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Too Little, Too Late

Malone V. Hill, III
Vincent Valentine, MD

University of Texas Medical Branch
Galveston, TX, USA

I had just started my job as an Anesthesia Tech in 2011 when our patient died in the operating room. After a relatively minor procedure for removal of a jaw mass, we transferred the 55-year-old patient from the operating table to his bed. Noting circumoral cyanosis, the anesthesiologist resumed masking the patient, but the pulse oximeter showed continued desaturation. Checking the cable connection and calling other anesthesia personnel into the room delayed our journey to the cardiac cath lab, where an emergent procedure found complete occlusion of the patient's LAD. The patient had died almost instantly, as soon as an embolus had lodged in his coronary artery, but this did not absolve the anesthesiologist overseeing the case. Afterward, the main focus was on why the patient's EKG leads had been removed before being transferred to his hospital bed. I heard that a formal investigation followed, and that the patient's family was devastated, but no party was deemed at fault because, in all likelihood, it was inevitable that the patient would experience a myocardial infarction eventually due to his atherosclerosis. In all likelihood.

Examples of medical error by omission are more rarely cited than those of commission [1]. Double-dosing of medication, operating on the wrong surgical site - such errors have a clear discernable origin, but this is not always so with errors of omission. The physician who administers too much medication provides a better teaching example than the physician who forgets it altogether, thus news articles and case reports tend to focus on the former. In fact, "errors" in which medical professionals apparently didn't "do enough" aren't always considered errors. This is because modern medicine is often tasked with preventing the natural history of disease, and lack of intervention might as well be the same outcome as an ineffective intervention. The anesthesiologist cited above might have monitored the patient's EKG more closely; he or other health care providers caring for him could have taken a more thorough history of cardiac health; the OR team could have moved more swiftly to transfer the patient to the cath lab, but none of those things happened, and we don't know how the outcome might have changed otherwise. So is this a case of medical error? We'll never quite know, confounding the definition of medical error by omission, and further explaining why such examples are less often cited.

Regardless of fault, patients and their families want explanations when tragedies occur. Often times there are no explanations. If I was family to the patient with a jaw mass, I would have a hard time believing that his death was not directly caused by the surgery. Couldn't someone have done more to prevent his death? How can we even tell the difference between the natural progression of disease vs. iatrogenic cause when the two overlap chronologically? These questions eventually erode patient faith in medical professionals, regardless of the outcome.

My mother has repeatedly told me that she doesn't want me to become an emergency medicine physician. Her opinion stems from a 2006 visit to the ED in Burnet, Texas after she was bitten by a feral cat. Upon cleaning and bandaging this minor wound, the young physician commenced discharge from the ED. "Don't I need a rabies vaccine?" asked my mom, but the doctor quickly dismissed her concern. Unassured, my mother contacted the State Health Department an hour later. The non-physician who answered escalated my mother's fear, telling her that Burnet had the highest incidence of rabies in the state. Though no adverse outcome followed (my mom was vaccinated the next day in Austin), I am reminded constantly by my mother how incompetent and negligent that particular emergency doctor was. Without knowing the full details of the event or the protocol for vaccination, I have contended that "negligence" is an unfair and uninformed conclusion, but my mother remains steadfast in her criticism not only of that doctor but of the specialty as a whole.

In the ACA-era of overspending in healthcare, it sounds strange to emphasize the examples of medical error by omission. As previously stated, this under-emphasis is derived from the fact that less identifiable, less concrete and less detectible acts of omission. It is difficult to determine if an act of omission is indeed, a medical error, just as it is difficult to tell if a hospitalized patient's death is attributable to their disease or some intervention. Nonetheless, those looking for answers - especially patients and their families, who physicians should concern themselves with most - cannot discern" errors of omission from errors of commission." Once the unfortunate outcome is final, they only know that successive efforts are too little and too late to matter. ■

Disclosure Statement: The authors have no conflicts of interest to disclose.


  1. 1. Grober ED, Bohnen JMA. Defining Medical Error. Can J Surgery. 2005 Feb; 48(1): 39-44.

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