The People's Perspective on Medicine

Show 1074: Surviving Medical Errors and Seeking the Truth

Nurse Donna Helen Crisp describes her own saga of preventable medical errors and how she uncovered the truth about what happened in her care.
Surgery, hospital, mistakes
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Surviving Medical Errors and Seeking the Truth

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Medical errors and misadventures account for surprisingly high mortality in the U.S. Some experts estimate that they should be considered the third leading cause of death in this country. Many such mistakes could be prevented. How can you protect yourself or a family member from becoming a victim of medical errors?

Many major causes of death and disability have their own institute within the National Institutes of Health. There is, however, no institute for the prevention of medical errors. Very little funding is available to study this problem. How does it affect patients’ lives?

The Patient in Room 2 Tells All:

Donna Helen Crisp was a nursing professor on the morning she was admitted to a hospital for surgery.  Instead of going home the next day, she suffered multiple medical errors and spent a month in the hospital, most of it in a coma.  When the hospital refused to comment, Crisp spent eight years researching and writing her book.

Research shows that most patients who have suffered medical errors want transparency with clear explanations of what went wrong, sincere apologies for the harm they experienced and a plan so that no other patients need suffer the same problems.

Health care administrators do not always respond with transparency and compassion, though. They may need training and practice to improve their skills of disclosure. We discuss the obstacles and how they could be confronted.

This Week’s Guest:

Donna Helen Crisp, JD, MSN, RN, PMHCNS-BC, is a former assistant professor of nursing at the School of Nursing of the University of North Carolina, Chapel Hill. She has worked as a nursing clinician, administrator, supervisor, consultant and researcher as well as teacher. Prior to earning her nursing degrees, she worked in social work, law and music.

She is the author of Anatomy of Medical Errors: The Patient in Room 2: A Nurse’s Story of Surviving Preventable Medical Errors and Discovering the Truth. There is more information at her website:

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The podcast of this show will be posted on the Monday following broadcast. It is available without charge for a month. A CD of the show can be purchased for $9.99.

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More Information:

If you are interested in this topic, you may also wish to read our book on medical errors: Top Screwups Doctors Make and How to Avoid Them.

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    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.” .
    Top Screwups Doctors Make and How to Avoid Them

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    As a former Emergency Dept nurse, I can tell you there are so many errors that you wouldn’t believe! I’ve reviewed charts that doctor’s have falsified, I’ve seen medication errors, and worked with my share of incompetent doctors. I was in PACU (formerly known as recovery room) and had a patient that had spent the night in the hospital, went through an operation in which she received a transfusion, and when she came to PACU, I discovered that she had someone else’s ID bracelet on! That was supposed to have been checked at least 5 times before she came to our dept.

    Also had the nursing home (infirmary) experience with my mother in which they kept making mistakes, I finally called the state in to straighten out what I could. Although she was 93, she still died of “natural causes”, was comatose for a week and no one ever told us why she went suddenly from an alert person to a comatose condition. I got some of the charts and found mistakes on charting, doctor’s visit charges for visits he never made , etc.

    Kudos to this nurse for her bravado in exposing what is going on that the public does not see. I tell all my friends that if they go into the ED or hospital, do not go alone, and call me and see if I’m available to sit with them.

    I enjoyed this nurse’s perspective on medical errors. After 32 years in nursing I realize medical errors do occur but I agree transparency is essential if the physician wants to maintain a good relationship with the patient they are treating.

    Most of us would be more understanding that in the normal course of treatments that unwanted complications/errors can happen if there wasn’t so much effort to cover the error. Ideally I think that when patient’s sign informed consent we should have our physician’s sign a full disclosure of any complications and errors that may occur and that if an error occurs they will share the plan to rectify the problem.

    While it increases the likelihood of errors being treated in a teaching institution also means that physicians are more likely aware of the most current treatments and trends so I wouldn’t necessarily eliminate those hospitals. I do like the patient advocate idea while hospitalized and would encourage keeping a notebook of events even meds by the person with the patient. That running log could be helpful if a problem arises.

    For ex. my father can’t tolerate narcotics after surgery; they make him confused as he ages. Keeping track of all the meds given can prevent a reaction that not all medical professionals might be aware of.

