The Truth About Medical Errors

When doctors make them, the results can be disastrous, a new review says

TUESDAY, June 4, 2002 (HealthDayNews) -- You can see how the hospital staff could have gotten confused. After all, the women shared almost identical names.

But the case of mistaken identity led to an unintended, and potentially dangerous, result -- one woman underwent an invasive procedure meant for the other.

To determine what went wrong and how to prevent future incidents, researchers did extensive interviews with the staff and the patients. They uncovered 17 distinct errors by nurses and doctors that led to the mistake.

The findings of the study, called "The Wrong Patient," appear in today's issue of the Annals of Internal Medicine in what will be the first of an eight-part series on medical errors.

The series was created in response to a 1999 Institute of Medicine report that found as many as 98,000 people die in U.S. hospitals every year because of medical errors, says Dr. Robert Wachter, the executive editor of the series.

"The report shocked the public, but it didn't shock people in the medical profession," says Wachter, the associate chairman of the University of California, San Francisco's department of medicine.

What makes this series so significant is that for the first time, researchers are using the "case study" method to expose deficiencies in the health-care system, Wachter says.

Case studies have a long history in medicine. But typically, they highlight the successful diagnosis or treatment of unusual disorders or diseases, Wachter says. Often written with the drama of a mystery novel, case studies involve a brilliant doctor faced with initially baffling clues who eventually solves the puzzle.

In many cases, the patient is cured. When the patient dies, the illness -- never the doctor or the health-care system -- is blamed, he says.

"The reality is far different from that," Wachter says. "There are many patients that suffer not just from their disease but from the errors committed by the health-care system itself."

In "The Wrong Patient," one woman accidentally underwent an invasive cardiac electrophysiology study, a test to detect heart rhythm problems in which a catheter is inserted in a blood vessel in the groin and threaded up to the heart.

She had been admitted to the hospital for two brain aneurysms, which are weakened areas in the wall of a blood vessel. She successfully underwent treatment for that condition before she was given the heart rhythm test.

Neither the patient nor the hospital was identified in the study.

Researchers from Mount Sinai School of Medicine in New York City did extensive interviews with the patients, nurses and doctors. They found 17 errors that led to the mistake, none of which was serious enough alone to cause the problem. The errors included:

  • Lack of teamwork. Physicians, nurses, staff from different departments failed to communicate with each other about the patient's course of treatment.

    "Everybody had blinders on and were trying to do their own little narrow part of the job instead of functioning as a team," says Dr. Mark Chassin, chairman of health policy at Mount Sinai, and lead author of the study.

  • There was no standard method of verifying the patient's identification. The names were similar and the staffers just assumed they had the right person.
  • When the patient objected to the procedure, saying she hadn't heard anything about it, no one listened to her.

"This adverse outcome wasn't caused by any one of those errors," Chassin says. "Instead, what it really exemplifies is the systems underlying these individual mistakes were not working. The individual mistakes were not prevented from doing harm. That's really the message we wanted to convey."

Chassin does not believe in punishing the staffers who made the mistakes in this case. People are fallible, and even those with the best of intentions err, he says.

Instead, systems and standard operating procedures that anticipate or compensate for human error need to be created and put into practice, he says.

Wachter says improving patient safety will also require a change in culture at hospitals. Mistakes should be discussed openly and analyzed. He also recommends that hospitals create a new specialty -- on-staff patient safety to work to prevent errors.

"Patient safety has to become a higher priority in the training of doctors and at hospitals," he says.

What steps can you take to protect yourself from medical errors? One way is to speak up.

"Patients should be outspoken and not hesitate to ask questions of their caregivers about their medication, procedures and details of their care," Chassin says.

What To Do

For more tips on keeping medical errors from happening to you, check the National Patient Safety Foundation, or the Agency for HealthCare Research and Quality.

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