MAY, 2005
WHEN BAD MEDICINE
HAPPENS
TO GOOD PEOPLE
Medical
errors kill as many as 100,000 people a year in the U.S.—
and injure
thousands more. Until doctors break their code of silence,
the cure is a long way off.
By
Mary A. Fischer
In September 2000, Richard Flagg, a rugged Vietnam vet, checked into
Meadowlands Hospital in Jersey City, N.J., to have a small, benign tumor
removed from his left lung. His surgery was the first on the schedule
the morning after the Labor Day holiday, and the staff seemed rushed
and behind schedule. But Flagg was optimistic; a CAT-scan had indicated
only a small portion of the lung would have to be removed and, in a
few weeks, the 59-year-old could return to his physically demanding
job aboard an offshore oilrig and a fully active life.
In the operating room, the table and instruments were set up for left
side surgery, the anesthesia was administered and Flagg drifted into
unconsciousness.
When he woke up in the recovery room a few hours later, he was stunned
at the sight of tubes extending from the right side of his body. There
must be some mistake, Flagg told the surgeon. But the doctor explained
he had found a tumor in the right lung that was about to hemorrhage
and, thus, had saved Flagg's life.
Over the next several months, however, Flagg's health deteriorated.
He never returned to work, had trouble walking, and was eventually tethered
to an oxygen tank 24-hours a day. Still believing what the surgeon had
told him about his right lung, Flagg happened to receive a copy of his
medical records when his primary group of doctors filed for bankruptcy.
After reviewing the file, he called his long-time girlfriend, sobbing.
On top of the stack of records was the pathologist's report that showed
no evidence of a tumor in his right lung. Outraged, he called the surgeon
several times and left messages, but the doctor never responded.
Flagg hired an attorney and sued. Desperate to regain his health, he
consulted a pulmonary specialist who delivered more bad news: His diseased
left lung could no longer be operated on. Flagg didn't have enough lung
capacity and wouldn't survive the surgery, the doctor said.
In September of last year, the tumor in his left lung ruptured and he
died.
Flagg's story is horrific and difficult to fathom but hardly an isolated
case. Incredible as it sounds, wrong-site surgeries account for one
in every 15,000 operations. Meadowlands Hospital won't comment on Flagg's
case, and settled it in May for over $1 million, but it appears that
a string of medical errors led to the devastating outcome, with something
surprisingly simple leading the list. Flagg's attorney, Charles Rock,
believes "the surgeon simply misread the CAT-scan film by flipping
it around, so that left became right." When the doctor entered
the operating room, the incision site had not been marked on Flagg's
chest, and no one on the surgical team verified with each other, or
with Flagg, the procedure to be performed. So the surgeon ordered his
patient repositioned and proceeded to cut out a portion of his healthy
right lung.
Newspaper headlines are full of stories about other tragic medical mistakes.
In 2002, at Duke University Medical Center, 17-year-old Jesica Santillan
died after the heart and lungs from the wrong blood type donor were
implanted in her chest. In February, an excessive dose of Lidocaine,
a common anesthesia drug, was partially to blame in the deaths of two
women at the prestigious Manhattan Eye, Ear and Throat Hospital. One
of them was the best-selling novelist Olivia Goldsmith (The First Wives
Club), who died after undergoing routine cosmetic surgery.
In 2002, without disclosing the hospital or patient names, Robert Wachter,
MD, chief of Medical Services at the University of California, San Francisco
Medical Center, reported an astonishing patient mix-up case in the Annals
of Internal Medicine. At "a large teaching hospital," a 67-year-old
woman identified by Wachter as Joan Morris was recuperating in her room
after surgery for two brain aneurysms, when nurses wheeled her right
back to the operating room. Mistaking her for "Jane Morrison,"
a 77-year-old patient who was scheduled to have cardiac surgery, doctors
proceeded to operate on Joan Morris again, only to discover their blunder
an hour into the invasive procedure. Luckily for Morris, she emerged
from the ordeal undamaged.
