Sometimes, it has to be said: ‘I made a mistake’

Not long ago, a nurse in my clinic burst into my exam room shaking like a leaf.

“I just made a terrible mistake,” she whispered, cocking her head toward the next cubicle.

Inwardly, I flinched. Outwardly, I stayed calm.

“OK,” I replied. “Let’s go over this step by step.”

She had been giving a patient two vaccines in preparation for his trip to Africa.

“Somehow I got his yellow fever and tetanus vaccines confused,” she said. “So instead of giving the tetanus intramuscularly, I injected it sub-q. I’ve never done that in my life! I still can’t believe I did it!”

As medical mistakes go, injecting a tetanus shot subcutaneously -- in the soft tissue of the upper arm -- rather than the muscle is far from catastrophic. Still, I identified with my co-worker’s dismay. To a conscientious nurse or doctor, even a minor departure from standard practice is upsetting. In some cases, it can also cause harm.

I braced myself for the next scene. “The first thing we need to do is to tell him what happened,” I said to the nurse. “Then we’ll take it from there.”

At some point in every medical career, a doctor will have to decide whether to disclose an error. Common decency says we should, but there are legal repercussions to weigh. Faced with skyrocketing malpractice premiums and jury awards -- not to mention the fear of losing insurance altogether -- many physicians today are naturally loath to reveal anything that might trigger a lawsuit.

Even when a doctor or nurse wants to come clean about a medical mishap, she or he must sift through contradictory messages on what to say to whom, and when. Hospital guidelines usually address only worst-case scenarios (like removing the wrong body part) rather than everyday, garden-variety mistakes.

And where a professional works in a large self-insured facility as opposed to a private medical office can make a difference. Some private malpractice contracts are considered void if the insured accepts liability upfront for an error.

The stakes were hardly high in the case of my nurse’s misadministered vaccine, but the feelings were familiar. For one thing, it was not the first time a vaccine error had occurred on my watch. A clinic assistant in the 1980s managed to inoculate a patient with 10 times the normal dose of cholera vaccine. Amazingly, when told, the patient merely shrugged her shoulders. (The error didn’t harm her.)

But the worst memory raised by the recent error was something far more painful -- a fatal injection I ordered almost 30 years ago.

It was 1977, and I was an intern rotating through a Veterans Administration hospital in Chicago. One patient on my service -- an emaciated man with end-stage cancer -- had left two days earlier to spend Easter weekend with his family. I saw him next on Monday morning, doubled over in a wheelchair. Too anguished even to talk, all he could do was moan and point to his middle. When I tried to examine him, he wouldn’t let me touch him -- an ominous sign.

His agony left me no choice but to act -- fast. “Fifty milligrams of Demerol, stat!” I called to the ward nurse, hoping to make him comfortable before finding my resident to discuss our next move.

The nurse emptied the syringe, the patient improved for a minute or two -- and then he died in front of my eyes. Our efforts to resuscitate him were futile.

I could have convinced myself that the patient had succumbed to his malignancy or his latest abdominal crisis, but I knew in my heart that the painkiller was the immediate cause of death. In hindsight, the standard dose was simply too strong for someone whose liver was eaten away by cancer.

With leaden heart and feet, I left the nursing station to find the patient’s wife and daughter and tell them exactly what happened. As shocked as they were, they understood -- and forgave.

Almost 50 years ago, an American Medical Assn. ethics handbook stated that physicians must report accidents, injuries or bad results stemming from their treatment.

Today, some professionals assume this means they should inform their superiors, or the hospital risk management office, rather than the injured party. Days or weeks can pass before patients learn the truth. Sometimes they never do.

I think patients deserve to know when medical mishaps occur, whether or not obvious harm has occurred. The steps involved in the disclosure and the person leading the discussion may vary from case to case, but one thing is sure: Belated or coerced confessions are certain to result in mistrust.

We all know that errors occur in medicine, as they do in other realms of life. Revealing them promptly can make the difference in preserving people’s faith in the humanity, and humility, of medical caretakers.

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Dr. Claire Panosian Dunavan is a professor of medicine and an infectious diseases specialist at the David Geffen School of Medicine at UCLA. She can be reached at drclairep@aol.com.