated mistake, and then out of shame/shock/lack of communication skills came off sounding flippant about it. On the other hand, I think it would be harder to make this mistake (for several minutes) than to, say, prescribe the wrong medicine or send someone for the wrong test, which takes only seconds.

So while I think you are right that suing is way to harsh, I absolutely encourage you to encourage the family, if appropriate given your relationship with them, to report this incident to the hospital and possibly the medical licensing authority. Someone needs to look at this error in the context of the surgeon's whole record. A competent professional will have a record that can stand up to a little bit of scrutiny, whereas a pattern of errors needs to be discovered before someone dies.
posted by sarahkeebs at 7:27 AM on November 4, 2010

The doctor's response to the error sounds completely inadequate. The error was stupid and sloppy. These are not good signs. The family can write a letter explaining the scenario and send it to hospital administration. If there have been a number of sloppy errors, and/or a number of really unprofessional communications with patients and families, the hospital will have received other such complaints. If it's only happened once, it will be a learning opportunity. Your letter can be respectful and polite and state the facts.

I'm glad your friend is okay, and I'm sorry for the family who got the correct bad news. Doctors are hardly ever saints or miracle workers, and some of them are incompetent, and protected by a hidebound medical establishment. If the doc has a problem, bringing it to light is very necessary.
posted by theora55 at 7:38 AM on November 4, 2010

If I were that family, I would contact the hospital and ask to speak to the patient relations or patient complaints manager. YMMV, there may be no such person, or they may be unhelpful, but you may be able to be heard and someone may make a permanent record of it.

At my organization, the complaint would go to the surgical QA committee. The surgeon would not be punished, but this way, errors such as these can be monitored to see if a systemic improvement could help the whole system prevent this error. If these complaints become a routine matter, this group would know about it.

If errors aren't reported, how can they be fixed?
posted by teragram at 7:44 AM on November 4, 2010 [1 favorite]

If it was my family, I absolutely would ask to meet the doctor and describe for him in a polite way how devastating that kind of error was to us and encourage him to be more careful in the future, while making sure to first thank him for the successful operation.

Unless the surgeon is a sociopath, I can't imagine he'd need this explained to him.

This seems like it's probably an understandable mistake, but one worth reporting. As others have said, your friend's family can't know if this is part of a pattern of sloppiness or mistakes. Reporting it to the hospital could be useful for that reason.
posted by Mavri at 7:49 AM on November 4, 2010

There is no need to try and trash his career or name

Then let it go.
posted by Doohickie at 7:55 AM on November 4, 2010

But that's the thing: this probably WON'T trash his career or his name.

If the hospital has a formal structure for investigating errors, they will be able to see if this is a trend and can do something about it to help prevent it from happening to other families.

If the hospital does not, well, nothing happens. But it won't ruin his career, not a mistake like this.
posted by teragram at 7:59 AM on November 4, 2010

teragram If the hospital has a formal structure for investigating errors...

This is not a medical error, nor is it professional misconduct. It does not bear investigating.

sarahkeebs to report this incident to the hospital and possibly the medical licensing authority

This would be wonderful advice, and I would agree with it wholeheartedly - if you had a valid serious complaint. You do not have a serious complaint. The physician made an understandable mistake which he quickly apologized for. All you have is "He should have apologized better," which is subjective and not a reportable concern.

I'd encourage you to report the surgeon if he'd done surgery on the wrong site, or left a sponge in your friend's body, or if he'd said "well, he's not doing well, but hey - people die," or if he had said "then why am I talking to you people?" instead of "I'm sorry" when he realized his mistake. But he did not make a mistake during the procedure nor did he ignore your friend's family's feelings - he apologized and moved on. That is not an incident that needs investigation.


Look, in the unlikely case that you're going to side with the more rabid responses and encourage your friend's family to report this, please make sure they report the entire scenario:

"Hi, patient relations? About Dr. Smith. He saved my son's/brother's/husband's life. And he did it as at least the second emergency surgery of the day. His tireless dedication to his patients means our guy will be okay. So tell him thanks from the patient's wife, father, mother, sisters, brothers, daughters, sons, cousins and friends. Every day that the patient spends with us is because of Dr. Smith, and he deserves more thanks than we can give.

Also, after the surgery he understandable confused us with the other patient's family and gave us unfortunate news. He immediately apologized, but in the future it would be nice if he could not make any mistakes ever, and if he does make a mistake it would be nice to see him grovel a little."
posted by Tehhund at 9:14 AM on November 4, 2010 [5 favorites]

Tehhund, it isn't a medical error, but it IS a patient experience complaint. I certainly don't know if this particular hospital has a system for managing such complaints, but at my employer, we do. If it were my family member, I would call say very much that same thing that you suggested. If it is an isolated incident, fine. If it's part of a larger pattern, no one will know if no one tells the hospital.

The point isn't to make a stink, but to improve care. That's all.

