Stories. Good ones, bad ones, funny ones, sad ones. We all have them. Our stories are what make us---and ultimately may be what break us. For so long I wanted to hide from this. To ignore it and act like it never happened. My website showcases the beauty of medicine. The innovation, the groundbreaking discoveries, and millions of lives saved by the wonderful healthcare workers of our world. To save a life is beautiful. To save a life is courageous. To save a life is brave. To save a life is strong. It takes a special type of person to enter the world of healthcare, walking into the unfamiliar universe of life and death being separated by a singular actions. It's absolutely breathtaking, and I so long to be part of it.
But to understand the beauty of medicine, we must also understand the horrors of it. 9.5%. A percentage I will never forget. 251,454. A number that will forever haunt me. Though just a statistic to you, 9.5% changed 100% of my life. I went from packing my bags to spend the summer with my father, to standing over his hospital bed watching artificial life support pump through him as his rolled back eyes depicted his lifelessness. As I watched my father breathe in and out my 8 year old brain was fogged in confusion, but brain death doesn’t care for comprehension. How was I supposed to grasp that my father was dead but breathing? How could I understand that my father was part of the 9.5% of patients that die due to medical errors? For so long I debated sharing this part of my life. I mean, think about it. An account devoted to sharing the beauty of medicine sharing the real, untold truth about its many faults. Why speak out? Why speak up?
For you. For any victim of medical negligence or malpractice. For any person suffocated with grief as they live in fear of the medical world and the many fatal mistakes made in it. We carry our stories with us through our many walks of life. No matter where I go, my father's accident will remain a vital part of my story. I no longer want to feel shame and hurt as I navigate my journey to becoming a physician, feeling haunted by mistakes that were not my own. I want to serve as a catalyst for other aspiring healthcare workers to share their stories without feeling as if they are going against their dreams. To learn about these mistakes and the various people affected by them is the first step into improving the quality of our healthcare once and for all. I pray for those who have been affected by the 9.5% and hope that this brings them comfort and understanding as they battle through the grief of losing a loved one in one of the most gruesome, senseless ways.
This is the story of my battle with the 9.5%. I will no longer let my love for medicine silence me from telling my truth. Mistakes are made, and people die. Fathers, mothers, and children are lost every year due to misjudgments and errors in hospitals--the place where people are supposed to feel the most safe. When these accidents happen we often think of who to blame. Maybe it was the wrong doctor, or the hospital didn't have enough available resources. Through my own journey I've come to understand that pointing fingers won't solve anything. The problem is not individualized but rather rooted in the healthcare system as a whole. What can we do to lessen these critical errors being made? How can we change the healthcare system to eliminate these senseless deaths? I share this information with the hope to educate and raise awareness towards this issue that affects the people of our world daily. No amount of awareness can bring those lost due to medical errors back. However, we can learn to understand these problems infecting our world and fight for worldwide change. As a student going into the same field that killed my father, I am inspired to continue fighting for him for as long as I live. This one is for you, dad.
Medical Errors: Overview
Medical errors are a significant concern in healthcare systems globally, and they can lead to adverse outcomes such as patient harm, prolonged hospital stays, and increased healthcare costs. Medical errors can occur at any stage of healthcare delivery, including diagnosis, treatment, and medication management.
Defining Characteristics of a Medical Error
Preventability: A medical error is a preventable event or act of omission that should not have occurred in the normal course of medical care.
Harm: A medical error has the potential to cause harm to a patient, including physical, psychological, or emotional harm.
Deviation from standard practice: A medical error often involves a deviation from the standard of care or established medical practice, such as a failure to follow established protocols or guidelines.
Unintended: A medical error is usually unintended, meaning that the healthcare provider did not intend to cause harm to the patient.
Adverse event: A medical error often results in an adverse event or outcome, such as a complication, injury, or death.
Error in judgment or action: A medical error may involve an error in judgment, such as a misdiagnosis or incorrect treatment plan, or an error in action, such as a medication error or surgical error.
Communication breakdown: A medical error may be the result of a breakdown in communication between healthcare providers, between healthcare providers and patients, or within healthcare systems.
Types of Medical Errors + Examples
1. Diagnostic Errors: Diagnostic errors are the most common type of medical error and occur when a healthcare provider fails to diagnose a patient's condition correctly. This can lead to delayed or incorrect treatment, causing harm to the patient.
Examples:
- Misinterpreting test results, such as misreading an X-ray or MRI.
- Failing to order necessary tests or imaging studies.
- Overlooking important symptoms or dismissing them as insignificant.
2. Medication Errors: Medication errors occur when a healthcare provider prescribes the wrong medication or the wrong dose of a medication, or when a patient receives the wrong medication due to a mix-up. This can lead to adverse drug reactions, medication toxicity, or other serious health problems.
Examples:
- Prescribing the wrong medication or dose.
