Sharing Difficult News

To the editor: The patient presented for lightheadedness, having been forced to cut short time with her grandson after nearly fainting. She had endured a lot recently, managing chronic conditions, a cancer diagnosis, and hospitalizations.

Her admission labs revealed a new concern: toxic levels of a medication with associated kidney injury. We verified her medication history and concluded this toxicity was likely from significant dehydration. She recently had similar toxicity while hospitalized for severe diarrhea. We temporarily discontinued the medication, then restarted her home dose while monitoring her labs.

As we prepared her discharge orders, a pharmacist called asking if we wanted to prescribe the 0.5mg or 5mg dose. With that question, the puzzle pieces suddenly fit together. The patient was on the 0.5mg dose. There was no reason for a 5mg prescription.

Combing through her records with this question in mind, I found notes from another institution autopopulated with a list of medications that included the 5mg dose. This prescription originated months earlier, before her first toxicity-related hospitalization. I recalled learning about the Swiss cheese model of medical errors in my patient safety course. Typically, numerous holes in the system need to align before medical errors affect a patient.¹ I was seeing this phenomenon firsthand.

Now convinced this 5mg prescription caused the toxicity and worried that the patient might still have these pills at home, we needed to promptly communicate this news. My resident asked if I would feel comfortable having this conversation. I did. It was the first time I shared information of this magnitude with a patient. How would she react? I started by focusing on the positives—we could explain the toxicity and prevent a recurrence—without minimizing the error’s consequences. I was prepared to hear frustration or anger but heard only gratitude. Knowing the prescription bottles could provide certainty, I promised to call her spouse.

On morning rounds the next day, her spouse was at the bedside, holding 2 prescription bottles labeled 0.5mg and 5mg. He remarked how similar the pills looked and wondered how that could be.

Sometimes medical errors are a reflection of the complexity of our health care system rather than the performance of any individual. With this patient, I communicated an error that had occurred before we met. I also had the sobering realization that, despite how meticulous I am in my patient care, I am not immune to errors. One day, I may need to draw upon this experience to explain an error of my own.