A Doctor’s Courage

Virginia Mason Institute

For generations the cultural norm in medicine has been that mistakes were discussed in private circles within the hospital or physician practice — if at all. It is this very culture, says Sarah Patterson, that must be challenged and broken down to create a genuine culture of safety within the medical center. “It’s changing the mindset in health care about defects and errors,” she says, “that we shouldn’t talk about them, we’ve got to hide them. The system puts it all on the backs of individual doctors and nurses, saying, ‘You’ve got to do the best you can to protect your patients. There’s no system out there. It’s just all you.’ We’ve got to change that mindset, and we’ve got to change the culture.”

Given the nonstop, high-risk nature of the work, Patterson says doctors and nurses, just to make it through the day, “have to minimize in their minds the risk their patients are exposed to. It creates an environment where people tolerate things that shouldn’t be tolerated: lapses, not following standard work, not building in enough checks. The PSA system is really our signal to the organization that we need to change this culture. We’re making good progress, but it’s a big change. People come to us trained at other institutions, then we have to start from scratch again every time we get a new nurse, a new doctor and say, ‘It needs to be different here, and you need to be a part of this.’”

This message was delivered with tremendous force in an incident during 2003, when Dr. Daniel Hanson, a talented young hospitalist who had served for five years as Chair of the Quality Assessment Committee, made a mistake. Dr. Hanson was filling out a paper prescription one day (this was about nine months before Virginia Mason had computerized physician order entry). He wrote an order for atenolol, a beta-blocker, for a fragile, elderly patient. In doing so, Dr. Hanson wrote: “25 mgms QD” — calling for 25 milligrams daily. There were two immediate problems: First, the Joint Commission had made it quite clear that QD was a potentially dangerous abbreviation and had recommended that clinicians discontinue its use. Their fear was that in the world of physician scribble, the abbreviation could be too easily confused with QOD (every other day), and QID (four times a day). The second problem was that the 25 was scribbled so that it was not entirely clear.

“It was late in the evening, and we were all busy trying to wrap things up for the day,” recalls Dr. Hanson. “The patient was very sick and fragile with heart disease. The atenolol would help slow his heart rate and lower his blood pressure.” Dr. Hanson wanted to start the patient on a low dose of the medication and increase it if needed. When the order reached the pharmacy, however, the pharmacist read the 25 as 75. Some patients tolerate such a dose well, but this patient was much too sick for that. When the medicine was administered, the patient’s heart rate slowed dangerously and his blood pressure dropped to an unsafe level. That night, he was transferred to the intensive care unit (ICU), where the staff sought to reverse the effects of the drug, but it was too late. It was clear the patient was in very bad shape and, in fact, he died soon thereafter.

The reality was that the patient was so sick his life expectancy would have been months, at best. Nonetheless, an error had contributed to his death. Dr. Kaplan asked Dr. Hanson to address his colleagues at a physician meeting about the incident. Doctors had talked about errors in the past, of course, but almost always in small groups. Hanson brought a couple of slides, including one showing his handwritten order. About half those present thought it read 25 mgms and the rest thought it read 75. It was an order, in fact, that any one of the doctors present could have written. Hanson’s handwriting was hardly perfect, but neither was it as illegible as that of many of his colleagues in the room. Doctors sat in silence, watching as Hanson became openly emotional about the incident.

Dr. Hanson took the blame, yet a PSA investigation found that there had been a series of breakdowns along the way. The ward clerk who received the prescription from him should have stopped the line on seeing that QD was written on the script. The same was true of the pharmacist and the patient care nurse. The problem was not Dr. Hanson — the problem was that the system had failed. There was not a culture of safety yet at Virginia Mason. “We can’t just write orders and walk away — we have to be good team members,” Hanson told his colleagues. The message to all physicians was, as Hanson put it, “We can’t just step in, fire off an order and not be accountable for how it’s interpreted.” Hanson’s colleagues listened carefully to his remarks. They knew how difficult it must have been for him and many expressed admiration for the courage it required for him to stand up in such a large forum and talk about the mistake.

Seven years after the mistake, in 2010, Dr. Hanson viewed the safety culture at Virginia Mason as dramatically transformed. He says when he goes to conferences around the country it is quite clear that Virginia Mason is far ahead of most other medical centers in its safety journey. “I go to these national meetings and see people struggling with things we are way beyond,” he says.

Cathie Furman sees this as a defining moment on the Virginia Mason safety journey. “For a well-respected hospitalist who is chair of the quality committee to stand up in a room full of his peers and describe what he had done — it was a profound moment. Everyone talked about it for months afterward. It was such a powerful example, and I have no doubt that countless times after that doctors stopped and thought about that before writing a prescription. I suspect some real mistakes were avoided because Dan Hanson had the courage to stand up there and tell his story.”

This is an excerpt from the book Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience.

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