My Medical Error

On this blog, I often write about medical errors –different kinds of errors, how physicians should handle errors, how physicians can avoid errors, etc. But, today, I’d like to write about an error I experienced: what happened, how the physician handled it, and my reactions.

The error didn’t happen to me, per se, it happened to my son during labor and delivery. I knew very early on that my second son was going to be a big boy. During a routine appointment in the middle of my pregnancy, I met with one of the partners in the practice. She was new, and while reviewing my records, she kept looking at my belly very puzzled. Finally she said, “I don’t have any concerns… Everything looks good… But, you’re just SO LARGE. Would you mind if I got an ultrasound just to see what’s going on in there?” So, I agreed, slightly anxious. She did the ultrasound, and said, “Yeah, you’re just going to have a giant baby.” (And, add to this the fact that I’m on the smaller side and I have small hips, and my husband is 6 feet 2 inches tall, I think this error was bound to happen.) But, more background first…

Because my first son was an emergency c-section, and we knew Linden was going to be large, we agreed to a scheduled c-section a week before my due date. But, that didn’t matter, because he came a week before that. My water broke and it was clear as day that this kid was ready to come out –I diagnosed the meconium myself. After making it to the hospital and being triaged, I found out that he was breach. (Side note: I did have my own kind of “errors” –an epidural that took four tries to be properly placed. The first few times it was clearly to the right of my spine, delivering such an electrical zing up my spine that it made me nearly black out each time.) Now to the real error. It wasn’t anything major. But, in the process of cutting open my belly, the physician also cut my son’s buttock. It was a good slice, about two inches long and it explained why he was crying before they pulled him out of my stomach. But, I do have to say, that I am probably the best kind of patient to have encountered this kind of error. My older son is medically complex and had two surgeries in the first month of his life and four additional surgeries since and we see three different specialists regularly. So, I have experienced many, many medical events, trips to the ER, complications, etc. So, a cut on the butt is nothing to me. Obviously minor. I was simply thrilled that this kid was totally healthy and had all of his organs functioning and in the right place. And, as I alluded to above, this error didn’t surprise me. By the end of that pregnancy it felt like my skin had been stretched as thin as possible just trying to house this child. But, that said, I was very pleased with the way the physician handled the error.

My physician immediately acknowledged the cut and showed it to me before I was even out of the OR. It had already been cleaned and bandaged, but he pulled back the bandage so I could see it. He then apologized. His language was a bit funny, in hindsight. He said, “I wanted to let you know that we accidentally cut your son when we were cutting you open for the c-section.” “We” makes me now think that he might have been covering for a resident who might have done the actual cutting. But, I guess that’s ok, because he’s the attending and everything is ultimately his responsibility, right? He then said, “I’m sorry it happened and I will keep an eye on it to make sure that it heals properly.” He was to-the-point and sincere. I was fine with all of it and so was my husband. He then asked if I had any questions. We didn’t.

So, what did this physician do right?
1. He immediately acknowledged the error.
2. Showed me the error/cut.
3. Explained how he already cleaned and bandaged it. (He dealt with the impact of the error.)
4. He apologized for the error.
5. He said that he would keep an eye on it to make sure that it would heal properly. (He acknowledged that he sees the follow-up care as his responsibility.)
6. He asked if I had any questions.
7. He was sincere.

Now, I realize that most patients would probably not be as understanding as I was. But, in light of the error, I think this physician did everything he could have to manage the situation well. And, Linden recovered just fine –all 9 pounds, 10 ounces of him.

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