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.
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.