The Faces of Medical Error...



Left to right, Dr. Leslie Farrington,
 Charles Cal, RN, Steven Pegalis ESQ.

On August 29, 2011 PULSE of NY sponsored an evening of education and dialogue at the South Nassau Unitarian Universalist Congregation, Freeport Long Island.  The topic was the value of the Informed Consent and the concept of Shared Decision Making process that impacts outcomes in medical care.  The video was a 45-minute movie called The Faces of Medical Error…. From Tears to Transparency is the story of Michael Skolnik, a 25 year old man from Colorado who died in June 2004 following unnecessary brain surgery.

 

His parents, Patty and David tell the story of Michael’s life and the care leading to his death with nationally recognized patient safety experts sharing their views. Three years before his death Michael fainted and multiple brain scans showed a non-life threatening cyst. But their consult with a neurosurgeon and his subsequent advice indicated that this was something serious that needed immediate interventions - surgery. Of note, is that this level of surgery was unnecessary and not consistent with the recommended guidelines in the clinical research. 

Michael never recovered. He suffered permanent brain damage and finally after three years of suffering the negative consequence that included nosocomial infections, he succumbed to his injuries and passed away with his parents at his side. During that time, his parents learned that the neurosurgeon was at fault and this case has since been utilized as a learning tool to educate others on transparency in medical care. In Colorado, the Michael Skolnik Medical Transparency Act was passed in 2007 and makes malpractice judgments part of the public record. 

The 45 minute panel discussion following the video was moderated by Charles E. Cal, RN, MS, MBA, CPHQ, Vice President of PULSE of NY. Panelists consisted of  Dr. Leslie Farrington, a gynecologist in private practice in Freeport NY and Steven Pegalis Esq., Founder and Senior Partner, Pegalis & Erickson, LLC., Great Neck NY.

Dr. Farrington explained that a doctor must have a conversation with the patient and when appropriate the family.  Mr. Pegalis agreed and explained physicians are required to protect the public.  Discussing the risks and alternatives with the patient keeps them thinking about what the risks actually are.  Mr. Pegalis also stressed that all doctors, as in any other situation, must be held accountable for their behavior. 

A passionate discussion between audience members and panelists ensued.  An audience member responded that the family was not informed of the alternatives including other doctors or other procedures and that Michael may be alive were they given an alternative of if they were made aware of what the literature recommendation beforehand. Another person questioned if Michael was old enough and capable of make his own decisions especially since he was under stress.

It was agreed that while a great deal was left out of the events surrounding the case, that it was a sobering reminder that medical errors, adverse events or negative outcomes in medical treatment are always very complicated. 

Through such discussion with the community, PULSE of NY fulfills its mission of engaging and educating the public and communities with the goal of progressing towards safer patient care experiences as patients interface with the health system.

This level of dialogue encourages the community to become informed and to proactively partner with health care professionals, paraprofessionals and hospitals, etc. in their care. By bringing together various experts, PULSE of NY, the grassroots patient safety organization,  is able to play a much needed role as they lead a discussion on informed consent and the importance that shared decision making brings towards improving communication and ultimately patient safety.

Sponsors of this event included: