Did anybody else see this show hosted to Elizabeth Cohen on CNN last weekend, titled “25 Shocking Medical Mistakes“? You can see a video preview or read the transcript online. I'm not sure if the whole show is available online for free or purchase (if you know where to find it, please post a comment).
I took some notes and will list all 25 items on their list, highlighting the things that are most clearly related to Lean, processes, and systems, even though it's almost always a system or process, as opposed to a bad person involved. They couldn't cover anything in much detail in a 60 minute program, but here's the list and discussion of the items and overall themes.
#25 Newborn babies stolen from the hospital – an alarm went off, but was not noticed… was this due to a system design problem where the alarm is too easily missed, or there's “alarm fatigue,” there's too much waste and confusion in the system for staff to respond promptly?
#24 Fake doctors – it's unclear how this ever happens. This seems pretty inexcusable.
#23 Treating the wrong patient – the hospital performed a CT on a pregnant woman, they had identified her only by her first name, clearly violating good guidelines to use at least full name and another identifier.
#22 Pharmacy mixup – wrong medication given to a patient with the same last name — it's disconcerted, but not unheard of, to hear the staff comments like “things get hectic,” due to phones ringing, the “onslaught” of really busy times. That's where the Lean concept of “muri,” or overburden, and the need to have systems that don't overburden people is so important.
#21 Botched plastic surgery – including a woman who, after a “butt implant,” had a piece of the implant (fat or silicone) break off and lodge in her lungs, causing a pulmonary embolism. The show recommends you only choose a surgeon certified by the American Board of Plastic Surgery… but does that really guarantee zero risk?
#20 Dosage errors – highlighting the case of the Quaid twins (much discussed here on the blog, including the systemic errors that caused this preventable mistake). CNN says, according to the Joint Commission, that medications are stocked WRONG in 4% of cases, a shockingly high error rate.
#19 Toxic transplants – a patient died after getting a kidney transplant… but the donor had rabies. Nobody suspected the donor had rabies… even though the donor had “all the symptoms of rabies” and they “should have never used the organs.” There are 100 victims of “toxic transplants” each year. They said it's tough to screen for rabies and all possible pathogens, so the best advice was to act quickly AFTER the transplant if the patient isn't getting better.
#18 Dumb discharge – a patient who just had brain surgery was sent home, alone, in a taxi. He was disoriented and didn't even know his own address. How do staff allow this to happen? CNN says “make sure you have a ride home” but I'd put more of the responsibility on hospitals to not let this happen.
#17 Ambulance errors – a 911 dispatcher sent an ambulance to Wells Street instead of Wales Drive (given the accents involved, it's somewhat understandable… but it would be a good practice for 911 to try to get a spelling if there's any uncertainty).
#16 Lost patients – Alzheimers patients gone missing from the nursing home… in this one case, the woman was found IN the nursing home, four days later, locked in a closet. They didn't do a good job of searching “every room,” as they had claimed, did they?
#15 Surgical souvenirs – that's a bit too flippant of a phrase for a serious problem, including the patient who had a footlong by foot-wide sponge left in his abdomen. An item gets left behind in 2 out of 10,000 surgeries. Famed patient safety expert Peter Pronovost commented on this and other cases in the show. “Nurses are supposed to keep track,” said CNN, but there can be errors on the inbound count or the outbound count. We can't just simply blame nurses, as there are many cultural factors in the O.R. that can pressure staff into cutting corners in these important steps (or errors in counting occur – it's human error we need to design around or find technology that addresses this).
#14 Baby switcheroos – a hospital worker gave the baby to a mother with the same last name… and she breast fed the wrong baby. Yet again, we need to check more than just the first name or last name. Yes, mothers should perhaps ask to match the ID bands, but that's the hospital's responsibility to do that properly.