* * *
Each year, 30 million Americans walk into the forbidding and unfamiliar
world of a hospital and put their lives in the hands of doctors, nurses,
and administrators. And each year, according to a 1999 landmark study
conducted by the Institute of Medicine that advises the government on
health policy, these medical professionals kill nearly 100,000 patients
because of mistakes, most of which are preventable.
That's more deaths than from breast cancer, AIDS, and automobile accidents.
Doctors and nurses operate on the wrong patients, amputate the wrong
limbs, take out the wrong side of organs, fail to monitor life-threatening
conditions, misdiagnose, and administer fatal drug overdoses. The startling
IOM report, entitled To Err Is Human, was the first to expose the extent
of medical errors; it also noted that tens of thousands more patients
suffer serious and permanent injuries as a result of them.
In a system designed to protect people, with the specific mandate to
do them no harm, how have things gone so wrong?
"The short answer is, over the last 50 years, medicine has become
increasingly complex, and with it has come more opportunity for error,"
UCSF's Wachter explains in his 2004 book: Internal Bleeding: The Truth
Behind America's Terrifying Epidemic of Medical Mistakes. The once simple,
fee-for-service doctor-patient relationship has been eroded by burdensome
paperwork, managed care hassles, advances in complicated technology,
more handoffs of patients from one set of doctors to another, and the
long-standing problem of fatigue. The largest number of hospital deaths--7,000--are
due to medication errors, largely from illegibly handwritten prescriptions,
confusion over drugs with similar names, and doctors' lack of knowledge
about the appropriate use of a drug.
Jennifer Daley, MD, Chief Medical Officer for Tenent Heath Care's 99
hospitals, can tell you how easily a situation like Richard Flagg's
can occur because it happened to her. Twenty years ago, when she was
a first-year resident in Boston's New England Medical Center, a patient
with breast cancer was having trouble breathing and her sign-out sheet
said to drain the left side of her chest. "I had been on duty for
22 hours straight and caring for 60 patients. I was tired and had too
much responsibility," Daley recalls. "It was the perfect recipe
for disaster."
Daley picked the left side of the patient's chest looking at her face
on, "but when I turned her around, because I was so tired, I didn't
accommodate for that and so, in my mind, left became right." As
soon as
Daley put the needle in, "I knew I'd done it wrong and withdrew
it," she recalls. "Fortunately, the woman didn't sustain any
significant damage. I took it incredibly personally as most physicians
do. I was very upset and felt terribly responsible. The patient didn't
know because, back then, we never told them."
Wachter attributes the Morris/Morrison mix-up to a scenario that should
scare us all. "It was one of those crazy, overflow days,"
he explains. 'It's tricky to keep track of who is where at any given
time, especially given the rapid turnover of patients and hospitals'
ever-increasing propensity to run fast and full in their desperation
to meet the bottom line."
By and large, notes Don Berwick, President and CEO of Boston's Institute
for Healthcare Improvement, a non-profit medical consulting organization,
and a member of the committee that compiled the IOM report, "errors
are not due to bad or careless doctors and nurses. Most problems are
wired into the system."
The tragic death of young Jesica Santillan underscores the point. "The
surgeon in her case was considered one of the best," says Wachter,
"but he screwed up, assuming the donor's blood type had been verified.
If all you do is focus the blame on him, you have not peeled back the
layer of the onion that made the mistake possible. You have to take
on the system that had no double checks built in for this incredibly
crucial piece of information."
Beyond all the technical and logistical glitches, however, an investigation
by this magazine suggests that the most pernicious problem is lack of
communication—-between doctors, nurses and their patients. It
is not only responsible for many fatalities and injuries, but also for
a profession that is, at its core, emotionally dysfunctional. When something
goes wrong, the medical profession usually remains entrenched behind
a wall of silence, which makes tragic situations even more painful and
perpetuates the occurrence of mistakes. In a few progressive hospitals,
a true revolution is taking place as doctors are acknowledging their
errors and saying they're sorry. By and large, however, most continue
to adopt a defend-and-deny position which, inherently, contains a sad
irony: Only by acknowledging errors can they ever be prevented.
