Resurrection Errors (12 mins)

Have you ever noticed how admission orders can be corrected, but a faulty discharge is nearly impossible to correct? Today's episode explores fake deaths, inaccurate discharges, and how to begin solving for resurrection errors in healthcare.
Key Points:
-Fake deaths are common
-Computers do not believe in resurrection
-Discharges are surprisingly inflexible

References:
-Wikipedia (2024). “Safety Coffin.” https://en.wikipedia.org/wiki/Safety_coffin.
-Stechyson, N. (June 19, 2024). “Noam Chomsky told us to question the media. This week, the media reported he had died.” CBC. https://www.cbc.ca/news/world/noam-chomsky-not-dead-1.7239373.
-Bruchac, J (2005). Code Talker. New York: Penguin.
-Clapper, C (October 16, 2023). Special Feature: Can we keep our patients safe? Asking an expert the tough questions with Craig Clapper. Quality for the Rest of Us. https://podcasts.apple.com/us/podcast/quality-for-the-rest-of-us/id1640141276

Transcript

Resurrection Errors

Everyone in the classroom stared.

“You’re supposed to be dead!” the professor stuttered.

“I know. I heard. Sorry to disappoint!” My husband took his seat and penciled a note to himself to re-enroll in his courses.

You see, an error had occurred in some paperwork over the semester break, and that error resulted in all of my husband’s classes being canceled due to his death. For a few days, he had no registration, no funding, and all his college professors were notified with a letter that offered counseling services for anyone affected by the tragic loss.

In this episode, we’re going to explore how surprisingly common these kinds of “resurrection errors” (as I like to call them) actually occur – and one of the most common places where they occur is in healthcare facilities.

Did you know that during the Romantic era, people were often buried with a bell, so they could ring for help if they woke up in the coffin?[1] Apparently, the fear of being buried alive was quite prominent at the time.

And no wonder, since apparently we struggle quite a bit to confirm or deny whether someone is dead.

Two months ago, the CBC printed an article about the famous linguist Noam Chomsky, titled “Noam Chomsky told us to question the media. This week, the media reported he had died.”[2] Apparently, a different news source published a report of his death and his wife had to post that he was very much alive.

In the hospital, when a patient was declared brain dead and eligible for organ donation, it did not always cancel their meal orders. So we would have meals delivered for dead patients – thankfully, that never occurred at a time when family was at bedside, but you can imagine how troubling that could be.

I also heard stories about nurses working in postpartum entering the room to receive a handoff report at the bedside – which is the recommended practice so that patients can provide insight about the report and speak up in case they hear anything problematic. But in this case, the oncoming nurse warmly congratulated the patient on the birth of her baby as they took their places to handoff with a thorough report. The problem was that the baby was stillborn, and this was a grieving mother recovering from physical and emotional trauma.

And it’s not just the healthcare industry that is affected by this error type. I recently finished a fascinating book that my son recommended called Code Talker by Joseph Bruchac, an historical fiction book about the Navajo marines who fought for the Allies during World War II and sent “unbreakable” encoded messages in the Navajo language.[3] At one point, in Guam, they discover the body of one of their friends and colleagues, Charlie Begay. His lips were blue, he wasn’t breathing, and he had a terrible sword-wound across his chest, neck and shoulder. They straightened his body, put his dog tags in his mouth, and buried him in leaves and bark, saying a prayer before they continued their march. Later, when his replacement arrived to help the team, everyone was speechless. It was Charlie Begay! He explained, “I don’t remember much of anything after the Japanese ambushed us. Except I started to feel my feet twitch and then I heard my heart beat. It seems that somebody… had put bark and leaves all over me, so I stated moving to shake that stuff off. Then when I rolled over I realized some helpful person had stuck my dog tag in to my mouth! I was not pleased about that. I was just trying to stand up when graves registration got to me.” He had suffered blood loss and was evacuated to a hospital ship, but eventually was ready to report back for duty. His friends were overjoyed that he came back to life. And Charlie Begay wasn’t the only one. Sometimes a soldier’s belongings were sent back to family with a note that they were killed in action, and then they would show up after surviving alone in the wild. Imagine the shock!

So it’s not just a healthcare problem, or an education or military problem. It’s a human problem. Sometimes we get it wrong, sometimes we are surprised, sometimes we assume too much. But the military was able to restore their active duty status, feed them regular meals, clothe and shelter them, and send a note to family, even back in the 1940s. But most healthcare systems struggle to restore a patient who is accidentally discharged.

This leads me to a question. Why is it that we don’t expect this type of error? It’s been happening in various industries for decades, even centuries, but we are constantly surprised and stumped by the problem. 

