On its web site, a hospital apologizes for a fatal error

Taking the idea of full disclosure to another level, a Seattle hospital has posted a public apology to the victim of a medical error with apparently no regard to how that may affect the inevitable lawsuit from the family. Robert Caplan, medical director of quality at the 270-bed Virginia Mason Medical Center, posted a public notice on the hospital’s web site taking full responsibility for the error that, according to press reports, involved a technician mistakenly injecting a 69-year-old woman with toxic skin-cleaning antiseptic instead of a harmless dye.

"Recently, a preventable medical error occurred at Virginia Mason that we believe caused the death of one of our patients," Caplan wrote. "We have offered our heartfelt apologies to the family of the patient and are doing everything we can to help them in this time of grief. But perhaps the only way we can make our apology real is to do everything we can to prevent medical errors in our system. Those efforts start with admitting that we make errors — as in this case, owning up to errors, learning from them and fixing the systems that allow them to happen," he noted.

Caplan went on to cite the 1999 Institute of Medicine report, which indicated that perhaps as many as 98,000 Americans die each year as a result of medical errors. "More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516). This is a stunning statistic," he wrote. "Virginia Mason has made a firm commitment to eliminate errors from our system entirely — by establishing processes that bring errors to the forefront for examination, and by developing systems to prevent such errors in the future."

Caplan explained that "open discussion of medical errors is essential, because it provides the best opportunity to understand what actually happened and to teach others the important lessons that have been learned." Talking about these issues openly is "painful and difficult, but only in doing so do we acknowledge the reality of the flawed systems that exist in health care today — and arm ourselves with information to do something about it."