* * *
Months before Richard Flagg finally saw the pathology report that showed
no evidence of a tumor in his right lung, "five doctors, including
the surgeon, had also seen the report, but none of them ever bothered
to call and tell Richard," says Charles Rock, his attorney. "They
wanted to protect their profession's image."
Another common communication error led to tragedy in the case of Lewis
Blackman. In November 2000, Lewis and his parents believed they had
little to worry about when he checked into Charleston, South Carolina's
respected Medical University Children's Hospital. A healthy 15-year-old,
he was having elective surgery for a condition--a sunken chest cavity--that
was basically cosmetic.
After the operation Lewis received large doses of Toradol, a powerful
pain medication that carried bold warnings about its risks of causing
perforated ulcers and kidney failure. Over the next 30 hours, however,
those caring for the boy missed that he was suffering from those side
effects and was in grave peril. When Lewis' temperature dropped and
his skin grew pale, a harried nurse concluded gas pain was to blame,
and did nothing. When his blood pressure kept dropping, inexperienced
first- and second-year residents concluded the pressure devices were
broken.
Helen Haskell, Lewis' mother, pleaded for an experienced doctor, but
the residents never summoned one. Meanwhile, Lewis' heart rate soared
and after a few hours he died. He had internally bled to death.
Haskell watched in agony as her son "went from perfect health to
death in a few days because of a basic lack of communication. Everyone
was reluctant to disturb the chief doctor at home, because they were
afraid he'd get angry."
In medicine "there's a pecking order and a sink or swim culture
that creates a climate of fear of seeking help when residents are in
over their heads," says Rosemary Gibson, a leading health care
innovator and research associate at the Robert Wood Johnson Foundation,
who coauthored Wall of Silence: The Untold Story of the Medical Mistakes
That Kill and Injure Millions of Americans (Lifeline Press, 2003).
Elizabeth Grimball has life-long paralysis because of another insidious
aspect of the medical culture--the arrogance of some doctors who don't
listen to their patients. In 1997, when she was eight years old, Elizabeth
told her doctors at the University of South Carolina Medical School,
in Columbia, that her kidney cancer, which had been in remission, was
back. They didn't believe her. Though the girl insisted the pain in
her legs was severe, and an MRI was ordered, the doctors dismissed her
complaints as psychological and canceled the test.
Over the next three months, Elizabeth’s pain worsened and she
lost 20 pounds. Frantic, her mother, Leila Grimball, continued to call
the doctors. “Everytime I told them she was getting worse, they
kept saying it was psychological. I began to think my child was going
crazy. I thought the doctors would never take these chances with a child
who had cancer, and rule out a relapse, so I accepted what they said.”
Elizabeth was ultimately admitted to an out-patient psychiatric unit
where, after having seizures, an MRI proved she had been right all along.
The cancer had spread to her spine and brain. The delay in diagnosis
resulted in permanent paralysis from the waist down and Elizabeth, now
15, is now confined to a wheelchair for the rest of her life.
"And for what?" she asks rhetorically. "I'm having to
suffer through no fault of my own. The doctors made me feel like I wasn't
there. My body was telling me one thing and the doctors were saying
something else, but I never thought my pain was psychological. If they
had just listened to me, they would have found the cancer. They know
they made a mistake, but they can't acknowledge or really accept it."
Lewis Blackman's family encountered the same silent treatment. "Where
the anger comes in," says Helen Haskell, "is when doctors
don't apologize, don't explain, and implicitly trivialize the life of
the victim." Of the five residents responsible for her son's care,
she says "only one has ever apologized and the rest refused to
talk to me after Lewis died."
* * *
Despite most doctors’ silence, many of them are apparently plagued
by mistakes they’ve made. And those who dare to break through
medicine’s wall of silence often find something remarkable and
unexpected on the other side.