- Failing to consider a patient's allergies or other medical conditions that may affect their medication.
- Giving medication to the wrong patient or administering it through the wrong route.
3. Surgical Errors: Surgical errors are rare but can be life-threatening. They occur when a surgical team performs the wrong procedure, operates on the wrong body part, or leaves an object inside the patient's body after surgery.
Examples:
- Performing the wrong surgery on a patient due to miscommunication or incorrect labeling.
- Operating on the wrong body part, such as performing a surgery on the left leg instead of the right.
- Leaving surgical instruments or sponges inside a patient's body after surgery.
4. Healthcare-associated Infections (HAIs): HAIs are infections that patients acquire while receiving healthcare, often due to inadequate infection control measures. This can lead to prolonged hospital stays, additional treatments, or even death.
Examples:
- Contracting an infection such as pneumonia or sepsis due to inadequate hand hygiene practices among healthcare providers.
- Acquiring a urinary tract infection due to catheter-associated infections.
- Contracting a bloodstream infection due to contaminated medical equipment.
5. Communication Errors: Communication errors occur when healthcare providers fail to communicate effectively with each other or with patients, leading to misunderstandings or errors in care.
Examples:
- Miscommunication between healthcare providers regarding a patient's treatment plan or medication orders.
- Failing to provide adequate information to patients regarding their diagnosis, treatment options, or medication regimens.
- Misunderstanding a patient's instructions due to language or cultural barriers.
6. System Errors: System errors occur due to problems with the healthcare system, such as inadequate staffing levels, faulty equipment, or inadequate training.
Examples:
- Inadequate staffing levels leading to burnout and fatigue among healthcare providers, which can increase the risk of medical errors.
- Faulty medical equipment or technology that can lead to inaccurate readings or incorrect diagnoses.
- Inadequate training or education on new medical procedures or protocols.
7. Documentation Errors: Documentation errors occur when healthcare providers fail to accurately record patient information, leading to errors in diagnosis or treatment.
Examples:
- Failing to document important medical history or current medications, leading to incorrect diagnoses or medication errors.
- Recording incorrect vital signs, which can lead to incorrect treatment decisions.
- Failing to document medication administration or dosage, leading to errors in medication reconciliation.
8. Procedural Errors: Procedural errors occur when healthcare providers fail to follow established procedures or protocols, leading to errors in care.
Examples:
- Failing to follow proper hand hygiene protocols, leading to the spread of infections.
- Failing to follow established medication administration protocols, leading to medication errors.
- Failing to follow proper surgical procedures, leading to surgical errors.
9. Equipment Errors: Equipment errors occur when medical equipment malfunctions or is used improperly, leading to errors in diagnosis or treatment.
Examples:
- Malfunctioning or inaccurate medical equipment, leading to incorrect diagnoses or treatment decisions.
- Using medical equipment improperly, such as using a defibrillator incorrectly
10. Administrative errors: These occur when administrative staff fail to perform their duties correctly, leading to errors in billing, scheduling, or other aspects of care. Examples include a billing department submitting incorrect charges to insurance or a scheduling department booking a patient for the wrong appointment.
Why Are Medical Errors So Common?
One of the main reasons why medical error rates are so high is the complexity of healthcare. Healthcare is becoming increasingly complex, with new drugs, procedures, and technologies constantly being developed. This complexity can make it difficult for healthcare providers to keep up with the latest advances and to provide the best possible care to their patients. In addition, the fragmentation of care is also a significant factor in medical errors. Patients often see multiple providers in different settings and receive care from a variety of sources. This fragmentation can make it difficult for providers to coordinate care effectively and to ensure that patients receive the appropriate care at the right time.
Communication breakdowns are another major contributor to medical errors. Miscommunications or misunderstandings between healthcare providers, between providers and patients, and within healthcare systems can lead to incorrect diagnoses, incorrect medications, or other errors in care. A lack of standardization in healthcare is also a significant factor in medical errors. Different providers and healthcare systems use different approaches to care, which can lead to variability in care and can make it difficult for providers to know the best course of action in a given situation.
Human factors are also a significant contributor to medical errors. Healthcare providers are human, and they are prone to making mistakes. Factors such as fatigue, stress, and workload can contribute to errors in care. Inadequate training is also a factor in medical errors. Healthcare providers may not receive adequate training in certain areas of care, such as new procedures or technologies. This lack of training can lead to errors in care. Finally, inadequate resources, such as equipment or staff, can contribute to medical errors.
Untold Stories
THE RHODE ISLAND HOSPITAL BRAIN SURGERY DISASTER: The Rhode Island Hospital brain surgery disaster was a tragic incident that occurred on January 19, 2007, in Providence, Rhode Island. The patient, 39-year-old Terry Sedlacek, had been experiencing severe headaches and was admitted to the hospital for treatment. Doctors discovered a blood clot in his brain and recommended surgery to remove it.
