“The Other Side of the Fence”: A Geriatric Surgical Case Study of Error Disclosure

By Robert Formanek, Jr, MD; Doug Bonacum, MBA, CSA

Winter 2008 - Volume 12 Number 1

https://doi.org/10.7812/TPP/07-048

Introduction

Learning and continuous improvement are cornerstones of the profession of medicine. Learning methods available for physicians and other health care professionals include case study and peer review. Through their application in the examination of clinical care, insights are gained to improve the performance of individual clinicians and teams as well as the health care system at large.
This article includes panel discussion, commentary, and excerpts from a letter entitled The Other Side of the Fence,a which was written by a patient’s daughter to a Kaiser Permanente (KP) facility Healthcare Ombudsman/Mediator (HCOM) following her mother’s death. It represents an actual case--a true story--that offers a number of dimensions from which to learn, including the unique point of view presented by the patient’s daughter about her mother’s course of care. In the letter, the daughter reflects on her mother’s care experience, which involved an unanticipated adverse event.