June 18, 2008

Surgery on wrong patient or site—and other big blunders
Procedures done on the wrong body part and to the wrong person are two of the National Quality Forum’s 28 “never events,” mistakes—including surgical materials left in a patient; artificial insemination with the wrong sperm or egg; and harm from malfunctioning equipment, as happened to Kristina Fox—that shouldn’t occur under any circumstances (see "Mistakes That Should Never Happen"). But they do. Out of 4,817 serious problems tracked over the past 12 years by the Joint Commission, the chief accrediting organization for hospitals, 625 were wrong-site surgeries. These are the nightmares: A Long Island, N.Y., woman in her 30s who never had cancer received an unnecessary double mastectomy—then died the following day of complications from the procedure. A man in a Brooklyn, N.Y., hospital had his healthy kidney removed—instead of his cancerous one.

In a perfect world, a surgeon would never remove a healthy breast or kidney, because the surgical team would follow the Joint Commission’s three-step presurgery protocol: Check two pieces of identification (to make sure they have the right patient); mark the site to be operated on; and take a short time-out before starting to make sure everyone agrees that nothing is amiss. Trouble is, not everyone does this safety check. According to recent Joint Commission data, 22% of its hospitals reported failing to take a time-out on at least one occasion.

Drug-resistant infections
Right now, “there’s a serious chance of getting a hospital-acquired infection—pneumonia or diarrheal illnesses passed from one patient to the next,” says Kaveh G. Shojania, MD, associate professor at the University of Toronto.

Alicia Cole knows firsthand the devastating toll an HAI can take. When the healthy 43-year-old checked into a top Los Angeles hospital in August 2006 for a routine surgery to remove uterine fibroids, she thought she was in for a two-day stay. But “on the second day, instead of going home, my fever went up to 103.6,” Cole says. “They said it was nothing to be alarmed about.” But Cole’s fever continued to spike as her body swelled from a size 6 to a size 14 and her abdomen grew rigid. A tiny black dot on her belly, first noticed by Cole’s mother, turned out to be a harbinger of a devastating infection: necrotizing fasciitis, better known as flesh-eating bacteria.

Two months later—after a month in the ICU, six surgeries, a 25-pound weight loss, and near-amputation of her left leg—doctors finally got the fierce infection under control enough for Cole to go home. Two years later, she still receives daily treatments to close and heal her wound.

Medication mess-ups
The average patient experiences one drug mistake in the hospital every day. “Everything from ‘I got my dose late’ to ‘I got someone else’s medication,’ ” says Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality. Life-threatening mistakes are particularly common with blood thinners (like Heparin), insulin, and chemotherapy drugs because they’re potentially so toxic.

Some hospitals are already reducing drug mix-ups, with help from computers. CPOE—computerized physician order entry—slashes medication errors up to 80%; it eliminates the challenge of deciphering sloppy handwriting and checks for drug interactions and incorrect dosages. The only problem? Just 37% of teaching hospitals and 16% of nonacademic hospitals have CPOE systems in place.

Diagnostic mistakes
“Diagnostic errors are really common and not captured by any measurement system we have,” says Robert M. Wachter, MD, professor and associate chairman of the department of medicine at the University of California, San Francisco, and author of Understanding Patient Safety. “Sometimes we don’t know we’ve made an error until the autopsy.” That was the case with actor John Ritter, who died after collapsing on the set of his TV series 8 Simple Rules for Dating My Teenage Daughter. The 54-year-old actor was rushed to a nearby ER where doctors misdiagnosed him as having had a heart attack when, in fact, he’d suffered from aortic dissection, a tear in the wall of the aorta requiring immediate surgery. He died at the hospital.

As Ritter’s case suggests, you’re especially likely to receive a botched diagnosis in the ER, where doctors and nurses are juggling more patients than ever, according to a recent report from the American College of Emergency Physicians. That’s what Tiffany Carboni, 34, of Pacifica, Calif., found last July when she went to the emergency room of the highly-rated local hospital where she’d delivered her two children. The doctors there missed her classic signs of appendicitis and instead sent her home with a diagnosis of gastroenteritis and a stiff dose of morphine. “They failed to do a simple blood test. If they had done it, they would have noticed that my white blood cell count was going higher and higher,” suggesting a worsening infection, Carboni says. The next day, her appendix burst, a potentially life-threatening condition requiring immediate surgery and a bigger incision and longer recovery time than if she’d been treated before the situation became dire.
Next: Foul-Ups That Should Never Happen

Back to Your Guide to Preventing Medical Mistakes Intro

By Lorie A. Parch
Additional reporting by Kimberly Holland and Brittani Tingle

Related Links:
How to Avoid Becoming a Medical Mistake
Skills to Use in the Hospital
Five Surgeries to Avoid

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