In 2002, at Brigham and Women's Hospital in Boston, anesthesiologist
Frederick Van Pelt, MD, prepared to administer a combination of powerful
drugs to his patient, Linda Kenney. The 37-year-old mother of three
was having surgery to correct a clubfoot.
Inadvertently, Van Pelt put the anesthesia in a vein. Kenney had a seizure
and went into full cardiac arrest. Doctors barely saved her life, and
worried she might have brain damage, but she eventually had a full recovery.
Van Pelt says he "felt so terrible about what had happened that
I wanted to be accountable and open about how it had affected me."
Kenney's husband, furious at Van Pelt, kept him from speaking directly
with his wife, as did hospital administrators. "They try to minimize
communication between doctors and patients, not to necessarily hide
an error, but because of the fear of litigation," Van Pelt says.
So he wrote Kenney a letter. "I said I was sorry and apologized
for causing the outcome. I told her that the event had had a dramatic
impact on me as well. It really shook me up." Van Pelt invited
her to call him, even giving his home telephone number, but it took
six months before she finally did.
When they met at a coffee shop Van Pelt recalls, "I basically asked
for forgiveness and she gave it to me." Kenney, who decided not
to sue Van Pelt or the hospital, says, "That's when the true healing
began.”
The experience had such a profound effect on both of them that they
co-founded Medically Induced Trauma Support Services, Inc., a national
support group for patients and their families who experience adverse
medical events.
The correlation between disclosing error and patients' decision not
to sue has been borne out in some hospitals. The Veteran's Administration
system in Lexington, Kentucky, for instance, has adopted a policy of
"extreme honesty," and found that the number of malpractice
lawsuits dropped by 30 percent.
"Until we can establish openness and honesty in health care, "says
Van Pelt, "it will be hard to make progress. Without openness,
you can't identify problems and fix them. It's really the core problem
in our profession."
Since 2000, Dan Shapiro, PhD, a clinical psychologist at theUniversity
of Arizona College of Medicine, has also discovered the therapeutic
value in allowing doctors to own up to their mistakes. When he first
invited physicians from around the country to participate in a kind
of group therapy session, "I expected them to talk about patients
who had taken advantage of them or had made them angry by challenging
their authority," says Shapiro. "But I was wrong. They came
instead to talk about their medical mistakes that continue to haunt
them."
To date, Shapiro has conducted soul-searching seminars with more than
400 doctors who, assured of anonymity, write heartfelt letters to patients
they have wronged or harmed, but unlike Van Pelt, never send them. While
the exercise helps relieve some of their anguish and guilt, “for
many of these doctors the pain and regret never goes away,” says
Shapiro.
One guilt-ridden doctor, who had missed diagnosing a cancerous tumor
in the lung of a patient, wrote to the man's widow: 'I'm so sorry we
killed your husband. I want to cry with you but I can’t. But I’m
crying in my soul, in a place where no one else can see."
*
* *
It's been five years since the IOM publicly exposed the dark side of
America's health care system. Since then, no definitive data has come
out to determine whether the number of medical errors has gone up or
down. One report in 2002 showed 195,000 hospital deaths a year resulting
from medical errors. Issued by HealthGrades, Inc., a commercial company
that sells medical products, the report, however, is not considered
scientific by the medical community.
Undisputed is the fact that the IOM report has stimulated some improvements
in patient safety, a few of them coming about in unexpected ways. Last
year UCSF Medical Center and a few other top teaching hospitals invited
United Airline pilots to train doctors and nurses in aviation teamwork
and communication principles. "The pilots were flabbergasted by
the lack of standardization within hospitals," notes UCSF's Robert
Wachter. "For example, they found that one OR, and one tray of
surgical instruments, was set up differently from another in the same
hospital. Pilots can walk into any 737 United airplane and they're all
set up the same way, because why would you want it otherwise?"
Increasingly, aviation parallels are serving as a model for improving
patient safety for a simple reason. "If pilots make mistakes, they
go down with the plane," Wachter points out. "In medicine,
we don't have that kind of personal incentive."
