When my son was home, he subscribed Scientific American magazine and also as part of the reward for one of his competitions back in 2007, we received, after he has left, two-year subscription which ended in 2009. Here’s an article in August 2009 issue, “Deaths from avoidable medical error more than double in past decade, investigation shows” by Katherine Harmon.
I have read this piece long ago. Recently I dug it out. I think I have read it before but not sure if I have shared the content here.
Here’s the shocking fact: “Preventable medical mistakes and infections are responsible for about 200,000 deaths in the U.S. each year, according to an investigation by the Hearst media corporation. … 44,000 to 98,000 people were dying annually due to these errors and called for the medical community and government to cut that number in half by 2004.”
“The annual medical error death toll is higher than that for fatal car crashes,” even though mechanisms have been imposed to make sure no wrong arm or leg amputated and they even “count the surgical sponges and instruments so they presumably don’t leave anything inside” patient’s body. Nice try!
Now, how much trust do you harbor in your heart when you have to go to hospital? A good question for me to ponder now that I start working in one of them.
As I have been kept being shocked by what I read about medical accidents from this book, I feel compelled to share these with my readers so that patients will know they need to take extra care of themselves when they are with their doctors. After all, to err is human and we don’t want this kind of error made on us.
This chapter focuses on wrong limb. pp. 121-125. It happened on Feb 20, 1995 when Dr. Rolando R. Sanchez, a Tampa, Florida surgeon, amputated the wrong leg of a 52-year-old patient name Willie King.
King had suffered for years from diabetes. As the result, the nerves in his legs were beginning to deteriorate, so severe was his problem that on 2/17/1995 he agreed to amputate his right leg below the knee, a below the knee amputation (BKA), a common procedure for advanced diabetics.
The computer schedule printout had it “patient Willie King — a left BKA.” The heads-up floor nurse spotted the mistake and called the operating room. The nurse receiving the call made a hand-correction on the printout without correcting the error in the system. Hence further printout showed no correction at all.
The surgeon saw the original printout, was mentally prepared to cut off one leg, without further checking which leg that needed to go. Here he went and the patient’s left leg was gone.
We have to remember this wrong-limb chopoff horror so that we will do the check and remember to remind the doctor which one need work before anesthesia knocks us down.
This is again from reading Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes, by Robert Wacher and Kaveh Shojania. When I read the chapter “Did we forget something?” I found myself an utterly disbeliever over the description of a medical accident happened in mid 2002 — a retractor, 12 x 2 inches in dimension, left in patient’s abdomen after a surgery at Regina General Hospital. p. 135.
Then I went online to confirm the story. When I searched “retractor left in patient’s abdomen,” about 495,000 results came back in 0.38 seconds. Headed the list is “UPMC Patient Finds Retractor In Abdomen Month After Surgery – kdka.com” This happened in 2008. “CT Scan Finds Device Inside Patient After Surgery,” reported by Marty Griffin, Feb 11, 2008 6:58 pm US/Eastern, Pittsburgh (KDKA) ― A CT scan taken of 57-year-old Daryoush Mazarei a month after his surgery showed a metal surgical retractor in his lower abdomen — a medical mistake even doctors call bizarre. A retractor is a 10-inch pair of tweezers used to pull back skin or hold something in place. The surgeon is supposed to hold onto it the entire time it’s in use.
As I continued with the reading, I realized “leaving a sponge or tool behind” inside the patients’ body happen more frequently than I used to think, making me wondering if patients have to take an x-ray to confirm nothing has been left behind after a surgery. How else can patients protect themselves against this kind of medical mistakes?
It happened in Great Britain on December 19 2003 by a 30-year-old junior doctor, Helen Pike. She ignored warnings from two nurses and injected an overdose of insulin into 58-year-old Tony Wright. Minutes later Tony suffered a massive heart attack and died in the hospital’s intensive care unit 10 days later.
Prior to the fatal accident, the junior doctor had worked more than 100 hours in the week. Obviously, exhaustion from working the crushing hours at Leeds General Infirmary played the role in the death of her patient.
When the junior doctors have to work extra long hours, under stress, suffering from exhaustion, it is extremely hard to expect them to be constantly equipped with the heads clear and cool enough to make life or death decisions in a split second. The truth is you are at high risk of being a victim of medical accident, if you are under the tender loving care of such a doctor.
Still from the book on Internal Bleeding. This is the case of Nurse-Kills-Patient-by-Administering-Overdose-of-Insulin. pp. 83-88
The patient, Geller, went to see her doctor for her chest pain. After elective cardiac bypass surgery, she was stable until one morning when the nurse heard a loud noise coming from her room and saw Geller “jerking violently on the bed: her head snapping back and forth, back arching, arm and legs thrashing. She was having seizure.” The patient suffered brain dead as the result and died shortly after life support was withdrawn.
“About an hour after the seizure, another nurse tidying up Geller’s disheveled ICU room noticed two different medication vials midst the syringes, … One was heparin, a blood thinner routinely injected in small doses through intravenous lines to make sure they don’t clot off. The other was insulin. The bottles were about the same size and shape, and their labels were also similar in appearance. Given the nature of Geller’s emergency, it did not take a rocket scientist to realize what had happened: Geller’s ICU nurse, intending to flush patient’s IV line with heparin two hours earlier, had inadvertently injected a fatal dose of insulin.”
Indeed, it didn’t take much to kill a patient. This reminds me of another killing case of insulin overdosing.
To be continued tomorrow…
Another real life story also from this book, the famous case of chemo quadruple overdose. This time a patient died of a killing overdose of cyclophosphamide. 39-ear-old Betsy Lehman, a mother of two young children and a breast cancer patient, had an experimental treatment at supposedly prestigious Dana-Farber, one of the best in the country, part of the Harvard Medical School.
The experimental protocol required patients to receive a high dose of cyclophosphamide at one gram per day. The physician order writes like this, “cyclophosphamide 4 g/sq over four days,” that is, the patient is supposed to receive a total four gram per square meter, spreading out over four days. The infusion nurse, unfamiliar with treatment plan, interpreted the order as 4 g on each of the four days and thus gave the patient four grams per day for four days, totally 16 g., thoroughly killing all cancer cells together with the patient’s life in three weeks, leaving two young children motherless.
Now, even if patients have done due research on the safe dosage of the drug and known that the doctor has written the right drug and dosage, they still need to be extra cautious to make sure that the nurse correctly carries out the doctor’s order. The mistakes of a nurse can be fatal, as in Lehman’s case. Well, it is our lives and we just cannot trust anybody else to do the right thing. We have to learn to be smart patients.
P.S. my daughter commented, “Indeed, you cannot trust them all. They are humans, too and they make mistakes like all of us.” Indeed, the cost of their mistakes is too dear for any one of us.
I have been reading this book by Robert Wacher and Kaveh Shojania, Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes, 2004. It was a disturbing discovery. Yet, it is good to know all the dark side of fact so that we can be wise patients when facing untrustworthy ones.
A 42-year-old patient suffering from chest pain died from wrong medication. His doctor prescribed Isordil 20mg every 6 hour but his poor handwriting made it look like Plendil. His pharmacist sent him home with a bottle of Plendil, 20mg 4 times, totally 80mg per day. Tragically, the safe dose for Plendil is 10mg per day. Patient died of massive heart attack. pp. 67-68
Two persons that we normally trust to take good care of us, failed this time, the doctor and the pharmacist, both being able to cure and kill. If the patient knew he could not blindly trust these people and had done some research on the nature and safe dosage of the drug that he was supposed to take, the tragedy might have been prevented. I don’t know whom we can trust other than ourselves.