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May 29, 2002 7:45  — 8:00 AM
Welcome!
Carl W. Armstrong, MD, President, VIPC&S; Senior Medical Advisor, Virginia Hospital & Healthcare Association & American Hospital Association

Good morning. I am delighted to see so many of you here! We have a great lineup of speakers today and I think you are in for a real treat. While you are getting settled, I’d like to tell you a little story. It is a true story and one I have not previously told to anyone.

Once upon a time, I was a house officer in an internal medicine residency in Boston. One day I was paged by the hospital operator, who said I had an outside call from a patient for whom I had cared. I became a little anxious because this was unusual -- patients usually followed up with their own private physicians.

"Doctor, do you remember seeing me in the emergency department a couple months ago? I was the patient who had pain and tingling in my hands, the small finger and ring finger in particular." I did remember the patient, a middle-aged male who was very concerned his symptoms represented a serious underlying disease. After taking an occupational history and learning that he performed a repetitive manual task with his elbows resting on a hard surface I reassured him his condition was most likely not serious; rather it was due to pressure on his "funny bone" during work, a condition called ulnar neuritis. I suggested he avoid bearing weight on his elbows and that if he did this his symptoms would very likely resolve on their own. In the meantime he could take some aspirin for the pain.

"My regular doctor says you should never have told me to take aspirin for the pain," he continued.

"Oh. Why is that?" I asked.

"Because I am on coumadin, a blood thinner, and he says aspirin increased my risk of bleeding." I was well aware of the danger of these medicines interacting but I did not remember him being on coumadin. I felt threatened by his accusation and humiliated that a patient was calling to correct me. After all, I was the doctor and I was supposed to know best! All I could manage to say to him was "Thank you for your call. I will look into it."

I immediately went and pulled the record. To my horror, there, in back and white at the top of the sheet the triage nurse had written "coumadin" in the block for "medications." And there, down below in my handwriting were the words "Take aspirin as needed for pain."

Why do I focus on this error when I have made others more recently? It is because I remember his call from 26 years ago as though it were only yesterday. In realizing the error I had made I felt ashamed and fearful the patient might sue the hospital. I kept the whole thing secret. Now, in retrospect, I wish I had had the strength to acknowledge my error and say to the patient "I am sorry." I wish I had shared information about the event so others could avoid making the same mistake.

I also wish the patient’s private physician had told this man, when he prescribed coumadin for him, that he should not take aspirin. Then the patient might have reminded me he was on coumadin when I told him to take aspirin. But I can’t blame the patient for what happened. Certainly there were ways the "system" might have helped to prevent the error from reaching the patient. An electronic medical record with decision support could have caught the error. In this teaching hospital, another pair of eyes on the record before the patient left the emergency department might have helped. Making it standard practice to highlight on the record certain high risk medications might have reduced the chances of overlooking a potential drug interaction.

Today the tables are turned. Now I am the patient and the one on coumadin. I am being treated by a great team of doctors and nurses and yet I have seen some "near misses" through the eyes of the patient. Following are some examples.

My medication is adjusted using the results of a weekly blood test called the INR. On one occasion no one called me after my INR. Eventually I called and asked that my test result be checked -- this led to a dose adjustment. On another occasion I was told "Increase your coumadin dose to 10 mg every day." I replied that I was already on a 10 mg dose based on a different physician’s advice (same practice) the week before. This made me wonder about the method of communication from one physician to another.

My favorite near miss is as follows. A nurse practitioner called to tell me "Your INR is too high. Stop taking coumadin for two days, and then begin 5 mg on Mondays, Wednesdays and Fridays." I was about to thank her and hang up when I decided to repeat back what I thought she was asking me to do.

"So, I should stop coumadin for two days, then resume 5 mg on Mondays, Wednesdays and Fridays, and take no coumadin on Tuesdays, Thursdays, Saturdays and Sundays?"

"Oh no!" she said. "I meant drop your dose on Mondays, Wednesdays and Fridays to 5 mg, but continue your usual 7.5 mg on Tuesdays, Thursdays, Saturdays and Sundays."

You see, what she said originally was consistent with what she was thinking. It was also consistent with what I was thinking. But we were both on different wavelengths! You may hear more later from Jim Bagian about the value of "repeat backs" for oral orders.

I leave you with three take-home messages. First, people will make errors. We can’t stop that because we are human. The key is figuring out how to anticipate and catch errors before they do harm to patients. Second, we need to share between all of us the lessons we have learned, like we are doing here today in this conference. Finally, we need to share the stories about our near misses and adverse events so we can discover new lessons.

Senate Bill 316, which passed in the last session of the General Assembly, has gone a long way to facilitate our doing the latter by protecting the confidentiality and discoverability of such information.

At this time I would like to call up and recognize Delegate Bob Brink who was the house patron on SB316.