In most hospitals, nurses now routinely ask patients their first and
last names before administering a medicine or wheeling them into an
OR. Doctors have mostly stopped using confusing abbreviations on prescriptions
and last year new regulations reduced the number of hours residents
can work each week from more than 100 to 80. And in June, so-called
Universal Protocols issued by the Joint Commission on
Accreditation of Health Care Organizations detailed guidelines for clearly
marking surgical sites and verifying patients' identities. Whether doctors
will actually follow such recommendations is another matter. "Physicians
don't like to be told what to do and they perceive these requirements
as slowing them down," points out Wall of Silence's Gibson. "They
don't want to take the two minutes for pre-op verification. It's a change
that is costless and yet the value is priceless."
Gibson worries that although residents may be better rested and fewer
patients are getting the wrong medication, "no meaningful change
will come until there is accountability in medicine and the culture
of secrecy is dismantled.
Some victims aren't waiting around. After her son died, Helen Haskell
channeled her grief into political activism and introduced a bill now
under review in South Carolina's legislature. Called The Lewis Blackman
Hospital Patient Protection Act, the bill would require hospitals to
inform patients that residents are treating them, and to have a board-certified
doctor present in the hospital at all times. "Any one of these
provisions could have saved our boy's life," Haskell says.
In the end, the correction of many medical errors will come down to
patients themselves. "Patient empowerment is key," stresses
Robert Wachter. The first step begins before a patient sees a doctor
or goes to a hospital. “They should do a little research,”
advises Wachter. State medical boards are a start, but they generally
give only limited information. They can indicate whether doctors have
lost their licenses, whether any malpractice claims have settled against
them or if their clinical privileges have been limited. The boards don’t,
however, collect data on adverse patient outcomes, nor do they assess
the competency of a physician. “Doctors can be awfully incompetent
before the state will intervene,” says Wachter. “It is unusual
for a doctor to be reported to the state because of questions about
their clinical care.”
Some states, including California, Virginia and Massachusetts, now have
web sites that provide profiles of physicians licensed there. They can
be accessed at: www.massmedboard.org, www.medbd.ca.gov, www.vahealthproviders.com
In addition, several other on-line services make basic information about
doctors available to patients. The best known are www.healthgrades.com
and www.docinfo.org, which give a doctor’s educational background,
board certification (an important element of quality), any state or
federal disciplinary actions and (sometimes) information about the quality
of hospitals they practice in.
When choosing a hospital, medical experts agree, it’s important
to determine if it has a patient safety officer--an administrative person
who monitors and investigates medical errors--and whether the staff
uses computerized prescriptions or still write prescriptions by hand.
Once in a hospital, a patient should have someone, a friend or relative,
to act as their advocate who will know all the medications being prescribed,
how often they are to be taken, and the correct dose. Some hospitals
have on-site duty nurses who, for a fee, can be hired as patient advocates.
“If you will be having a test performed,” points out Rosemary
Gibson, “make sure you find out the results, and give your full
name and date of birth so you get the tests results meant for you. Don’t
assume that because you hear nothing about the results that everything
is fine.”
Before surgery, a patient or a family member should confirm with the
doctor their full name, the procedure they are there for and, if relevant,
the correct part of the body to be operated on.
"Patients should be gently inquisitive about what the overall medical
game plan is,” points out Wachter. “They shouldn’t
be afraid to speak up, but also not go overboard. If the doctors and
nurses feel like they are going to be assaulted every time they enter
a patient’s room, they might just walk by when the visit is elective.
Remember, they’re overworked human beings.”
Finally, and perhaps most important, is what 15-year-old Elizabeth Grimball
knows all too well: “"Doctors aren't perfect. They make mistakes
so I would tell people to trust their instincts because they know their
body better than anyone." Taking action, by getting a second opinion,
is the next step.
“Sparing a doctor’s feelings is not worth the price if a
physician is wrong,” adds Elizabeth’s mother, Leila Grimball.
“Medical negligence is painful for everyone, but it is the patient
and his or her family who bear the brunt of the tragedy. And the heartache
never totally goes away. One just learns to live with it.”
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