    I would like to share a medical error that happened to my wife , after a routine colonosopy . Sounds like a simple procedure that is done thousands of times daily ,but my wife had very painful gas from the very beginning ,in the waiting room ,but the nurse and the Dr. Insisted that this was normal and just go home and go to bed and try to get rid of the Gas !
    Sounds easy but the pain did not go away ,and my wife called and reported this several time to the nurse and she insisted that this just would go away with time , but it did not . The Dr. Finally called about 7:00 pm and told her to go to the ER .
    We went ,and and waited in the waiting room for about 4-5 hours before seeing a real Dr. And had a MRI ,which showed a perforated colon,which required a emergency abdominal surgery about 1:00 am. She spent 6 days in the hospital as this was major surgery with many possible complications . The Dr. came by the next day and he said that he was sorry and we did not see him again .
    After the rehab.period ,the hospital sent us a bill for approx. $1800.00 , after our Ins. Paid the majority of the charges ,and we refused to pay and we then ask the responsible Dr. To pay this balance ,but he refused ? It wasn’t the $1800.00 but we wanted the Dr. To do the right thing and pay this amount,but they accepted no resonsibilty and the Medical Board agreed , that he was not negilant ?
    I am sure that we have been turned over to a collection agency , but we have refused to pay ,on general principle , not the money !
    The Dr. Pays for Ins. , but doesn’t want to use it, because his premiums will go up and I am sure he can’t afford to pay ! Poor Dr.may have to eat rice and beans for the rest of his greedy life !
    That’s my story and I am sticking to it !

    I also think that the use of hospitalists causes big problems. So you go to your family doctor for 20 years or so and he knows you very well. Then whe. You are sick and go to the emergency room, you get admitted to a hospitalists care who never saw you before.

    Just when you really need your own doctor, you get randomly assigned to whoever is on call. You do not know what kind of a doctor he or she is. They have to ask you all kinds of questions because you are new to them. If they even care to take the time to ask you. We are stuck with this system of hospitalists, and it has caused big problems for us.

    How does the public guard itself against this? I’m certain this is a fear many of us have. I feel my mothers death was a result but could never prove it. She was 84, had arythmetha and was diabetic…but it was treated it like “oh well”. So sad.

    In my late 20s, I decided to have a tubal ligation. I was told they would make a small incision near my belly button, and I’d be discharged later that day. Instead, I was in the hospital for a week because someone cut into my intestine!

    No apologies. In fact, it was my fault because I was so thin! My mother was an RN, and I think she was angrier than I was. Not only that, they still charged my insurance and I had to use vacation time to recover.

    I just saw a retina specialist for a stubborn eye problem I have tried to chase down for 15 years, 5 ophthalmologists. Saw a number to middleman people before seeing the retina specialist that day. Specialist wanted to give me a injection of something he called “carrot juice” so they could see the back of the eye.

    I questioned what was in this injection that was administered through my arm. My concerns were ignored by the minions and was told it was “vegetable based”. The good news is that the retina specialist could see that what the other docs thought were signs of Age-Related Macular Degeneration was not that at all. It still effected my eye sight. It changed my life since I was an avid reader and had worked in libraries for 30 years. Within the next couple of days after the injection, I started to develop pimple like outcroppings on various places on my body, one on my eye lid.

    Bottom line is I break out in sore hives from iodine on the outside of my body but also the inside. When I looked up what was injected, it was most likely that it contained iodine. I had noted on the 5 pages of info I filled out that I was allergic to iodine. Was this ignored? Most likely. The other curious thing I encountered where questions about pneumonia vaccine, flu shots, etc. Of course I knew I had had them but exactly when I did not have at my fingertips.

    I could have filled this information in from home but it was no anywhere on the 5 pages I filled out and why was this important to an eye doc?

    I have been both crippled and blinded by the Veterans hospital here in West palm Beach. In fact, the surgeon who operated on my ankle, did so to please his girlfriend so he could brag to her about how many ankle operations he had done! He was fired and the VA hospital now does not allow any compensation for any damage the doctors have done!