Why are we so shocked when a death report is false? Because it’s not an isolated or freak occurrence, yet we “feel” like it is highly unusual.

In truth, we have a lot of anticipation for an ending—whether birth, discharge or death—that it’s difficult to imagine it could be false.

A false death simply seems impossible. And all of these final endings have a myriad of dependencies that require close monitoring for accuracy. They really require a plan and procedure for when errors occur – because they do occur.

Given that there are so many dependencies, from ordering meals and meds to billing, would you be surprised to hear that there is typically no protocol or plan for how to resolve such errors?

When I think about it, there are a lot of dependencies for other important actions, and they DO have a plan for reversal. For example, if a doctor orders outpatient admission, then quickly changes the order to inpatient status, there is a procedure for that. There are rules about how to capture the timestamp and ensure the admission status is correct, and there are ways to update it.

But if someone discharges the roommate rather than the correct patient, that poor soul will not receive meds or meals. In affect they become totally invisible, like a ghost in the system, and even with help from the house supervisor it can take hours to resolve. The patient did nothing, it was just a couple of clicks in the computer, yet so many problems and delays ensue in the delivery of their care. And there is no way to click on the patient and undo the discharge or put them back into the system under the same encounter number. The ugly reality is that the electronic record is extremely unforgiving in matters like these. They often end up with two separate encounters that get lumped together later after a lot of manual effort. Orders have to be re-entered, because there is no easy way to restore them. Consults must be requested again to appear on the list of the visiting specialist. Procedures are canceled. It is hell on earth for the resurrected patient and everyone who cares for them or uses their record.

While I want to laugh and quote Monty Python and the Holy Grail, “Actually, I’m not quite dead yet,” I think it’s time to move past the shock and start crafting intelligent procedures for these situations. These errors cause dangerous delays in patient care, yet they never seem to make the patient safety list. 

Can we start by admitting that they happen? We would have to get over the shock and consider what a patient goes through. We would need to walk through that scenario and uncover the strengths and limitations of the current guardrails – usually a pop-up that asks if you’re sure. Well, when if I know I’m discharging patient A, then I might be quick to click Yes, I’m sure. It’s only afterwards, when patient A is still in the system and patient B has disappeared from the list, that the error is discovered.

Perhaps with two signatures, the team could undo the discharge in the electronic record and restore the patient’s active orders. We could write a policy that shares who to report the problem to. We could include false deaths and discharges on the list of safety events.

After all, when the goal is to make a system that is resilient to problems, we have to start by identifying the problem. Then we can proceed through the quality improvement cycle and attempt to plan, improve, and evaluate the workflow.

When we try to be resilient, we often think of toughness. We think of being able to withstand force. But in my interview with safety expert Craig Clapper, he explained that High Reliability Organizing requires a degree of flexibility to be truly resilient.[4]

I live in hurricane country, and someone pointed out to me that many of the local trees are soft woods. You see, in hurricane-force winds, a strong but stiff tree will not bend, and it is actually more likely to break. But a palm tree, for example, can bend in the wind. It is resilient against force because it is flexible.

Our health system is so big, it is challenging to be flexible. Human beings are one of the most flexible assets, and we often push against the inflexibility of machine rules. That’s not a bad thing. A machine would never anticipate that a patient could move from dead to alive, but humans can observe the evidence and accept that this situation can happen. 

I guess we are more comfortable with the need for an undo button. 

This is why it’s critical that we listen to honest frontline workers who willingly tell us exactly how the mistake happened. If we allow ourselves, we can imagine that if it happened once, it can happen again.

To see admission as a flexible thing, but discharge and death as totally inflexible is a false dichotomy. While death is permanent, the documentation of death is not. Such inflexible endings are a risk to patient safety. Today, my ask of safety professionals and healthcare administrators is to ensure that false discharges and deaths are on the list of safety errors for reporting and write a policy for employees describing how they should handle this type of situation.

Because no one wants to be a ghost in the hospital.

When I discharge a deceased patient, I want to be able to ring a bell if they turn out to be alive after all.

[1] Wikipedia (2024). “Safety Coffin.” https://en.wikipedia.org/wiki/Safety_coffin.
[2] Stechyson, N. (June 19, 2024). “Noam Chomsky told us to question the media. This week, the media reported he had died.” CBC. https://www.cbc.ca/news/world/noam-chomsky-not-dead-1.7239373.
[3] Bruchac, J (2005). Code Talker. New York: Penguin.
[4] Clapper, C (October 16, 2023). Special Feature: Can we keep our patients safe? Asking an expert the tough questions with Craig Clapper. Quality for the Rest of Us. https://podcasts.apple.com/us/podcast/quality-for-the-rest-of-us/id1640141276