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The Overlooked Never Event

by: Ryan Van Wert, MD

John’s Story

Since his college days, John was always a runner.  Now at age 65, limping with arthritis, his orthopedic surgeon has recommended a left knee replacement. John completed a consent form authorizing the procedure.  In the operating room, John falls asleep as the anesthetic agent runs through his veins, hearing reassuring words from his nurse that everything will be okay.  When John awakes, it is very clear that something is very wrong.  His surgeon and nurses have gathered around his bedside and have devastating news: an error had occurred.  John had been mistaken for another patient scheduled for an above knee amputation, and the surgical team had removed his left leg.

This is one of the most terrifying scenarios that patients and surgeons fear, a family of adverse events called “Wrong-site, wrong-procedure, wrong-patient errors (WSPEs)”.  At the turn of this century, increasing awareness of these events led to the contemplation of “Never Events”. What ensued was an incredible culture of change in operating rooms to improve patient safety and the implementation of policies to reduce the chance of these devastating errors, including checklists, procedure time-outs, and empowerment of the surgical team to voice concerns before and during a procedure.  Medicare no longer reimburses any costs associated with these events, and WSPEs are medico-legally indefensible.  As devastating as WSPEs are, how often do they occur?  Most estimates put the risk at about 1 in 100,000.  And yet, immense resources have been deployed and fundamental changes to reimbursement have occurred to ensure that John’s story never happens to anyone else.

Susan’s Story

Susan has advanced heart failure; her care team has said there are few other treatment options and her prognosis is limited.  She completes a Physician Orders for Life-Sustaining Treatment (POLST) form – a durable medical order many states use to help patients get the care they want – confirming that she prefers not to have CPR or be admitted to the hospital.  Her preference is to spend her remaining time with family and have her symptoms controlled with medication. One day, she becomes short of breath. She is transported to the hospital and cannot speak for herself.  The POLST form is nowhere to be found and there is no copy in the medical record.  Unaware of her preferences, physicians insert a breathing tube to provide mechanical ventilation.  Her family is reached several hours later, extremely upset to learn that their mother is on life support.  They come to the hospital, order the breathing tube to be removed, and Susan passes away in the hospital several hours later, dying in a way completely contradictory to her care preferences.

Medical Errors Related to Life-Sustaining Treatment

Let’s compare the stories of John and Susan.  Both authorized, in writing, a treatment plan.  Both received procedures that directly contradicted that plan.  Both suffered severe, life-altering consequences of the error.  Both of these adverse events were completely avoidable.  So, why is Susan’s story not considered a Never Event by patient safety organizations?

As an intensive care unit physician, I can tell you that Susan’s story is not uncommon.  There are various factors that expose patients to risks of having an adverse event related to life-sustaining treatments:

  • The healthcare system (defined broadly) has never asked the individual about their preferences, or encouraged a process of systematic advance care planning
  • Documentation of care preferences is missing, or incorrectly documented in the EHR
  • The individual has not communicated their wishes effectively with their loved ones, putting surrogate decision makers in the heart-wrenching position of making treatment decisions with limited knowledge

How frequently do these medical errors occur?

Daren Heyland, a Canadian intensive care physician and researcher has a growing body of work to quantify the extent of the problem both over treatment and under treatment relative to the patient’s actual care preferences.  In a research study published in BMJ Quality and Safety, Heyland’s group performed a multi-center audit of elderly individuals with advanced, life-limiting illness admitted 16 acute care facilities.  Researchers asked patients or their surrogates about their preferences for life-sustaining treatments at the end of life, and then checked their medical record for physician orders related to cardiopulmonary resuscitation and do not resuscitate orders.

Using the medical order or “code status” in the patient record for this study is key, since these are the orders that would be followed by the care team in the event of an in-hospital emergency situation.  The findings were profound: overall, 37% of patients experienced a medical error in documentation of life-sustaining treatment preferences.  Certain sites had an error rate of 67%. Most of these errors put the patient at risk of over treatment.  These patients had clear preferences not to have CPR, yet documented medical orders were to provide CPR if needed. Two percent of patients experienced errors related to under treatment, that is, stated preferences for CPR with a “Do Not Resuscitate” order on the chart. One in six patients (and remember these are all individuals with an existing life-limiting illness), had no documentation on their charts about the use of life-sustaining treatments.

Let’s reflect on the potential consequences of these medical errors. Under treating an individual means near certain death; over treatment is similarly grim. After undergoing CPR – a painful procedure that often results in broken ribs – only 10% of individuals are discharged from hospital with favorable neurological outcomes.  ICU admission exposes patients to higher rates of hospital-acquired complications from delirium (confusion), pneumonia, muscle weakness and blood clots.  It is not uncommon to have many months of rehabilitation after an ICU stay, and long-term negative psychological effects for both the patient and loved ones.  ICU interventions are inherently uncomfortable and include large bore intravenous lines, uncomfortable breathing tubes and other routine procedures that require the use of powerful narcotics and sedatives for a patient to tolerate.

How are the consequences of an unwanted life-sustaining intervention any different than being left without a limb due to a medical error? At the turn of the century, a positive sea change took place in operating rooms across the country to define and systematically eliminate Never Events.  Now is the time for our health systems and patient safety organizations to embark on a similar mission to eliminate Never Events related to life-sustaining treatment.


Julia Ragland said…
Fantastic post. Thank you for writing it. I could not agree more. It would be refreshing to see the QI/Peer Review process examine all patients who undergo CPR and determine if there were missed opportunities to communicate with patient/family about prognosis/goals/preferences for life sustaining treatments. Typically the QI/PR process only looks at underuse of care or missed diagnoses and rarely, if ever, looks at overtreatment or deficient communication about advance care planning.
Unknown said…
Well-written piece! Thanks, Ryan. It is a very important question you are posing, on the care side as well as the patient side. The changes over time as to what is possible for life-sustaining interventions make the question even more critical now than years ago because the chances of surviving in a condition one may have elected against are so much greater these days. The answer is well-worth determining and informing new policies and procedures.

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