David and Farren Wyner lost their son Ethan at the age of 11 years to a brain abscess.
From Ethan’s symptoms, it is likely that this abscess had been growing for quite a while. However, there were multiple diagnostic and therapeutic missteps along the way, and it was not until after multiple urgent care/emergency department visits, a course of steroids, a hospitalization, and acute deterioration that a head CT was performed and the mass found. Unfortunately, it was too late for Ethan.
The Wyners transformed their tragedy into an ongoing partnership with Children’s Hospital Colorado to change the culture of not admitting to or discussing diagnostic errors. They have worked to develop a culture in which there is systematic and ongoing review of all admissions to screen for possible diagnostic errors and in which there are ongoing efforts to create an environment that provides psychological safety when discussing misdiagnoses.
Pediatrics early released a Family Partnerships article, entitled “A Family and Hospital’s Journey and Commitment to Improving Diagnostic Safety,” about this journey on which the Wyners and Children’s Hospital Colorado have embarked (10.1542/peds.2021-053091).
The Wyners and their co-authors (who are also their Children’s Hospital Colorado partners in this journey), Dr. David Brumbaugh and Dr. Joseph Grubenhoff, discuss the dangers of anchoring bias, the power imbalance between patients/parents and clinicians, the importance of “maverick” thinkers who think beyond what is written in the medical record, and the importance of true partnership with patients/parents.
How did we get to the point where we are expected – and maybe more importantly, expect ourselves - to be infallible and perfect? As you read this article, there may be many elements of the story that remind you of situations you’ve encountered in practice. And this happens over and over again, probably every day.
Most hospitals have strategies and initiatives to change this type of mindset. But it’s not easy.
Please read this article. You will undoubtedly be awed by the courage of the Wyners, and I hope that you will be inspired to consider your practices and your hospital’s practices. Are there ways that you can create or improve processes that will decrease the likelihood of a diagnostic mishap? Are there ways to model maverick thinking for your trainees – or even for those established clinicians? Reading this important article will provide some ideas to get you started.