A short while ago the Boston Globe ran a story about Carolina Carcerano, a 74-year-old who went into Tuffs Medical Center for a routine back pain procedure. The operating neurosurgeon requested a special dye to test the location of a tube that had been placed in her spine. The pharmacy didn’t have the specific dye, so they provided a different one.
The neurosurgeon checked the label and saw the name of the dye he expected to see – one that was safe for spine injection – but because of the pharmacy swap, he missed a dye’s label that said it shouldn’t be injected into the spine.
“A mistake was made,” said neurosurgeon Dr. Steven Hwang. “We gave her the wrong dye.’’
Carcerano died the next day.
Cognitive Bias
Thousands of patients are injured each year by “cognitive bias,” defined as when physicians see what they expect to see on medical charts and medication labels, instead of what they actually show.
“[The surgeon] saw what he expected to see and proceeded,” said Dr. Saul Weingart. He said it’s an example of cognitive or “confirmation bias.”
Even more troubling is the fact the some malpractice insurers don’t offer compensation even when an indisputable medical error has occurred.
That was the case in Carcerano’s death, as the malpractice insurer denied that the surgeons and pharmacists were responsible for her death.
“A mistake was admitted, and now they’re saying it’s not their fault,’’ said Carolina’s son Stephen.
Stephen and his brother Michael filed a lawsuit against the hospital, and the insurance company settled after the Boston Globe began asking about the case.
Preventing Errors
After the error Tuffs implemented a variety of hospitalwide improvements to cut down on errors, including requiring caregivers to submit detailed written medication orders to pharmacists and proper patient positioning during intravenous line removal. State investigators said a follow-up investigation showed vast improvements in care.
In addition to hospital improvements, six hospitals have started a pilot program to offer patients and their families who have been harmed by medical errors a swift apology and earlier financial settlements. The program is hoping to determine how earlier resolution impacts patient and family satisfaction.
“You should be able to work out compensation even if there are multiple defendants if there is a clear-cut avoidable injury,’’ said Dr. Alan Woodward, one of the leaders of the pilot program. “It’s morally and ethically the right thing to do.’’
Dr. Silverman comments
This is a sobering take on a challenging problem. Confirmation bias, meaning you see what you expect to see, is unfortunately present in our everyday behavior.
Ascertainment bias is also present and strongly being reinforced in this “teamwork” approach. But this also highlights another problem of the law of unintended consequences. These checks and re-checks in a teamwork approach often lead to a diminution of individual responsibility into collective responsibility.
In collective responsibility, people can become inhibited from speaking up despite all encouragement to do so. For example, in this situation at least three people said this was the right dye to use. How many of the people really read the label before handing the bottle to the nurse who showed the bottle to the doctor?
Related source: Boston Globe