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Other Features: Teaching and Learning Moments

Adverse Events: Learning the Science Behind the Art

Nundy, Shantanu MD

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doi: 10.1097/ACM.0b013e31818fdfda
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My stomach turned when I answered my pager. As a fourth-year medical student in general medicine, I felt I could handle most situations, but this one caught me off guard. It was about a patient I had just discharged, and read “new admission: probable drug reaction, rule out Stevens Johnson.”

Instantly the culprit medication came to mind – Bactrim. During her last admission, I had diagnosed Ms. SR with a urinary tract infection (UTI) despite the absence of symptoms and decided to treat her for concerns of loss to follow-up. Reviewing her record now, I was shocked to learn that Ms. SR had a documented allergy to sulfa drugs. Somehow a week earlier, I had missed it.

After interviewing Ms. SR, I concluded her story fit perfectly with a drug reaction, though she repeatedly denied any drug allergies. The realization that my error had led to her suffering made me feel guilty, ashamed, incompetent, and frankly, physically sick. Through the rush of emotions, I recalled a course in patient safety I took during my second year of medical school. Errors do not result from the failure of one person or one system; instead, they result from multiple failures in multiple systems. To best address an adverse event, I had to first try to understand it.

While I initially could not move past my own mistakes, I eventually pieced together the adverse event step by step. First, Ms. SR denied having any drug allergies despite having a history of a drug reaction. Second, her electronic medical record was incomplete. The allergies section of her chart was empty, despite multiple discharge summaries that documented allergies to sulfa. Third, I did not review her record as thoroughly as I should have and failed to practice evidence-based medicine by treating an asymptomatic UTI. Fourth, the prescription for Bactrim was signed by my resident with little oversight, despite my status as a medical student. Finally, underlying these failures were both the culture of my team, which emphasized efficiency over safety, and our workflow, which at times was overwhelming.

Next, I went to see Ms. SR. I began by asking her what her understanding was of how she became ill. I made it clear that her suffering was because of a mistake I had made and apologized. After a period of silence, she asked, “What now?” “Now we are going to get you better again.” She replied, “Okay doctor, tell me what I need to do.” I have never felt closer to a patient than I did at that moment.

Afterwards, I took small steps to decrease the chances this would ever happen to Ms. SR again. I updated the allergies section of her chart and discussed with Ms. SR the significance of her sulfa allergy. And finally, I discussed the case and my safety concerns with the medical team.

This experience taught me that responding constructively to an adverse event can be learned. While I initially felt overwhelmed by the situation, I was more prepared than I thought. Before I even saw my first patient, I had taken a ten-hour elective course in patient safety. The course had preprogrammed me to seek disclosure, and as a result I never once questioned telling Ms. SR the complete story. It also taught me how to disclose an adverse event, which helped me through what was a difficult conversation. Finally, the training gave me the right lens, so to speak, through which to understand how the event had unfolded. Without it, I may have simply dismissed the errors as inevitabilities instead of addressing them as preventable harm.

If only anecdotally, this case suggests the importance of patient safety training in medical school curricula. In medicine, we often focus on learning the science of medicine and leave the art to chance; in the case of addressing an adverse event, I think there is science in the art, one that can and should be learned.

Shantanu Nundy, MD

Dr. Nundy is a resident in the Department of Internal Medicine, University of Chicago Medical Center, Chicago, Illinois; e-mail: [email protected].

© 2008 Association of American Medical Colleges