Breaking the ‘do no harm’ rule: When clinicians take shortcuts

By Kristen Fuller, MD | Fact-checked by MDLinx staff
Published February 9, 2023

Key Takeaways

  • Reports of the fatality of a pregnant Black woman in 2020 due to an anesthesiologist’s handling of her epidural shed light on what can happen when a physician cuts corners to save time and effort.

  • This incident also called attention to research stating that racial disparities in maternal death are prevalent in inner-city hospitals such as the one where this occurred.

  • Healthcare professionals (HCPs) may want to use the lessons learned from this high-profile news story to be mindful of the conduct of colleagues and consider reporting preventable carelessness or possible racial bias to authorities.

For a time, it was hard to open a web browser without seeing the daunting medical news story about a doctor who reportedly killed a pregnant patient during labor while inserting an epidural in 2020.

Physicians are humans and prone to mistakes, but what differentiates an honest mistake from intentional harm? What happens when inequality and race may be the underlying factor associated with a pattern of medical errors?

A deeper look at this cautionary tale may shed light on the predicament that can occur when a physician takes shortcuts that could contribute to patient harm.

The incident

The New York Times reported that on July 3, 2020, Dmitry Shelchkov, MD, an anesthesiologist at Woodhull Medical Center, a public hospital in Brooklyn, NY, “botched the routine procedure” while giving an epidural to Sha-Asia Semple, a pregnant 26-year-old Black woman who was in labor.[]

The catheter to deliver the anesthesia should have gone about four inches into her lower back. Instead, he kept inserting the line, threading it in and up for more than 13 inches, a state medical review board found.

Then Dr. Shelchkov administered a full dose of anesthesia without waiting to see how Semple responded to a small test dose, according to the state board. The anesthesia landed in her cerebrospinal fluid and circulated around her central nervous system.

According to the New York Times article, Semple said “I can’t breathe” as her breathing grew labored before stopping.  “I can’t believe this is happening again,” another doctor who came in to help shouted at Dr. Shelchkov, according to a federal hospital inspection report.

Medical error or intentional harm?

Did this physician intentionally harm his patient? Or was he so distracted or exhausted that he made a serious judgment of error that ended up costing his patient’s life?

In this case, Dr. Shelchkov continued to insert the epidural into a deeper space than he was supposed to, causing a mix of spinal fluid and medication.

He also continued to skip the test step, and instead of administering a small dose of anesthesia to see how the patient reacted, he administered the full dose. Despite this pattern of negligence, administrators and department heads did nothing to monitor him.

The Woodhull hospital report showed that six other laboring patients suffered adverse outcomes due to anesthesia in the past 2 years before this deadly incident. In almost all of these cases, Dr. Shelchkov was involved.

Dr. Shelchkov attributed these medical errors to burnout and exhaustion from working extreme hours during the COVID-19 pandemic.

Following investigations of the 2020 fatality and other incidents, Dr. Shelchkov’s medical license was revoked in 2021.

Related: I made a medical mistake I'll never forget

Did race play a factor?

Medical mistakes are more common than one may think. Research published by The BMJ found that they are the third-leading cause of patient death in the US.[]

Researchers publishing in JAMA Network Open found that medical mistakes account for 98,000 to 251,000 deaths in the US annually.[] Physician burnout, miscommunication, lack of double-checking, and clunky medical records are common underlying reasons for medical errors.

A study published by the University of North Carolina School of Law found that quality of care drastically differs across hospitals in inner-city neighborhoods.[] The New York Times article noted that racial disparities in maternal death are prevalent in inner-city hospitals. As a result, Black women are often more likely than white women to deliver at hospitals with lower-quality obstetric care.

In research published by Women’s Health, investigators wrote that “while the rate of pregnancy-related death steadily increases in the United States, this tragic outcome is disproportionately devastating US-born non-Hispanic Black women at a rate that is three to four times that of their White and non-Black Hispanic counterparts.”[]

A study published by BMC Pregnancy and Childbirth surveyed Canadian HCPs who cared for inner-city pregnant women.[] The HCPs said that many of these patients felt their maternal health was at risk because of their perceptions of how physicians had treated them due to their race.

“Many of their patients fail to obtain care due to negative attitudes toward providers or the healthcare system in general,” the authors wrote.

"Patients may have had adverse experiences with rude or judgmental providers or faced obstacles in obtaining care due to distance, inflexibility, or unavailability of appointments and services."

Heaman, et al., BMC Pregnancy and Childbirth

Implicit bias and racial disparity

Implicit bias may affect HCP’s judgments and medical decisions, possibly creating inequality in healthcare for people of color, especially regarding maternal healthcare.

Implicit bias can negatively impact patient-clinician interactions, health outcomes, and treatment decisions.

Many HCPs refuse to acknowledge how implicit bias is often tied to racial disparities in their practice, according to the authors of research published by the Journal of Women’s Health.[]

"Because implicit bias is unconscious, it can be difficult to measure, and actions resulting from it often are challenging to recognize and control."

Saluja and Bryant, Journal of Women’s Health

Contributors to MMM

A University of California study found that, after adjusting for medically necessary procedures, cesarean deliveries were more common among Black and Latina women than White women.[]

Researchers found that Cesarean deliveries lead to more negative health outcomes for both mother and baby; research on obstetric care increasingly considers rising C-section rates to be a source of maternal morbidity and mortality (MMM).

Three of the six leading causes of MMM are associated with Cesareans: hemorrhage, complications of anesthesia, and infection.

Be mindful

In a study by the Society for Maternal-Fetal Medicine published by Obstetrics & Gynecology, 84% of physician respondents agreed that racial disparities affect their practice, but only 29% believed that personal biases influenced their ability to care for patients.[]

The underlying reasons may never be determined as to why Dr. Shelchkov had a pattern of neglectful mistakes. They ended up costing him his medical license, his career, and a patient's life resulting in a motherless child.

But this devastating story brings to light the seriousness of racial disparities and the quality of medical care in the US.

It also calls to mind the importance of being mindful of questionable behavior and practices among colleagues. HCPs should be on the lookout for incidents in which coworkers may be prone to harm patients due to carelessness or racial bias.

If warranted, they may consider reporting such occurrences to institution authorities so that they can be investigated in the interest of protecting patients from further harm.

What this means to you

The story of Dr. Shelchkov can act as a cautionary tale as the cost of cutting corners when practicing medicine. In this case, it cost a patient her life as well as his career. His claim that burnout from the COVID-19 pandemic led to his mistakes could be a factor, but his past history speaks to a pattern of negligence. The possibility of racial bias in such incidents is also troubling. Be mindful of your conduct and that of your colleagues to ensure that all patients receive the best care possible in every instance.

Read Next: How the criminalization of medical error hurts doctors—and their patients
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