    More recently, the doctor there has blinded my eye by double dose the prescription for glaucoma and, of course it wasn’t the pharma it was going to happen anyway! Well, when I started using the same pharma in my other eye my vision started going down again! So, I am now using a nutritional supplement and so far no bad side effects!

    Now, you should know the VA Hospital does not compensate for any damage they have done. The lawyers have been told to lie! And the doctors have been told not to do any follow-up treatment on their errors since, this would be an admission of GUILT!

    This was a very informative show and it was mentioned that transparency is critical. So I couldn’t help but wonder why the hospital and doctors involved were not named. That is certainly one way to avoid what happened to your guest.

    Wow–I learned so much. Particularly appreciated section about informed consent (25:00) and the section about risk management & how medical facilities operate (41:00-50:00). Ordered the book and see it is now a best seller on Amazon. Looks like you are helping lots of people. Many thanks to Nurse Crisp and The People’s Pharmacy. May silence & deny & defend end. This podcast is my favorite, and I have been listening for over 20 years!

    Thank you for sharing!! I would like to tell you my Dad’s story.

    For years, my Dad had had a pain pump embedded in his abdomen that dripped into his spine to deal with pain from chronic pancreatitis and a previous back surgery that hadn’t healed as hoped. Saturday, the day after the usual every-six-week refill, he didn’t wake up.

    Mom called 911 and medics, thinking maybe the device was putting too much morphine into his spine gave him an injection of Naloxone. While most of the med-info websites say Naloxone doesn’t hurt very much, my Dad’s experience was different. We learned later that he was fully conscious but unable to move a muscle. The Naloxone felt to him like a burning fire moving through his body stripping out the effects of the morphine. It didn’t help and he was rushed to emergency.

    There, they couldn’t hear his silent shouts not to give him another injection, so he was given a second, equally painful treatment. On Monday the hospital called the pain clinic that managed his pain pump. Within minutes they had someone at Dad’s side removing the fluid in the pain pump to be analyzed, checking the computerized drip ratio (that was OK), and asking why they hadn’t immediately been notified. A neurologist was called. My mother was in the room when the neurologist came, stood at the door, saw my Dad’s shaking hand (he had Essential Tremor) and appparently comatose body and announced my Dad had end-stage Parkinson’s and prescribed massive doses of dopamine. Unfortunately, we believed him.

    Within 3 days the lab results on the pain pump fluid came back and it was not morphine. It was Baclofen and some other things. The CEO of the pharmaceutical company in Florida that sold the fluid to the local pain management office called to personally apologize and promised to pay any of Dad’s hospital costs that insurance wouldn’t cover and told us the person who had filled the order had been fired.

    Dad was in the hospital almost for three months, trying to recover and be able to walk again. He developed bed sores and began a weird tongue thrusting movement which we later learned was called tardive dyskinesia which is a side effect of massive doses of dopamine. The hospital sent him home when they thought he could walk a little with a walker.

    We immediately called to make an appointment with a Parkinson’s doctor – he could see Dad in three months. We still had to cath him and feed him easy to swallow food and thickened liquids, as his swallowing was still very poor and his digestion hadn’t started working right yet either. His stomach wasn’t working right either – apparently no peristalsis – so he bloated out after eating until the food finally drained out. He kept losing weight and getting worse and his mouth was bloody from his threshing tongue. We took him to our family doctor who got on the phone with the Parkinson’s doctor and said “You either see this man immediately or he won’t be alive for you to see him at all.”

    The Parkinson’s doctor saw him the next day. He said he had 300 patients and he had never seen anyone take as much levodopa as Dad was taking. He said it would do irreversible damage. Dad was to get off of it right away slowly. He didn’t know the best way to step it down so he wished us well and sent us home. Getting Dad off of it was difficult. Each time we stepped it down, we ended up sitting up all night helping him clear large quantities of foamy mucous out of his mouth so he could breathe.

    My Dad gradually got better, but he never got as good as he was before the wrong medicine was put in the pain pump. The hospital stay was a mixed blessing. Many of the nurses were quite nice. On the other hand, they had taken away his false teeth but hadn’t been taught to put them in water, so the dentures dried out and got misshapen. My question is, could alerts be put in the computer software that our hospital uses that would tell the nurses every time they gave him the massive L-dopa dose that it was an alarming quantity and certain side effects should be watched out for?

