- Define what it means to be a professional.
- Identify three challenges faced by health care professionals when they uncover potential errors that occurred in the care delivered by their colleagues.
- Review how to balance systems thinking with individual accountability in health care.
- Describe two examples of well-defined processes to identify individual accountability for adverse events and respond to the findings in a measured and fair way.
A 55-year-old woman with a history of type 2 diabetes on metformin presented to the emergency department (ED) with 3 days of progressive malaise, diffuse abdominal pain, and nausea and vomiting. On presentation, she was afebrile, tachycardic, and hypotensive, with normal oxygen saturation. Her laboratory data was notable for an elevated white blood cell (WBC) count of 23,000/mm3, acute kidney injury with an elevated creatinine of 2.2 mg/dL (up from a baseline of 0.8 mg/dL), and a severe metabolic acidosis secondary to lactic acidosis, with a pH = 7.05 with a lactate of 18 mmol/L (normal 0.5–1.6 mmol/L).
Based on her clinical presentation, she was treated for severe sepsis and given intravenous fluids and antibiotics. In reviewing her medical record, the admitting team noted she had been admitted 3 times in the last 2 months with the identical clinical presentation. Each time she had been diagnosed with sepsis even though no clear source of infection had been found, and each time she had improved and was discharged after 5 days in the hospital. In addition, during two of those hospitalizations, she required mechanical ventilation from pulmonary edema and volume overload from getting aggressive fluids to treat her "sepsis."
The admitting team re-examined all of the information and realized the clinical presentation was not consistent with sepsis; rather, it was far more consistent with acute lactic acidosis secondary to metformin (a well-recognized complication of metformin treatment). The metformin and antibiotics were stopped, and she was treated conservatively and did well. The metformin was added to her allergy list, and, since stopping, she had no further episodes.
The attending physician on the admitting team wondered why the diagnosis had not been made during the previous admissions. Although the degree of illness and lactic acidosis could be consistent with sepsis, no clear source of infection had been discovered; recurrent sepsis without a source is highly unlikely. In addition, the degree of lactic acidosis was out of proportion to the degree of illness, which should have prompted exploration for other causes of severe lactic acidosis (i.e., metformin). She felt like this was a diagnostic error—that the multiple clinicians and teams who had cared for the patient had likely "anchored" on the diagnosis of sepsis and didn't consider other possibilities. She wondered what to do. What was the most effective way to give feedback to the previous teams? Should the providers be blamed for possibly missing the diagnosis? Because the patient likely experienced harm because of the error, should anyone be punished? What could be done to prevent this from happening in the future?
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Figure. Professional Accountability Pyramid. Adapted from (6) with permission of the author.