The People's Perspective on Medicine

A Medical Mistake Leads to Tragic Death

We are overwhelmed by medical statistics. Though hundreds of thousands die from health care harm it has very little impact. A story is far more compelling.
Medical error medical mistake doctor error wrong site surgery

In May, 2016 researchers at John Hopkins University ignited a firestorm of controversy with an article in the BMJ titled “Medical Error–The Third Leading Cause of Death in the US.” They suggested that over 250,000 people die every year because of a medical mistake.

We suspect that underestimates the true incidence of error-driven mortality, but even this number aggravated a great many health professionals. Many physicians questioned the research and some went so far as to ask the BMJ to retract the article. What is often missed amidst the furor and point-counterpoint is the human tragedy that results from a medical mistake. Here is just one story:

Q. My wife died because of a medical error. A serious kidney problem led to a biopsy and a prescription for steroids.

While she was in the hospital another doctor noticed a possible blood clot in her arm and started her on a regimen of blood thinners without telling us. As a result, her biopsy bled badly. Even though she was operated on to stop the leak, she deteriorated.

A hospital-acquired infection in her leg could not be healed. Her intestines became impacted and 13 weeks later she passed away. I do not understand why the second doctor did not notice that she’d had a biopsy that would make an anticoagulant inappropriate.

A. We are so sorry to learn of this tragic outcome. Patients or their family members must always be informed of hospital treatments and double-check for possible mistakes. You should have been told about the anticoagulant and the surgeon who conducted the biopsy should have been consulted before such medication was administered.

Hospital-Acquired Infections:

The CDC has changed the name of HAIs (hospital-acquired infections). It has been sanitized to “healthcare-associated infections.” We cannot explain the reason for this modification except to us it seems to downplay the role of the hospital in triggering a life-threatening infection such as Clostridium difficile (C. diff). Whatever you call them, these infections are responsible for 75,000 deaths each year. According to the CDC, “On any given day, about one in 25 hospital patients has at least one healthcare-associated infection.” 

What Can Patients Do?

As hard as this is to accept, it is likely that at least one medication mistake will occur every day someone is hospitalized. That is the conclusion of the prestigious Institute of Medicine. What that means is you should anticipate there will be missteps every day you or a friend or loved one are hospitalized. Some may be relatively minor, such as the wrong kind of food on the dinner tray. A diabetic, for example, should probably not get a high-carbohydrate meal with lots of sugar. Others, though, could be life threatening, like the tragic story of the person who contacted us at the top of this article.

Mistakes must be caught before they do irreparable harm. It is crucial for a hospitalized patient to have someone with her at all times. If the patient cannot speak up, ask questions, and verify virtually everything that is done; the advocate must step in and take charge. The patient’s life may depend upon the advocate’s vigilance.

Our book, Top Screwups Doctors Make and How to Prevent Them, offers checklists to help patients and their advocates be extra vigilant.

A medical mistake is not inevitable if everyone works together to prevent such errors from doing damage. Patients and their families must be included in all aspects of the decision-making process.  Every medication must be double checked by the nurse, pharmacist, physician and patient.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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Hello, I too experienced outright medical laziness. My PCP, ER doctors, and a medical practice all outright verbally admitted to not looking at my chart prior to giving me Rx, injections, and IV’s.

I have many allergies. My tongue swelled up and I was having breathing problems, due to wrong medications with my asthma. They refused to report my reactions to the medications because they did not want to go through the medical red tape.

When I started having breathing problems, my ear drum busted, 10 out of 12 cranial nerves damaged, Vision loss, hearing loss, exhaustion, facial paralysis, difficulty speaking, and difficulty swallowing, I was sent back to the ER and urgent care twice each. During each of those visits I was treated like a fourth rate animal.

I was hospitalized for four days. During which, they tried to force me to take blood thinners, antipsychotic drugs, anti-anxiety drugs, antidepressants. I refused all of the medications until they explained what it was for and how they would benefit me. I refused the drugs previously mentioned. My ear ruptured leading way to intense pain whenever the nurses and doctors came around my room yelling. I repeatedly requested that they speak softly. THEY ALL REFUSED AND THEN TREATED ME LIKE I WAS CRAZY.

My husband noticed and took a picture of IV drugs and told the doctor that I should not have been given those drugs when I refused them earlier and that I was an asthmatic. That all happened on December 19, 2015 and it is now September 21, 2016 and I am still dealing with the side effects of what happened to me and of the medical laziness.

None of the doctors treating me cares to tell me what on earth is going on and definitely they are not treating me. On September 6, 2016, one of the doctors asked me what happened to my eardrums, because there is a huge holes in them? He asked if I had a medical mishap with a surgical procedure? My hearing loss is enough to have permanent hearing aids.

My vision went from 20/20 to 20/65. These are significant issues surrounding medical laziness. What ever happened to the oath they took prior to becoming a doctor? In my case they took that oath in vain. They do not adhere to it. They do not care. Oh, and they have attorneys to threaten the patient if they question anything they do to the patient. I fear that the next time that I am taken to the ER that they will kill me and they would not even ha an eye. They will tell my family (with young children) that I died due to something else that they did not diagnose. Their medical laziness will harm me in the future.