    Medical errors do and will happen as long as you there are providers that are dismissive to their patients. My mother is suffering now from her intestines being severed during a routine gall bladder removal and on a personal level, I got hurt badly from a fall to the concrete ground at work. The first Dr. Only focused on the area that was hurting at the time and totally disregarded the full impact that was done to my body from making contact with the unforgiving ground. Two days later I’m in the ER with a diagnosis of a bad sprain of the shoulder, a fact that occurred on initial contact and was misses by the first doctor. They took me out of work for 6 days. When I went for a follow-up, that doctor correctly deemed that I wld need Physical Therapy. However, I have gotten progressively worse and noone stopped to think that x-ray only picks up bone and does not show damage to muscles and ligaments. I am suffering bcz the error with these doctors were that they were not thorough. :(

    Ms. Crisp is correct in pointing out the web of obfuscation that surrounds “medical errors.” I am a surgeon with over thirty years experience in private practice and have witnessed adverse outcomes in patient procedures both in my own patients and in others’ patients.

    Notice that I changed the terminology from “error” to “adverse outcome.” I do so because it is much easier to define “adverse outcome” than “error.” In the former, the result of the intervention speaks for itself and is clearly at odds with what was expected. “Error,” on the other hand, is defined in the dictionary as “a wrong action attributable to bad judgment or ignorance or inattention,” and has to be judged as such.

    The process of judgement is where things get murky. Who determines if there was an error? Were there contributing factors independent of the action? The questions go on and on. Who ultimately handles these questions? The attorneys, of course. Make no mistake, the attorneys have ONLY their client’s best interest at heart.

    When a patient has an “adverse outcome” from a procedure, THREE attorneys are immediately involved, the hospital’s, the malpractice carrier’s, and the surgeon’s (the malpractice carrier’s attorney does NOT represent the surgeon’s best interest). There may even be more attorneys getting into the mix if specialized equipment or materials were used. Before the surgeon can say anything to the patient, the attorneys must be consulted because failure to do so can forfeit malpractice coverage.

    If the incident results in a lawsuit/claim, another attorney, the patient’s, is added to the fray. When a settlement is reached, there is ALWAYS a provision stating that the terms may not be made public.

    This all has to change in order for there to be better communication between health providers and patients after an adverse outcome. In order to do research on the subject, a method of making the details available after settlement must be worked out – one that is free of blame and consequences. One that cannot be used by attorneys for their own purposes. I am not sure how that can ever happen.

    I wonder, how is this issue handled in nations that have single-payer health coverage? If the state is paying hospitals for medical treatment in a centralized way, does that change the way these financial interests balance out in medical error cases? In the sense that hospitals are kept basically secure, they’re not worrying that they might have to shut down if too many uninsured patients walk in and they have to absorb that cost. If they’re needed in an area, say, a small rural hospital ends up subsidized under a unified national system, in a way. So that makes me wonder if that financial shift could lead to a change to this “cover it up” response to errors.

    In Oct., 2013 I had acute coughing and other symptoms on a Sunday. Monday morning I went to the ER and was diagnosed with acute bronchitis. I was given a script for an expensive inhaler. They sent me home. By Friday I could hardly walk and had difficulty breathing. I phoned my family doc and they told me to might in. They immediately took me in and after the tech took some vitals she got the doc ASAP. Before the doc finished with the stethoscope she grabbed the phone and called the ER. I had been having a heart attack for a week. The hospital put in 3 stents. I only have 45% use of my heart. This happened in Lewes, DE. My suggestion is try and get to a reputable hospital if possible.

    You have every right to go to the medical record department in any hospital, and I urge you to learn to do so. You will find out many things that the doctor never told you. Learn about the lab tests and X-rays. Look up words online. Ask a nurse or doctor friend. Keep track of your medical history.

    Unfortunately, I lost my husband last year after he was given induction for a general surgery. Surgery was never started. He died 2 hours after 4 drugs were given to anesthetize him. He should have never been cleared for surgery. His blood count was very low. His last chest X-ray showed pneumonia. They did not do the lab test to monitor his blood thinners for one week. His ekg was abnormal. I cannot believe that I lost my husband to such negligence.