The surgery began as planned, but during the procedure, a medical team member accidentally disconnected a monitor that was monitoring Sedlacek's blood oxygen levels. The monitor was intended to alert the medical team if Sedlacek's oxygen levels dropped too low, but due to the disconnection, the alarm did not sound. As a result, Sedlacek suffered from oxygen deprivation for a significant period, causing significant brain damage.
After the surgery, Sedlacek was transferred to the intensive care unit, but his condition continued to deteriorate. He fell into a vegetative state and died several months later, never having regained consciousness.
The incident sparked significant public outrage, with many calling for an investigation into the hospital's policies and procedures. The Rhode Island Department of Health launched an investigation, which found that the incident was the result of a series of errors and failures, including miscommunication among the medical team members, inadequate training, and poor adherence to established protocols.
As a result of the investigation, the hospital was fined $50,000 by the state health department, and the medical team members involved in the incident faced disciplinary action. In addition, Sedlacek's family filed a lawsuit against the hospital, which was settled for $15 million.
This disaster was a tragic reminder of the critical importance of effective communication, proper training, and careful attention to detail in the healthcare industry. It underscored the need for healthcare providers to remain vigilant and ensure that every possible precaution is taken to protect patients from harm.
LEILANI SCHWEITZER: Leilani Schweitzer's son, Gabriel, was just 16 months old when he was diagnosed with a rare genetic disorder that required him to undergo regular blood transfusions. In 2005, during one of his routine transfusions at Lucile Packard Children's Hospital in Palo Alto, California, Gabriel was given the wrong blood type.
Schweitzer, who worked as a nurse at the hospital, immediately recognized the severity of the mistake. She demanded that the medical staff take action to correct the error, but her concerns were dismissed. Despite her protests, Gabriel was given a second transfusion of the wrong blood type.
As a result of the transfusion error, Gabriel suffered from severe brain damage, which left him in a permanent vegetative state. He required round-the-clock care and lived for another five years before passing away at the age of six.
Following Gabriel's death, Schweitzer began to advocate for patient safety and healthcare transparency. She shared her story with healthcare professionals and the public, emphasizing the importance of open and honest communication in the healthcare industry. She also worked to develop programs and protocols to prevent similar errors from occurring in the future.
In 2013, Schweitzer was invited to speak at the National Patient Safety Foundation's Annual Patient Safety Congress. During her speech, she shared her experience and urged healthcare providers to take responsibility for medical errors and to learn from their mistakes.
Schweitzer's story has had a significant impact on the healthcare industry, helping to raise awareness of the importance of patient safety and the need for improved communication and transparency. Her advocacy work has inspired many healthcare professionals to take a more proactive approach to patient safety, helping to reduce the incidence of medical errors and improve the quality of care for patients.
JESSICA SANTILLAN: Jessica Santillan was a 17-year-old girl who suffered from a congenital heart defect that required a heart-lung transplant. In 2003, she underwent the transplant at Duke University Medical Center in Durham, North Carolina. However, shortly after the surgery, it became clear that a mistake had been made.
The medical team had failed to match Jessica's blood type with that of the donor, which led to a severe immune reaction known as hyperacute rejection. Her body rejected the new heart and lungs, and she suffered severe brain damage as a result.
Despite attempts to save her life, Jessica passed away just a few days after the transplant surgery. Her tragic death sparked public outrage and led to an investigation into the hospital's policies and procedures.
The investigation found that the hospital had failed to follow proper protocols for organ matching, and that there had been significant miscommunication among the medical team members. As a result of the investigation, the hospital was fined $10 million and was required to implement new policies and procedures to prevent similar errors from occurring in the future.
Jessica's death also had a significant impact on the healthcare industry as a whole, raising awareness of the critical importance of effective communication and adherence to established protocols in the transplant process. It underscored the need for healthcare providers to remain vigilant and to take every possible precaution to protect patients from harm.
Jessica's family has since become advocates for patient safety, working to raise awareness of the risks associated with organ transplantation and advocating for improved communication and transparency in the healthcare industry. Her legacy has inspired many to work towards a safer and more reliable healthcare system.
ALYSSA HEMMELGARN: Alyssa Hemmelgarn is a young woman who suffered a life-altering medical error. In 1998, at the age of seven, Alyssa underwent a surgery to correct a condition called pectus excavatum, which causes the chest to appear sunken. However, during the surgery, Alyssa's aorta was punctured, leading to a massive loss of blood.
Despite the error, the surgical team did not realize the severity of the situation until Alyssa's vital signs began to deteriorate rapidly. Alyssa was rushed to the ICU and underwent several emergency surgeries to repair the damage. The surgeries were successful, but Alyssa suffered a stroke due to the lack of oxygen to her brain during the initial surgery. The stroke caused significant brain damage and left Alyssa with permanent disabilities.
