As I prepare to give my lecture on “Disclosing Medical Errors” to veterinary care providers in Calgary this evening, I recall what is still to date the most difficult experience of my veterinary career. It was when I realized that a mistake that I made killed a dog in our intensive care unit (ICU). As vulnerable as I feel now sharing my story, I am doing it because I want others to know that even as veterinarians, we are not infallible; we are human and we make mistakes.
I was a third year small animal emergency and critical care resident at the time and working in a busy ICU at a renowned veterinary teaching hospital in North Carolina. I remember the events as if it were yesterday. The ICU was full, I was sleep deprived, and I was facilitating the placement of a nasal feeding tube for a dog named Laci that was under the care of a medicine resident in the hospital. It was a Friday afternoon and everyone was busy and it was one of those times when everything that could go wrong did go wrong. I asked one of the technicians to place the feeding tube and then take an x-ray so that I could confirm the tube was in the right place. The first x-ray showed the tube was indeed in the correct place, but the end of it was kinked. I asked the technician to pull the tube back slightly to allow the end to flip forward towards the stomach and then repeat the x-ray. Unbeknown to me, the tube was removed completely and replaced. When I went to review the second x-ray, in haste, I only looked to see that the tube was directed towards the stomach (and that the kink was removed) and made the mistake of not reviewing the entire x-ray to ensure that the tube was correctly placed in the esophagus and not the trachea (airway). It was this mistake that led to Laci getting fed food into her lungs. And it is for this reason that she experienced cardiopulmonary arrest and died overnight.
Those events took place almost 10 years ago now and I am certain I will never forget them for as long as I live. What happened after the error was discovered (after Laci died) was agonizing. The owners waged a lawsuit against the university and everyone involved, which went on for years. A complaint was filed with the North Carolina Veterinary Medical Board, which correctly identified that despite following the standard of care in this situation, I had made an error in interpreting the x-ray.
I recall berating myself for the mistake and telling myself I didn’t deserve to practice veterinary medicine. I remember questioning all of my medical decisions that I made for weeks. And I remember being terrified to interpret x-rays for months. But most of all, I remember thinking about how I would feel in that situation if it were my dog in the ICU who died as a result of a medical error.
It is because of my experience that I lecture to veterinarians and other veterinary care providers the importance of disclosing medical errors to clients. In my situation, despite telling my advisor what happened immediately after it was discovered, the owners were not notified until days after they had lost their beloved family member. I am certain that this only served to fuel their desire to file a lawsuit. Research shows that in human medicine when medical errors are disclosed and involved personnel apologize that family members are much less likely to sue. Contrary to what some might think, ignorance is not bliss when it comes to medical errors, because the only person who benefits from not coming clean is the person who made the mistake.
While the process of telling a client about an error that was made is extremely difficult, especially if it resulted in an adverse event or death, in the end, full disclosure is the best for everyone. It allows the animal to receive the treatment that it needs, in an effort to lessen the medical consequences of the error. It helps to explain otherwise unanticipated problems that the animal might be exhibiting after the mistake is made. It strengthens the relationship between the veterinarian and pet owner, who will trust that the veterinarian will be honest with them no matter what situations arise. And it reduces the emotional distress for everyone involved and helps bring closure and understanding to an already difficult situation.
Most importantly, it allows us to learn from the mistake and make changes in hospital protocol or policy to help prevent the error from happening again. After my mistake, the hospital in North Carolina implemented the “Laci Rule”, which stipulated that every feeding tube would have its proper placement confirmed with an x-ray interpreted by a radiologist before any feedings would commence through the tube.
My final plea to everyone in the veterinary profession who at some point realizes that they made an error that harmed a patient is to please exercise self-compassion and forgiveness. We are human and we make mistakes. It is how we handle these mistakes that defines us as veterinary care providers; not the mistakes themselves.