#13 Air bubbles in blood – removing the patient's central line led to a sucking chest wound… nurses “failed to follow basic rules on removing a chest tube” (as in “standardized work” in the Lean parlance). The patient should have been laying down and they should have sealed the hole airtight with Vaseline. The mother (a medical student) begged for help, “but nobody called a doctor until it was too late.” CNN said (from the Annals of Internal Medicine) that this type of error occurred 10 times in one hospital's ICU in one year.
Midstream commentary — I know the theme of the show is “The Empowered Patient,” but I don't like all of the talk about putting some sort of burden on patients to ask if standard processes are being followed. As I've written about before, it's not fair to ask the patient to inspect our processes and work in hospitals. Are drivers asked to double check if the tire change place has properly tightened the lug nuts on all of your wheels? Are passengers supposed to double check that the airline pilot has properly followed their checklists?
#12 Misdiagnosed – a doctor refused to listen to the parents of a child who had been hit in the head with a baseball… he said she just had the flu. After finally relenting and doing a CT scan (which the parents had been begging for), they found (and fixed) a blood clot in her brain. “1 in 10 diagnoses may be wrong” (is that a process issue?)
#11 Transfusion confusion – a surgery patient was given the wrong type blood for his transfusion. When the patient's blood was drawn, there was a LABELING error and they typing was done on the next patient over, in error. Keep in mind, this isn't a highly technical error… the lab was correct, but they did the work on the wrong specimen. Specimens are supposed to be labeled IMMEDIATELY after being drawn… and the patient died because this did not happen. CNN says “know your blood type, so you can double check the bag to see if it's a match” — but that only works if you're awake and coherent. That's an unfair burden, once again.
#10 Getting burned – a balloon was inserted into a patient's throat to stop the flow of gasses from his lungs. The doctor punctured that with a laser and “instead of stopping the surgery, the lasers started an explosion.” An expert says these types of errors occur due to multiple errors in setting up the operation. There are 650 surgical fires each year in the U.S.
#9 Look-alike tubes – a medical day care center made a mistake and pumped medicine (for her stomach) into her veins. The central line and feeding lines “look an awful lot alike” — so we need to design better solutions. “People get rushed… they cut corners” says an expert, Dr. Otis Brawley. So, how do we create situations where people aren't pressured for time? Can we use color-coded tubes or other error proofing methods? 16% of nurses and doctors say these mistakes happen in their hospitals… and, again, CNN says you, the patient, needs to double check!
#8 Biopsy blunder – they discussed the case of Darrie Eason, who I've written about before. These types of errors still occur… and it's something I'm going to blog about soon. We need to stop mislabeling specimens… getting a second opinion on a mislabeled specimen does no good.
CNN had some animation of how the error occurs… a person working with two specimens at once and they put the wrong one into the wrong cassette. CNN says 1 out of 1,000 lab specimens are mislabeled. That's completely preventable. I'm surprised CNN didn't recommend you follow your specimen into the lab!
#7 Having the wrong baby – mixup at a fertility lab… they had implanted another couple's embryos into the wrong patient — AGAIN, the same last name. When is healthcare going to learn?? Instead of saying “double check the petri dish,” CNN again recommends accreditation. I would assume the lab in Darrie Eason's case was accredited by CAP… did that help?
#6 Operating on the wrong body part – a surgeon cut into the wrong eye, “frankly, I lost sense of direction,” said the surgeon. The surgical site marking was covered up by the draping of the patient. There are 7 “body part mixups” everyday in the U.S…. and, yup, CNN says YOU should double check that the surgeon isn't going to mess up and “don't be shy about doing it.”
#5 Radical radiation – CT scan errors… patients' hair falls out. The scanners were programmed wrong and the patients got “monster doses of radiation” (8x the allowable dose). CNN says basically to “if possible, get ultrasound or MRI” instead of a CT scan. That's not getting to the root of the problem at all.
#4 Infection infestation – patients getting Hospital Acquired Infections, often viewed as preventable. Pronovost highlights the need for better hand hygiene amongst caregivers… “we're no different than a mosquito causing malaria,” says Pronovost. “Hospital infections kill 100,000 patients a year” (see sources and other data). CNN wants you to nag doctors and nurses to wash their hands. Sigh.