    You can get the Medicare link to report a complaint, and they will get the records to evaluate the standard of care that was given. This is what I am doing now. I will never trust a hospital again. Get your records, and read them. You must be your own advocate and an advocate for a loved one. Stay at the hospital as much as you can, and ask questions. The hospital will never tell you that an error occurred. They have lawyers to fight for them. You must learn to fight for yourself and family. I live with this every day that I did not discover more information before it was too late.

    Medical errors are world wide and do not only happen in hospitals. Error in prescriptions happen every day without due care for the patient and side effects, some of which could be deadly. Pharmacists are very good but can only follow doctors’ orders, and we the patients are responsible to read the pamphlets that come with the drug after the drug has been issued. There has to be a better way of making the patient aware of the harm that possibly could come with it and giving us an option of potential risk.

    In my case,the hospital’s response only made me want to get as far away from them as possible. I had a TIA. Had a bad UR from X-ray showed blockage of carotid artery. Vasc. surgeon asked resident to write order for MRI. Resident who was still on duty from the night before wrote order for MRI of brain rather than of MRI carotid artery. I ended up with two additional MRIs to rule out blockage. I had no blockage. At my and my insurance expense. I wrote to hospital and recieved a note from an administrator giving her best medical opinion that the resident wrote the correct order.

    Doctors have done me way more harm than good. I am 87 years old. They were only treating patients the way they were taught. So much new medical information is out, I am hopeful that generations beyond me will be healthier all their lives.

    A big part is that patients are not made part of the health team. Most doctors can’t give patients the time they need to understand what is going on and still get the salary they expect. Even if the patient were given more time, all the doctor has to offer is drugs or medical procedures.

    I don’t fear actual death, but I horribly dread the way I will be cared for when I can no longer care for myself. I am better off than most in that there are sites like People’s Pharmacy to learn about alternative ways to help my body and save me pain. I fear for my children who are in their fifties and sixties. When that generation was children if they got sick or were in pain, we taught them to “Go to the doctor.” That should be a last resort IF we are educated on alternative methods.

    Over and over I have pulled myself out of illness with alternative methods. I can’t say “alternative medicine,” because these helpers are not drugs.

    Doctors simply are unwilling to admit that a treatment or medication administered under their watch may have caused harm to a patient. They complain about patients who lie to them. The opposite is just as big a problem.

    I have survived 2 medical errors in my 30’s & at 60. The 1st one damaged my sciatic nerve where I have neuropathy, & the 2nd one was during back fusion surgery. Different doctors, different doctors in different cities . I still have severe pain & will be on narcotic pain meds the rest of my life . Lyrics helps, but more than 150mg affects my vision. There was nothing I could do about the 1st one because my records disappeared, xrays and all, and the 2nd one was a fluke… just be aware that these things can & will happen. Need another back fusion but I’m too scared to have it done…

    Oh, yeah and now with extended hours for young doctors in training, expect to see a rise in medical errors for overworked residents who now are allowed to spend 24-hrs on shift. Do you want a resident doctor on his 23rd consecutive hour on duty writing your orders? Another example of conventional medicine taking a step backwards.

    Try to take care of yourself as best you can and stay out of the hospital as long as you can. Since I lost my husband after general anesthesia for a Bariatric surgery, I am determined to stay well until an emergency. You would think that a hospital that has a Bariatric clinic right there , would have anesthesiologist who knew how to take care of overweight people. Then they tell you he was not in good shape! What obese person is in good shape? Diabetes, high blood pressure, high cholesterol are all problems with obesity. Gastric sleeve operation was supposed to be so great. I advise anyone to exercise, eat right and stay away from surgery.

    And what about the nursing staff who have to work 12 hour shifts which usually turn in to 13 or 14 hour shifts and then come back to work the next day? Also the short staffing causes the nursing office to ask nurses to work doubles, overtime, etc. of course it pays well so nurses will do it for the pay. You cannot find hospital jobs that are eight hour anymore in nursing.

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