Outrageous medical errors

July 15, 2008  |  General

I’ve written before about medical errors. Recently there was a horrendous one, in which a man in Boston got an operation on the wrong part of his body. Other than underscoring the fact that humans are fallible, what can we learn from this terrible incident?

There are supposed to be safeguards in place to prevent this kind of thing from happening. The process can best be summarized as confirming the answers to these questions: Are we doing this to the right patient, doing the right procedure, and doing it in the right place? Clearly this ‘time-out’ step was not done in this case. The result was tragedy.

The CEO of the hospital immediately admitted and evaluated the error here. It makes interesting reading. He admits the error, but he also makes oblique excuses for it, citing how chaotic and pressured the environment was, implying that somehow lessons the culpability.

The problem with that, as Dr. Bob Wachter explains on his excellent blog, is that we should plan for chaos and a pressured environment. It’s the way things always are. Dr. Wachter is a noted authority on patient safety issues. He uses examples as varied as the airline industry and service at the International House of Pancakes to emphasize that we certainly can devise systems that protect individuals — both the patients from harm and the doctors from ourselves.


10 Comments


  1. YAWN accidents happen, its why they put erasers on pencils and ejection seats in Jet Fighters. Much more interesting would be for you to tell us about YOUR biggest mistake. You can present it as a hypothetical if you’re worried about Statue of Limitations things. In fact, if you’ll tell yours, I’ll tell mine.

  2. Of course I’ve made mistakes — big ones, little ones, medium-sized ones. One particularly sticks in my mind because it’s a good example of why standard protocols help. I overlooked a serious compartment syndrome in a patient’s arm because I assumed (wrongly) that a thorough secondary trauma survey had been already done, so I didn’t do it myself, and I was distracted for a time (like the doctor was in Boston) by other serious injuries the child had. Fortunately I saw the problem once it was glaringly obvious and the child ultimately did okay, but he had to spend much more time with the orthopedists than he might have if I’d been meticulous in following standard protocol.

    And yes, errors happen; there’s no way we’ll ever get rid of them. We do, however, have some simple, validated ways to reduce them, mainly by taking a systems approach to the problem. The specialty of anesthesiology did that a couple of decades ago and the result is that anesthesia is much safer and, as a side benefit, malpractice premiums for anesthesiologists are much lower. What I find the most interesting about this incident in Boston was that the system wasn’t followed. Like a lot of folks, I joke now and then about the “right patient, right procedure, right site” thing when I’m about to do a procedure and the nurse pulls out a checklist and makes me verify everything. It seems dumb. But a lot of research has shown checklists makes things safer.

    Here’s one example of a simple systems approach that recognizes that human error is inevitable. The ventilator circuit of the old Baby Bird ventilator had connectors that made it possible to set up the circuit backwards, causing the child to rebreathe all the expired gas instead of fresh gas. I saw it happen once or twice in about 1978 or so. That sort of thing’s impossible to do on ventilators today. Anesthesia machines were also reengineered to make them more idiot-proof (insert gratuitous anesthesiologist joke here).

  3. Good Examples, Chris. I plugged a Bear Hugger into the back of my Anesthesia machine one day…can you say “Popped Circuit Breaker” Of course the ventilator is gas powered so it’ll run forever, but all my monitors were gone till I unplugged the warmer and reset it.

  4. Frank–

    “Yawn . . .accdients happen. It’s why they put erasers on pencils . .”

    I realize that physicians have to keep their distance from emotions that could get in the way of doing their job –including fear of making a mistake. But this does seem extraordinarily flip. (I’m assuming you’re a physician simply because I cannot imagine a layman taking such a cavalier attitude in response to this post.)

    I thought Paul Levy, the President and CEO of the hospital where it happened, was courageous in wirting about this tragic error on his blog. I also agree with Johnson that Wachter made the crucial point: “we should plan for chaos and a pressured environment. It’s the way things always are.”

    I also thought Johnson took your challenge seriously, and shared an error that caused unnecessary suffering–and that he deeply regretted.

    Your reply–describing how you short-circuited a machine–didn’t seem quite as brave, or candid.