#3 Metal in the MRI room – a hospital worker walks into the MRI suite with an oxygen tank… of course, it goes flying to the magnet, hitting the boy in the head, killing him. “While the mistake is relatively unusual,” it does happen. Again, CNN suggest you make sure there's no metal on or around you. BUT I DON'T CONTROL WHO ENTERS THE ROOM. This advice needs to be given to the hospital staff and leaders, not the patient.
#2 The ER waiting game – after triage said the little girl just had a virus, she waits with her parents for FIVE hours and her fever climbs higher. She really had flesh-eating bacteria, not a basic virus. Cases like this show how important it is to improve E.D. patient flow. Check out the great book The Definitive Guide to Emergency Department Operational Improvement to learn more about how to do this. As they said in the show, you can't always tell who is sickest at triage… so I'd add that's why we need to improve flow for all. The average wait time in the U.S. is just over four hours. But, hospitals are often able to reduce this time by 40 to 50% through Lean process improvements. CNN suggests a workaround that fails to work if EVERYBODY does it – ask your doctor to call the E.D. while you are on your way because “doctors listen to other doctors.”
#1 Waking up during surgery – OK, this was just horrifying, the cases of patients who were paralyzed but feeling every “poke, prod, and cut” during the surgical procedure. Scary. Without adequate anesthesia, your brain stays aware… the reasons for underdosing could be “just a goof” like a vaporizer tank getting disconnected or being empty (“not defendable” said an anesthesiologist on the show). This happens in 1 out of 1,000 patients… “awake and aware” but not in any pain. CNN suggests asking for local numbing instead of general anesthesia… but that's just generally good advice, even if there wasn't any risk of error.
That show was exhausting, especially knowing how preventable most of these problems are. Thanks to CNN for the national “FMEA” exercise about what DOES go wrong… I hope their next special is about FIXING these problems. Which of these problems have you been able to address?
From the end of the show:
No good doctor ever means to hurt you. Doctors and nurses and everyone who takes care of us are just like us, human and make mistakes. Now you can help them get things right.
This is the job of hospital leaders and physicians… not patients. Yes, it's possible to get these things right. But, the healthcare industry needs to take responsibility and improve things…
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Wow. Scary stuff. As we work on the Partnership for Patients and the Hospital Engagement Networks, our goal is zero harm. Looks like we have some work to do to develop (and use) ways to prevent these horrific forms of harm.
Are those Iowa initiatives, Dean?
No, they are national initiatives started by CMS. The PfP started last year, and the HEN began about 6 months ago.
Oddly, I *do* check the lugnuts (and other easily accessible parts of the car) after each service after having had it go wrong before. :-)
Yikes – that’s an error that can kill you if a wheel flies off at highway speeds… but I’m sure the defect rate for a dealer or tire change place (or the factory) is much lower than a hospital…
Mark,
This was your best blog ever. I may not sleep tonight, but I will remember all the horrors that can befall me if I end up in a hospital.
Thanks, Barry. That’s why I said the CNN show was exhausting… hearing about or dealing with one potential failure mode is enough to get you fired up about this (angry that it happens or motivated to fix it). But hearing about all of these in a row… the patterns of poor processes and workplace overburden… too much for one hour.
Huh I had the same things on my mind after reading this. Maybe it’s better not to know all these things :s
To each their own… even if I can’t do anything about it, as a patient, I’d rather know the risks and dangers. Surgery is not something to rush into for no good reason…
Great post Mark.
For the MRI error, I can’t believe CNN tells the patient to know who is in the room to make sure there is no metal. Don’t they know that MRI patients have to keep still?
I have a friend who was a transplant patient and experienced a fake caregiver. My friend was used to many people coming in and out to poke and prod them at the hospital. A stranger came in and did an invasive assessment and my friend didn’t think anything of it until she asked the staff about the results and nobody knew who did it and why. If it was a real caregiver, there was obviously a documentation error. Scary!