(My desk is next to our patient experience manager. The woman is saint. She talks to patients with very legitimate complaints...and also to patients who didn't like they didn't get an antibiotic for a viral infection and DEMAND that the CEO visit them at home. I didn't really know there were people like that.)
posted by teragram at 10:04 AM on November 4, 2010 [1 favorite]

Response by poster: Thanks again for the advice. Again; the goal was never to make the surgeons life worse or to receive a "better" apology. If however a letter would aid an oversight like this never being made again then its worth it. But from the responses here it sounds like he will not be making the same mistake again anytime soon. I mentioned his callousness only because it seemed like he would not learn from his mistake and take better precautions in the future.
posted by Felex at 10:05 AM on November 4, 2010

Also, I'll add, the types of changes that end up happening because of patient complaints are things like reminding pediatricians that older children should be offered a gown for an examination and having support staff hand patients printed letters from the printer (because they are more likely than physicians double check that two letters for two different patients weren't stapled together). Nothing life or death, but things that make the care experience better and more comfortable for our patients.
posted by teragram at 10:13 AM on November 4, 2010 [1 favorite]

Doctors are people. Mistakes happen.

If you're interested in learning more about how they're trying to prevent more of any kind of error in medicine in general, you should read The Best Practice, which is the history of the Quality Movement in medicine, and Better, by Atul Gawande. Both great reads.

But seriously. They are just people, and Dr'ing is just something that people do, like carpentry or anything else. Individuals do make mistakes, and this one didn't physically harm anyone.
posted by kryptonik at 10:19 AM on November 4, 2010

Yeah, it sucks for the family, but on the scale of "bad things that happen in hospitals," this ranks pretty much near the bottom of the list. He's only human, and those checklists are more effective if they only exist in places where they are actually medically necessary.

This makes no sense to me. Asking "Are you the family of X, admitted for Y?", or whatever, is hardly an arduous procedure to have to follow, and as this incident shows, actually seems kind of necessary. I can understand forgiving the doctor for making a mistake one time and not remembering to follow the procedure, but the idea that telling people whether their family members are dead or not is too trivial to require any kind of codified plan is absurd. What if the doctor had told the other family their relative was OK? What if he hadn't made that small mistake and been corrected within five minutes? This could have had all kinds of consequences, some of them serious. So fine, be grateful it wasn't worse. But this kind of thing is absolutely worth taking measures to prevent.

Also, a lot of people seem to think that the fact that the doctor successfully performed surgery on the OP's friend means he has no professional shortcomings or that those he has don't matter. I don't understand that. We basically don't know anything about this man except that he 1) saved the OP's friend, 2) didn't save the other guy who had the same surgery, and 3) mixed up their families at the end of the day. Nobody knows whether he's guilt-ridden, or tirelessly dedicated, or even not a sociopath, all things that have been assumed about him in these answers. There are all kinds of doctors out there, and we don't know what kind he is. Only the hospital has some idea. I think it's fine for the family to report this incident to the hospital with politeness, compassion and gratitude, if they like, and let them decide, based on what they already know about this man, how serious or minor it is.
posted by two or three cars parked under the stars at 10:22 AM on November 4, 2010 [1 favorite]

Also, it's not like the family has to keep either their thankfulness or the true nature of their concerns a secret in whatever letter they write, and leave the hospital guessing and the surgeon thinking this ungrateful family hates him and wants him punished. Say, "[We're grateful] and we understand that people make mistakes. We would just like to know that there is a procedure in place to prevent this from happening again, and we thought you would like to know that it happened because it's your hospital/to stop it from happening again/in case it's part of a pattern/whatever. Thank you." It's a normal communication that can be qualified and explained; it's not like dropping off a big red F- on a otherwise blank white sheet of paper.
posted by two or three cars parked under the stars at 10:33 AM on November 4, 2010 [1 favorite]

Unless the surgeon is a sociopath, I can't imagine he'd need this explained to him.

Seriously: is there a hospital administrator or patient advocate who *wouldn't* want to know about this? What if, for example, it turns out there's a pattern of this kind of event repeating itself not with a particular doctor but during a particular shift? How are administrators going to find out that the hospital may have a scheduling or overwork issue - an issue that may result in more serious "medical" errors down the line, teragram - if no one lets them know there's a problem?

Felex, it's not just about that doctor. It's about procedures in that hospital that can be improved, and about mistakes that may indicate other deeper issues the hospital administration will want to address before they result in a much more serious mistake.

If the family is at all upset about this episode, Felex, you should encourage them to send a polite letter describing the incident to the hospital administrators. It's by far the right thing to do.
posted by mediareport at 4:41 PM on November 4, 2010 [1 favorite]

IANAL, but isn't the doctor at fault for not verifying the patient's relationship with whom he was speaking and then proceeding to discuss an unrelated patient a HIPAA violation?
posted by jrishel at 1:06 PM on November 5, 2010 [1 favorite]

If there was no PHI/identifying information about the other patient mistakenly relayed, then no, it's not a HIPAA violation as far as I'm aware.
posted by elsietheeel at 1:45 PM on November 5, 2010 [1 favorite]

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