  5. Maggie, what was the “tragic error” you refer to? From what I have read of and by Dr. Levy about this incident, the patient was not harmed in any significant way. Tragic errors sometimes do occur in hospitals, and patients sometimes suffer severe consequences, but in this case, your description is hyperbolic.

    Chris, a reference please for your statement that “a lot of research has shown checklists makes things safer.” That may be true on a observational status in some human endeavors (aviation inevitably gets mentioned in these discussions), but I have seen errors in the OR despite, or because of checklists. Are there studies that prove that the checklist is responsible for decreased errors? The checklist becomes the end instead of the means- “if it’s documented, it’s done.” What a lot of research on my part has shown is that paying attention to the task at hand, rather than a checklist, is what makes things safer. In today’s OR, MDs, RNs, and techs are often distracted by requirements for documentation and pay less attention to the patient and the operation- getting the patient through the operation safely remains the responsibility of the physicians, while the support staff places more emphasis on process.

  6. jb–thanks for your comments. As an intensivist, of course I’m most familiar with the use of checklists in the ICU setting. Some of the best data about their effectiveness is Peter Pronovost’s New England Journal article about blood stream infections and central lines (NEJM 2007. 356:2660). You could also see Dr. Bob Wachter’s discussions of the issue, such as at http://www.the-hospitalist.org/blogs/wachters_world/archive/2007/12/09/atul-gawande-s-the-checklist.aspx. His blog also has several comment streams about implementation of checklists, as well as useful links elsewhere.

    I agree with you that sometimes the documentation can get in the way of making sure the thing being documented actually happens. But I don’t think that’s a knock against the use of checklists.

  7. I’m still skeptical. What you call adhering to a checklist is what I call doing it right. I read the entire article by Dr Gewande in the New Yorker. He is truly a skilled writer, but some of what he writes is fiction (12 inch jugular lines, sending “the entire blood volume through the dialysis machine every few minutes”). Like many other ideas that start out promising and get totally f’ud up when bureaucracy and government get involved, the checklist inevitably morphs from the means to a better result into the ultimate final product- see what happened when a good idea- getting antibiotics into pneumonia patients- becomes a game where hospitals compete to see which one gets the better score.
    Even the apparent improvement in line infections is very likely a Hawthorne effect- outcomes are better when folks are watching (http://en.wikipedia.org/wiki/Hawthorn_effect). I will become a believer when there is a randomized study of checklists in otherwise identical patients. Until then, I will resist giving nurses another excuse to stop patient care and instead walk around with a clipboard. There is entirely too much of that already. Do the procedure right, and the patient will do fine.

  8. Thanks again for your perspective. I agree with you that the paper burden is already pretty high for everything we do and, like you, I’m reluctant to add another step. Yet it appears that at least some of us need still another nudge to getting it done right. My experience has been similar to that of others — doing things wrong is much more likely to happen the more hectic things get. If a checklist can reduce the risk of that happening, I’m willing use one, though reluctantly.

    And, as you say, the Hawthorne Effect is real. In the PICU, for example, folks wash their hands much more regularly when they know someone is watching.

  9. Chris, we’ve been members of a large HMO here in Portland.

    They made an error in medication that went on for one whole year. Finally, it was explained to me that my doctor’s assistant wrote down a 1. where it was supposed to be Levoxyl 0.75 mcg.

    Nobody caught the mistake until I started complaining, month after month, about tests that were showing hyperthyroidism — almost off the charts.

    Finally, I demanded an appointment with the head of the endocrinoloy service.

    He figured it out immediately — a transcription error! Needless to say, my husband and I decided to pursue them for compensation. They were happy to oblige after hearing my story.

    My primary care doctor said he was sorry. His assistant didn’t even remember making the error — after all, it was more than a year previously.

    A person has to be alert to everything done by anyone treating them these days.

    Enjoy your column very much.

    Cordially,

    Ellen Kimball

  10. Ellen:

    Thanks so much for your comments. It’s always good to know somebody out there is reading what I write. But even if they’re not, just writing sharpens one’s thinking.

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