Wow, how frightening. I would have had no idea that “fake doctors” was a real problem. Scary, indeed.
Mark,
When is CNN going to hire YOU as a commentator on these shows? The truly frustrating part for me was watching the “real” answers remain unsaid–fix the process, fix the process, fix the process. Error proof those tubes; do standard work and checklists to ensure. Most of these errors should be just about impossible to commit. While it is true that the struggling, vulnerable patient and family ARE the last possible link in the chain, it is not wise and not right to count on them to perform inspection. Good ol’ Sanjay Gupta just doesn’t think this way. TV needs somebody who does!
I wish John Nance had been on the CNN show….
I know of a hospital that had a couple near misses related to giving the wrong baby to a mother. The investigation concluded that the nurses weren’t diligent enough in comparing the wristbands. They are supposed to match a six digit number on mom and baby’s wristbands. But guess what. The six digit numbers are assigned sequentially, not randomly. so a nurse could take care of several babies and moms and only have one digit of difference on this identifier between all of them.
Scary. That’s why one blood transfusion error proofing product specifically produces codes that are NON-sequential for its patient wrist bands and blood transfusion bag locks, to avoid that risk factor.
I hope the hospital has learned to NOT have sequential numbers.
This is terrifying! I am only a medical assistant but I triple check everything all the time. How bad would it be to take blood from the wrong person? I cant even imagine being the nurse that mixes up someone’s baby!
Just because you are not certified or recognized by American Board of Plastic Surgery doesn’t mean your incompetent. I have been in practice for almost 20 years and Board Certified American Osteopathic Board of Opthmaology Otolaryngology completed and certified as a Otolaryngology Head and Neck Surgeon Facial Plastic Surgeon. Your facts need to be corrected.
@EBilofsky – your complaint is with CNN, not me. I was sharing what they said about choosing a board certified surgeon and I asked, skeptically, if that guarantees safety. You seem to agree with me that it does not.
I saw this show last night and wished I had taped it. It brought back terrifying memories of a Colonoscopy I had years ago with such intense pain that I was still in a state of shock when they returned me to recovery. It was just like what the show described. I screamed and saw everyone and the doctor and could not believe he kept on doing the procedure and was ignoring my screams. I did not know he could not hear me. I have lived in terror of going under for any type of procedure now. The doctor shows on my orders the so called anesthesia and dosage I was “given” and insists I did “fine”. This has to be stopped. One in 1000 is too many if that one is “you”!
I also wear a necklace around my neck warning doctors and medical techs I cannot ever have an MRI. I was sent for one after having a Cerebral Aneurysm years ago and thankfully the tech actually read the paperwork I handed him because it indicated I had a “Metal” Clip in my head from the Aneurysm surgery. He told me I could have been killed if he had done the MRI on me! I now live with fear someone won’t notice my necklace and still do an MRI one day. If I am in a hospital, I tape up a card above my bed for all nurses to read. Would you believe last time I was in, the nurses actually forgot to look at the card? I guess you would from your article. Thanks for bringing attention to all these serious medical mistakes we face when we are in the hands of those who train to “save” our lives.
Ms. Marino,
I sympathize with your experience with the colonoscopy, it sounds horrible. The problem in situations like yours is that gastroenterologists most often do colonoscopies with just sedation given at their order by their assistant, not with an anesthesia practitioner giving it. GI doctors do not EVER give anesthesia, just sedation. This means they give you a sedative in your IV, which is usually enough for most people to be fairly comfortable, but in some people is not enough. The gastroenterologist is limited in how much of this sedation they can give you because there is no one trained in anesthesia there to monitor your breathing and vital signs. Usually if the patient is not sedated enough with what they can give you, they stop the procedure and reschedule it requesting anesthesia services from a Certified Registered Nurse Anesthetist (CRNA) or anesthesiologist (MD). I’m sorry that this didn’t happen in your case, it’s very painful and frustrating when the patient is not listened to. It’s not a medical error, though, because you were given sedation by the gastroenterologist, not anesthesia, which is a very different thing. Awareness under anesthesia does occur, rarely but it does, unfortunately. In a colonoscopy sedation, though, without an anesthesia provider, the expectation is that you may have mild discomfort, and may remember some things, because it is not a general anesthetic. I’m so sorry for your bad experience, if you have the procedure again, request that you have a CRNA or anesthesiologist to be there for your anesthesia! We are always happy to provide this service, but unfortunately are not always requested. Insurance will cover the cost in most cases, though some insurance companies are trying to cut this out, but that is a whole other story.
