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

This is an unfortunate story of care that went wrong for an elderly patient, her daughter, and her surgeon. The daughter, in spite of a close relationship with the attending surgeon, was left questioning whether the health care team had been on “the other side of the fence.” As the story unfolded, all experienced great pain in one way or another. In the aftermath, the daughter resolved to share her mother's story as a learning device with the aim of preventing similar future occurrences. The story is not unique because of its rarity, as most health care professionals can attest. In all likelihood it is not the “worst case we've ever encountered.” Neither does it stand apart because it so perfectly illustrates a single point. It is special simply because it is available for our examination, not having been lost to the vagaries of the legal system or conveniently concealed as an embarrassment or threat. In telling the story, the daughter and attending surgeon display great personal and professional courage, openness, and humanity as models for all of us to emulate when things go wrong. For this we are indebted to them. The issues involved were multiple and complex. We are invited to take the lessons, directly or by analogy, to our own clinical settings and apply them through the prism of the “curing” and “caring” roles that we all strive to fulfill in our quest to be complete professionals in a complete and caring health care delivery system. Open, timely, and empathetic communication is the foundation on which trusting, therapeutic relationships are based and on which the safety and quality of care depend. Our opportunity is to continuously improve the safety and quality of care for our patients by respecting their values and beliefs, and in this way to provide them, to the best of our ability, with the knowledge and confidence that their health care team is on their side. Illusion The greatest problem with communication is the illusion that it has been accomplished. — George Bernard Shaw, 1856–1950, Irish poet and playwright, 1925 Nobel Laureate in Literature