Alyssa's story highlights the devastating impact that medical errors can have on patients and their families. It also underscores the need for healthcare providers to prioritize patient safety and take all necessary precautions to prevent errors from occurring. Since her injury, Alyssa's family has become advocates for patient safety and works to raise awareness of the importance of preventing medical errors.
Solutions
To address the issue of medical errors, it is important to take a comprehensive approach that involves healthcare providers, healthcare organizations, policymakers, and patients. One approach is to improve communication and coordination of care through the use of electronic health records, standardized protocols and guidelines, and team-based care models. Another approach is to invest in training and education for healthcare providers to ensure that they have the necessary knowledge and skills to provide high-quality care. It is also essential to invest in research and innovation to develop new tools, technologies, and approaches that can improve patient safety and reduce medical errors. Effective examples of this include:
1. Improved communication: One of the most significant contributors to medical errors is a breakdown in communication between healthcare providers. Implementing effective communication strategies, such as standardized protocols and team-based care, can help to ensure that all members of the healthcare team are on the same page and that critical information is shared effectively.
2. Patient engagement: Engaging patients and their families in their care can help to identify potential errors and prevent adverse events. Patient engagement can take many forms, including providing education about medications and procedures, encouraging patients to ask questions, and involving patients in decision-making about their care.
3. Use of technology: Advancements in technology, such as electronic health records (EHRs) and computerized physician order entry (CPOE), can help to reduce medical errors by providing real-time access to patient information and automated decision support.
4. Continuous quality improvement: Implementing continuous quality improvement (CQI) strategies, such as root cause analysis and process mapping, can help healthcare organizations to identify and address systemic issues that contribute to medical errors.
5. Strong leadership and a culture of safety: Creating a culture of safety within healthcare organizations requires strong leadership and a commitment to transparency and accountability. Leaders must promote a culture that values patient safety and encourages reporting and learning from errors.
6. Education and training: Providing education and training to healthcare providers can help to ensure that they have the knowledge and skills needed to provide safe and effective care. This includes training on medication safety, infection control, and communication skills.
7. Increased regulatory oversight: Increased regulatory oversight, such as mandatory reporting of adverse events and inspections of healthcare facilities, can help to identify and address issues related to medical errors.
Implementing these solutions, both individually and in combination, can help to reduce medical errors and improve patient safety in healthcare.
Why Is This Important?
Firstly, raising awareness and speaking out can help to reduce the incidence of medical errors and improve patient safety. This is crucial as patient safety is paramount, and medical errors can be prevented by taking necessary precautions.
Secondly, accountability is important when medical errors occur. Speaking out and raising awareness can help to ensure that those responsible for medical errors are held accountable for their actions. This can lead to improvements in healthcare practices and ultimately reduce the likelihood of future errors.
Thirdly, medical errors can provide valuable opportunities for learning and improving healthcare practices. By speaking out and raising awareness, we can help to identify areas for improvement and promote greater transparency in the healthcare industry.
Fourthly, speaking out and raising awareness can help to advocate for patients and their families who have been affected by medical errors. It can also promote greater patient engagement in their care and empower them to take an active role in ensuring their safety.
Finally, by raising awareness and promoting accountability, we can help to prevent future medical errors from occurring. This can improve the quality of care provided by healthcare organizations and help to rebuild trust between patients and their healthcare providers.
Notable Quotes
"As healthcare providers, we must be diligent in identifying and addressing medical errors. It is our responsibility to ensure that patients receive the best possible care and that mistakes are not repeated." - Dr. Atul Gawande
"We have to remember that medicine is an imperfect science, and that mistakes can and do happen. What is important is that we learn from those mistakes and use that knowledge to improve patient care." - Dr. Robert Wachter
"Medical errors are not only a tragedy for patients and their families, but also for healthcare providers. It is a reminder that we must always strive for excellence in our practice and never become complacent." - Dr. David Nash
"Transparency is key when it comes to medical errors. It is important that we acknowledge our mistakes and take responsibility for them in order to prevent similar errors from happening in the future." - Dr. Lucian Leape
"We must always remember that our patients are people, not just a set of symptoms or a medical history. By keeping the patient at the center of our care, we can reduce the likelihood of medical errors and provide better outcomes." - Dr. Darrell G. Kirch
More Information
To choose medicine is not only to choose its beauties but its many faults. Mistakes happen everyday and for the most part they are not fatal. But someone needs to speak for those who can't, the 9.5% who die due to these mistakes. The 9.5% will forever impact me, but I will no longer allow it to silence me. This is a key part of my story in its realness and truth and I hope that this post leaves my readers with a deeper and more authentic understanding of the medical world. As future health professionals, it is our job to address these issues and do what we can to solve them. One person at a time.
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