Contributors:

Linda Kenney, Patient, President and Executive Director, Medically Induced Trauma Support Services

Rick van Pelt, MD, Anesthesiologist, Brigham and Women's Hospital, Board Chair, Medically Induced Trauma Support Services

Linda Kenney went into the hospital for an ankle replacement. She came out with a host of complications resulting from a mistake that no one was willing to admit. Until Rick Van Pelt, her anesthesiologist, stepped forward.

In Part One of this video case study, you’ll find out what happened in the immediate aftermath of the surgery — and learn about common barriers to the open disclosure of errors in health care.

Learning Objectives

After watching this video case study, students will be able to:

• Identify constructive approaches to responding to errors in a health care setting.
• Describe the impact of mistakes on patients and on clinicians.

Discussion Group Questions

1. Why do you think it was so important for Rick Van Pelt to talk to Linda Kenney and her family after the surgery went wrong? How might you react if an action of yours had harmed a patient?
2. Rick Van Pelt said he was urged to leave this case to “risk management.” Why might the hospital have had reservations about his desire to talk to Linda Kenney? How reasonable do you think those reservations were?
3. What are some of your fears surrounding the idea of apologizing to a patient after making a mistake?