The field of patient safety became all too personal for me last week when my mother-in-law almost died from an iatrogenic C. Difficile infection of the large bowel caused by the inappropriate use of antibiotics and the failure of healthcare personnel to report their concerns to management or the family. 
My mother-in-law is 91 years old and lives in an Alzheimer unit in a senior living community in the Pacific Northwest. Despite her significant cognitive impairment and increasing frailty, she is in remarkably good health.
Four weeks ago, she was prescribed Augmentin, a broad spectrum antibiotic for suspected bronchitis and/or pneumonia based upon a history of productive cough, weakness and increasing cognitive impairment. Doctors performed no complete examination, sputum culture/gram stain or X-ray. One week later her cough improved, however, she developed abdominal cramps, loose stools and decreased appetite that worsened over a three-week period. She then spiked a fever for which doctors prescribed Cipro for a suspected urinary tract infection (UTI), without a complete examination or urine sample. Two days later my wife and I found her in acute distress with left lower-quadrant abdominal pain, low-grade fever, dehydration and was transferred to the emergency department of a local hospital where doctors diagnosed her with her C. Difficile colitis and she was successfully treated with IV fluids, IV Flagyl and admitted to the hospital for a week.
The med-aide confided in me that she and the staff were aware that our mother-in-law was not given appropriate care by the physician with antibiotics prescribed based upon incomplete evaluations, and suggested that we find a more committed and thorough practitioner to prevent further inadvertent adverse outcomes.
While my mother-in-law was in the hospital, I compiled a summary of her care and forwarded it to the leadership of the senior living community, its managing corporation and the healthcare service that employed the physician and asked for three things in return:
- Acknowledgment of responsibility
- An apology
- A plan of corrective action so that recurrences of this near miss would be less likely in the future
I thought this was more than fair--no legal action (despite a huge hospital bill to treat the infection), no financial compensation--just accountability, organizational reflection and potential improvement.
Unfortunately, life is never that simple nor reasonable. When the director of operations for the Pacific Coast region of the managing corporation contacted me after speaking to a limited number of individuals, he informed me that the unfortunate complication my mother-in-law experienced was the result of poor medical decision-making and that the staff at the facility did nothing wrong as they merely followed the physician's orders and kept her guardian informed appropriately.
I felt I was in a time warp (circa 1965), harkening back to the day when the expert had sole responsibility, when accountability for an adverse outcome merely reflected the failure of a physician to measure up to society's high professional standards. Nurses, management and staff were merely subordinates who played a dutiful and passive role in fulfilling the physician's needs and expectations.
As we now know through the work of James Reason (Swiss Cheese Model) and others, the truth is more complex. Errors and adverse outcomes occur because of the penetration of multiple organizational layers, unchecked by any effective barrier or resistance.
Active errors by a single individual at the frontline (sharp end) are seldom sufficient to cause an adverse outcome, are supported by a wealth of enabling passive systemic errors throughout the organization (dull end) that permit the active errors to result in potential harm.
For instance, in my mother-in-law's case, why didn't:
- The agency that employed the physician utilize evidence based pathways or algorithms that would have made it impossible for him to prescribe antibiotics inappropriately without an organizational audit in real time so that the medical director could intervene?
- The Alzheimer's unit provide training and support to staff to go up their chain of command if anyone felt uncomfortable or uneasy with a resident's condition or care at any time day or night?
- The senior living facility share the concerns of the staff with the family guardian so that he could make more informed decisions?
- The head nurse at the senior living facility make daily rounds through the Alzheimer's unit to personally observe the health status of the residents, speak to staff and review the records?
- The head nurse at the senior living facility perform audits of antibiotics prescribed for all institutionalized residents to insure appropriate antibiotic stewardship?
It's true that the physician should be held accountable for his decision to take clinical shortcuts which unfortunately are common in institutional settings. However, the solution is more complex and it takes a chain of errors for real harm to occur.
In 2010, the American Association of Critical Care Nurses (AACCN), Association of Peri-Operative Registered Nurses (AORN) and VitalSmarts interviewed over 7,000 physicians and nurses and found that:
- 84 percent of physicians witnessed co-workers taking dangerous short cuts
- 88 percent of physicians witnessed co-workers making poor clinical judgments
- 88 percent of nurses were unwilling to confront a co-worker providing sub-standard care
- 99 percent of physicians were unwilling to confront a co-worker providing sub-standard care
Thus, we perpetuate a culture of silent or passive enablement where an individual makes medical errors without any feedback, correction or accountability, only gets blamed after the fact. This is a terribly dysfunctional system that does not reflect well on anyone within it and can cause harm to individuals who are least likely to defend or advocate for themselves.
David Marx in his model just culture comes closest to acknowledging that accountability should be an appropriate balance between what is within the reasonable control of an individual and what requires multifactorial systemic support to enable appropriate performance by all.
My mother-in-law's near miss from an iatrogenic complication was not the result of one, but of many. Hopefully, leadership will acknowledge this contemporary attitude so that it is in a position to protect others from a similar plight.
Jonathan H. Burroughs, M.D., is president and CEO of The Burroughs Healthcare Consulting Network. He's also a certified physician executive and a fellow of the American College of Physician Executives and the American College of Healthcare Executives.