I meant to say, that the doctors would not bat an eye when they eventually killed me.

I will second what Annie wrote. Question everything. I was in the hospital for a total thyroidectomy and a day of observation thereafter (to be sure my parathyroids were functioning properly). An RN came in and told me that the surgeon said I should be given Motrin (600 mg) and Calcium (1,000 mg) every 8 hours. I said OK to the Calcium, but refused the Motrin. I had been clearly told to *not* take any NSAID, nor any herbals at all, for two weeks prior to surgery and none after surgery until at least my post-op exam, due to the bleeding risk. I told the RN that if she disagreed, feel free to call the doctor. No problem, the surgeon called in on his own. She asked. And sure, enough, it was a mistake.

I got to thinking about how this error probably occurred. I realized that if one were to misspell the surgeon’s name, it might look a lot like Motrin. Whoever took the note from the surgeon’s call about the calcium wrote the notes incorrectly and whoever read the notes later decided that it must mean Motrin and Calcium. How did they come up with 600mg of Motrin? Clearly, they made it up. Humans are human. Mistakes are made. People try to bury their mistakes, which can lead to compounding errors.

In my case, the error was caught. No harm. Even if the error were not caught, the risk in my case was low. But, yes; it is easy to see that there are probably millions of mistakes made every year and some of these lead to catastrophe.

An analogy comes to mind. In the airport, there are people and luggage. Very few people end up in the wrong destination. It used to be that lost luggage was very common. The rationale being that people know where they want to go; luggage not so much. (Barcoding luggage has reduced the lost luggage problem significantly. ) The problem in the healthcare setting is that patients do not always know their destination; they do not fully understand the procedures; they do not fully understand the medications. We act (and, at times are treated) a bit like luggage. Some procedural changes help (like us constantly being asked to recite our date of birth). I am sure that helps; a bit like barcoding the luggage. But, the essential problem remains. We need to take more responsibility for knowing our destination, if we want to fare better than luggage.

It is possible to sharply reduce HAI’s if the system protocols are followed. The problem is, they are not. Physicians resist gloving and gowning when they enter a patients room, for instance. Not to mention the washing of hands.

But, outside, top-down intervention working directly on the problem rarely works for long. The need is for a systemic attitude and action change that is internally generated by a different form of intervention.

This form is called Positive Deviance. You can find a great deal about it on the Web. You might also contact the Billings Clinic in Billings, Montana where they have successfully cut HAI’s in certain sections of the hospital by more than 85%. It’s not rocket science but it does require everyone to join the march for “first, do no harm” that is required to achieve these results. And it requires a person to manage the process who is inside the client system. There were six other hospitals throughout the USA who were part of the cohort doing PD. Billings can tell you who they were and their results.

This happened a good number of years ago. I will try not to identify anybody involved for their own privacy and protection. Because of this some issues might be somewhat vague.
My wife experienced what seemed to be a very severe reaction to food poisoning. Her physician told me to take her to the E.R. After waiting 7.5 hours in the waiting room she was admitted to the E.R
A short time later I was told they wanted to keep her overnight. The next day when I visited her she was in the ICU. After one or two more days, I was asked by the medical staff to meet with them in the conference room. The very first thing they asked me was “does your wife have a living will?” I was totally shocked and upset, but recovered, and was able to finesse the issue. I don’t remember all the details, but after a few more days I was told they are weaning her off the steroids. (She was also on just about every wire, cable, hose, tube, catheter, etc. that ever existed).The very next day she was on her way to getting better. At a later date, the individual who apparently demanded that the steroids should be discontinued me, that, in fact, the medical team was literally killing my wife with steroids. Eventually she was discharged and came home.
I write this, anonymously for obvious reasons We are frequently told to “ask questions” but nobody tell us lay people what questions we should ask. As much as you may be very reluctant to ask questions, it could be critically important to do, no matter how foolish the questions may APPEAR to sound foolish to you, and keep a written diary off all that goes on. You may really need it at a later date.

comments by readers, please

As a retired nurse and wife (now widow) of a GP I think there are 3 “rules” we should all follow when faced with a hospital admission. These are:
1. Don’t go unless you absolutely have to.
2. While there question EVERYTHING. If you are unable to do this have someone with you who can and will.
3. Get out as fast as possible, to minimise chances of getting an infection.

I think it is sound advice.

I was in a hospital for uncontrolled diabetes, osteomyelitis and an abscess on my shin that was MRSA. After surgery, I was given Dialaudid for pain as well as Benydryl since I’m am allergic to most pain meds. I also have migraines and was on Tizanidine and Gabapentin for Diabetic Neuropathy.

I had an awful reaction to the conbination with me literally “going off my gourd”. I read later that Benedryl is an Anti-cholinefgic and does not mix with Tizanidine and Gabapentin as well as other meds. I feel that the doctors and pharmacists at that hospital should have noticed this but it seems to have flumoxed most of the staff. One doctor was helpful in that he felt it was not dementia and cut several of my meds.

Another retired R.N. agrees with this advice

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