Welcome back. Last week I made the assertion that it is irrational to talk of rational agency in healthcare. We followed the story of a 31-year-old man who had spent time in a Emergency Department (ED), had dialysis, and been transferred to a general medical ward. We saw how the process of care had stripped him of what little opportunity he had to exercise agency and self-determination. This week we will bring our patient’s story to its conclusion. We will also begin to tease out the social and complex nature of decision making. Let us continue our story…

A story of systemic harm

It’s 21:30 and our patient has just arrived on the ward. He has been in hospital for seventeen hours. He has had two un-witnessed falls. He has been reviewed by four medical officers, and cared for by at least six nurses.

At 21:30 the patient is reviewed by a Registered Nurse (RN). The RN notes that the patient is complaining of shooting pain in his lower back and altered sensation in his upper thigh. On examination the RN finds that the patient has bilateral lower limb weakness and altered sensation. These findings are communicated to the medical officer covering the ward for the evening. The RN notes that these appear to be new findings; and recommends that the oncoming shift perform hourly neurovascular observations.

Indeed they are new findings. At least from the perspective of the RN. The patient arrives on the ward and complains of pain. In the process of establishing baseline observations the RN follows up this complaint with neurovascular observations. The observations are then documented and communicated to the medical officer who happens to be on the ward at the time.

The requests for hourly neurovascular observations suggests that the RN is concerned about this patient. The request for ongoing observations seeks to determine if the ‘new’ symptoms exhibit a worsening trend. But as we are aware the pain, weakness, and altered sensations are not new symptoms.

Unwitnessed falls, altered sensation and pain

In the preceding 24hrs our patient has had two unwitnessed falls. After each fall he has been reviewed by a medical officer. He has also complained of altered sensation prior to and after dialysis. In each instance he has again been reviewed by a medical officer. Each review has generated data about the clinical state of this patient. Yet this data was either unavailable or inaccessible to the nurse on the ward. From the perspective of this nurse his review was the first, or baseline clinical assessment that corresponded with the symptoms. At 22:00 the RN finished his shift and handed over care to the oncoming night shift.

At 10:50 the next morning the patient mentioned his pain during ward rounds. The pain was no longer isolated to his lower back but was also present in his legs. The patient was unable to mobilise. An x-ray was performed at 14:30, the results indicated a compression fracture at Thoracic Spine (T7). A CT scan was performed at 16:45, and an MRI scan was performed at 19:32. The results of the MRI scan confirmed the diagnosis of a T7 fracture and an epidural haematoma from T1-T12.

The patient has been in hospital for a little short of two days. Throughout his time in hospital he has been cared for by concerned, rational, and competent professionals. Yet here we are, just forty-four hours into our story and a patient who was sent to hospital for a review post a fall has T7 fracture and a epidural haematoma. Now our story begins to develop a sense of urgency. In under three hours our patient will be anesthetised…

At 23:50 the patient attended the operating theatre for a T5-T8 laminectomy, removal of extradural lesion, and spinal cord decompression. The patient was transferred to intensive care post-operatively. Forty-four hours after surgery the patient was transferred to a medical ward… where he was met by another nurse whom had not yet met. The patient had no pain, and no sensation. Since surgery the patient has been unable to move his legs and remains on the waiting list for spinal rehabilitation. All for the want of a cigarette.

A case of systemic harm due to a failure of perspective

At this point it is redundant to count the number of professionals involved in his care. There is no need to count the number of hours. Was it the fall in the care facility that did the damage, or one of the two falls in the emergency department? Was it a process of incremental damage? There will be no definitive answer to these questions. However, the outcomes are clear. After four days in our care this patient can no longer walk. What little agency he had is further diminished.

The series of events described here happened recently in an Australian hospital. This patient, a patient with a clear mechanism of injury, suffered from systemic iatrogenic harm. Systemic because the harm did not result from one intervention or error. Indeed he received comprehensive care delivered by attentive professionals. Who acted in a competent manner. Ultimately it was the system itself that caused the harm. The harm suffered by this man was foreseeable and therefore avoidable. Our story is the result of a failure of perspective.

Throughout our story each professional responded to the situation at hand. A sea of concerned professionals attended to, assessed, and attempted to alleviate the patient’s pain. Yet at no point were any of these professionals aware of the broader complexity of care. The fragmented and complex nature of our hospital system meant that each professional was acting alone. Many of us continue to think of our team as localised and hierarchical. In our daily practice we recognise that in a poorly functioning team uncertainty goes unnoticed and unchecked.

Everyone involved in a patient’s care is a member of the same team

In our story the team functioned poorly. Yet at each juncture of this patient’s journey the local teams provided safe and high quality clinical care. The failure to recognise uncertainty was due to a failure of perspective. At no point was the team conceptualised as everyone involved in the patient journey. In modern healthcare systems each professional is part of a distributed network. As such we must incorporate predictions about the coordination of care into our assessments, practice, and documentation. The alternative to making these predictions an integral part of our clinical vocabulary is reorganising how services are delivered. A lack of awareness about our own limited perspective and role in the arc of patient care will lead to harm, regardless of the quality of immediate clinical management.

Next week our story continues. We will describe how each individual clinician is responsible for the injury suffered but how none can be held accountable…

This article contains information on a critical incident investigation. Names, dates, and some of the details have been removed or changed to protect the identity of those involved.