When Things Go Wrong in a Hospital

Sudhir Sharma, 58  was wheeled into the operating room early in the morning for what looked like a routine bypass surgery. The surgeon Dr. Roop Singh met his worrying friends and relatives, reassured them that he does not anticipate any complications and hopefully he will be done in 4 hours. The doctor seemed to be in good spirits and quite confident of the outcome.  

The relatives and friends of Mr. Sharma repaired to the Subway joint in the hospital for a quick breakfast and the morning coffee. The mood was hopeful and upbeat.

Not known to them things in the OR had gone horribly wrong. As Mr. Sharma was being put on a heart lung machine, disaster struck. A terrible mistake was made. Mr. Sharma’s aorta was connected with the line supplying oxygen from the machine. The mistake was discovered immediately and the team tried to revive Mr. Sharma,  but by then it was too late. Everyone in the team was shattered and were in a state of shock. One small terrible mistake had cost Mr. Sharma his life.  

They had to inform the expectant relatives of this unspeakable tragedy. Dr. Singh being the lead surgeon had this difficult task at hand. But before that he had to report to the hospital administration of this terrible error and the deadly consequences. Soon everybody in the upper echelons of the hospital administration was aware of the issue at hand and were busy figuring out a way to address the ‘problem’.

1. What do we tell the relatives of Mr. Sharma? How much should we disclose of what transpired in the OT?

2. How do we limit the damage to the hospital’s reputation by keeping all this under wraps?

3. How do we handle media, who were sure to turn-up sooner than later?

The options were relatively straightforward.

The family of Mr. Sharma had to be informed of the tragedy. The question was whether they should be told of what happened in the OR or they be fobbed off with the standard ‘ post surgical complications’ line. The same applied to media, where they could be told that a bypass surgey does have some risk and unfortunately Mr. Sharma succumbed to unexpected problems arising out of the surgery.

I would have expected this hospital to have done exactly this. Hide behind the usual drivel doled out after such unfortunate incidents. However, I was plesantly surprised that the hospital administration decided to make a clean breast of things with everyone.

They informed the relatives of Mr. Sharma about his sad demise. Dr. Singh took complete responsibility for what happened in the OR. The hospital arranged for a post mortem and sent the body to another hospital for an independent examination. They shared the unfortunate incident inside the OR with the media and did not hide any facts. They were remorseful and painfully honest. The media went to town with the story, however since there was no cover-up the media did not have too much to dig or speculate. The story died a natural death.

I am not sure how many hospitals will have the courage to be this honest. Most of them I would reckon would try and put a lid on something like this. The unwritten rule of the hospitals that you just do not talk about these things in public would apply.

The hospital has also initiated an internal enquiry to fix accountability for the incident and to figur out why something like this happened in the first place. Hopefully, the enquiry will not only fix blame, it will also find a solution for something like this never to happen again.

Our lessons, hospital processes and surgeons are falliable, there is no such thing as a ‘routine’ bypass surgery and when something goes wrong, it is best to be completely honest.

I have changed the names of the patient and the doctor concerned. The incident was recently highlighted in the media in New Delhi.

 Pic courtesy www.flickr.com/Dorellana

2 thoughts on “When Things Go Wrong in a Hospital

  1. There are three key issues here

    1. The loss for the family of the patient is irreparable and does cast a shadow on the hospital. I am sure the study into the incident will highlight corrective measures . The implementation of these would be of utmost importance.

    2. The fact that the hospital chose to be truthful and transparent is heartening. It take brave leadership to be as transparent as this. Hopefully this transparency standard will become the benchmark in not just reporting but also in day to day interactions with patients.

    3. How does the message of transparency get communicated to other participants in the healthcare .. other hospitals , testing centers , doctors etc?

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