P.S. He could hear your screams, it was not the same situation as in surgery when a patient is unable to scream aloud because of the medicine they are given that stops movement, but they don’t have enough anesthetic for pain or unconsciousness. Your situation was very different from that one and can easily be remedied.
Sarah – although I’m sure you’re technically correct, the point is that Bea says she was in extreme pain… something went wrong.
It doesn’t sound like she’ll readily trust the medical system again after that experience.
How would you feel if you were in agony and the doctor, apparently, dismissed it by saying “you did fine”?
I’m sorry if I didn’t address her pain enough, that must have been an awful situation and I’m sure it will be difficult for her to trust the system. The doctor should have stopped the procedure, as I said, until she was comfortably sedated. I was just trying to explain how it may have happened because in her case, it’s not difficult to fix it in the future. Medical errors are multifaceted, and not easy to fix quickly, but in her case it would be. I was trying to help her have less fear if she did have to have another procedure by telling her what to ask for next time. I’m very sorry to Ms. Marino if I appeared cavalier and not concerned about what she went through, that was not my intent at all.
I agree with you Mark, I don’t think making the patient responsible to prevent errors is good advice. How is a patient supposed to do that under sedation or general anesthesia? As an anesthesia provider, my responsibility is to keep my patient safe while they cannot do it themselves, and I take that responsibility extremely seriously. Errors do occur, but as you said, most often we need to look at system fixes. Sadly, though, in hospitals I don’t see real emphasis placed on preventative system changes by the administration until it is tied to reimbursement, such as timely antibiotic administration tied to CMS reimbursement. And the atmosphere of intimidation in hospitals that has been shown to lead to errors has not been addressed at all in most places (see IOM report “To Err is Human”).
Have you seen the latest IOM report “Best Care at Lower Cost”?
Arguably, we haven’t made great progress on quality and safety since “To Err is Human.” The IOM is calling for “continuously learning” and continuously improving healthcare organizations… but that requires great leadership.
The payment model is certainly part of the broken system… it’s hard to blame individuals when they are acting rationally within our screwy system.
Mark and Sarah: I thank you both for your replies and the information you provided. What I was given at the time was the exact medications they give one when we have an endoscopy and we wake up and don’t remember anything that happened. However, when I came out of this nightmare I was shaking and terrified and remembered everything. What concerns me the most now is that Mark seems to think the doctor heard my screams. It was not like I was vocally screaming but I was in my own head. How could any doctor hear a patient scream the way I was and begging him to stop and just keep going on with the procedure. I have never had Versed cause me to feel any pain with other such type procedures. Something went terribly wrong that time and unless I can get them to do what Mark suggested, I will not be able to trust another doctor for such procedures again. This doctor would not even try to figure out what when wrong so I will never know. All he said was “you did fine”. Thank goodness he is no longer my Gastro doctor! Thanks for both of your replies and additional info.
Bea – I’m sorry if I was unclear. I understood that the doctor didn’t hear your screams (because the screams weren’t really coming out of your mouth), but I was referring to your discussion with the doctor after the fact or that he told somebody after the fact “you did fine.”
As to the MRI risk… it’s inexcusable that the system operates so poorly that you’re at risk of being given an MRI when that clearly isn’t in your best interest… we have to look at system design rather than blaming individuals and we certainly shouldn’t be putting the burden on patients.