After medical error led to his mother’s death, Boston doctor felt shut out by hospital

Jonathan Welch is convinced the hospital where his mother died in 2010 messed up. While undergoing treatment for cancer, she was hospitalized for a systemic infection that often occurs among people whose immune systems are compromised during treatment. Even as Welch, an emergency physician at Brigham and Women’s Hospital, pushed the Wisconsin hospital’s staff to start a standard drug treatment, her nurses and doctors delayed. His mother died.

“I felt trapped in an alternate reality where the medical rules were the opposite of everything I’d learned and practiced, where doctors and nurses were oblivious to impending disaster,” Welch wrote in an essay published Monday by the journal Health Affairs.

Welch’s family did not want to sue the hospital, which he didn’t identify. It went against their “midwestern family mind-set.” What Welch wanted was an opportunity to talk with physician leaders or administrators at the hospital, to explain what went wrong and to hear how they would fix things.

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After months of waiting, Welch had one phone conversation with a hospital administrator, who offered “a sanitized, verbal admission of error.” Most of Welch’s concerns were unallayed.

“Seeing all those errors serially occur was really shocking to us,” Welch said in an interview Monday. “But even more disappointing was after the hospitalization, learning how difficult it was to give feedback to this hospital. I wasn’t on my home turf anymore.”

Health care is moving toward more transparency. Welch highlights programs in other parts of the country, including a policy encouraging disclosure of errors at the University of Michigan Health System, a unique patient advocacy system in Pittsburgh, and an effort in Massachusetts to formalize patient feedback as part of the hospital’s standard procedures. His own story highlights why hospitals and doctors should continue on that path, he said.

Welch said he questioned nurses about why they were not more carefully monitoring his mother’s vital signs, then pushed to have her moved to the intensive care unit. When the standard treatment was not started even then, Welch was told that his mother’s oncologist had not authorized it.

“I was losing my own confidence as a doctor, becoming instead the helpless son of a sick patient, someone who couldn’t get anything at the hospital to work,” he wrote.

During care, patients and their families can help alert providers to problems or confusion in their care, for example during nursing shift changes—if providers are open to hearing from them.

“Every single patient, every single family can play a role in those care processes,” Welch said.

After care, he said, doctors should see families as a valuable source of information about how they are doing and how their hospital performed. “You learn things about your own care processes that you may not have known.”

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