A Fatal Error
After a harrowing ordeal, the worst seemed over for 6-year-old Michael Colombini.
Earlier that week, doctors had discovered that Michael had a brain tumor. It was a startling diagnosis, fortuitously detected when he'd been brought to the emergency room with a nasty bump he'd gotten from a fall at the playground. The child was operated on two days later, and his prognosis seemed promising.
"Everything went well with the surgery," recalls his father, John Colombini, of Croton-on-Hudson, New York. "Michael was alert and functioning by the next day. Amazingly, he was fine."
Before the child could go home, however, doctors needed to do a final MRI-a magnetic resonance imaging test of his brain-to confirm that the entire tumor was gone.
On July 27, 2001, Michael was placed inside the tubelike confines of an MRI machine, which uses a ten-ton magnet to generate images of the body's cells and tissues. John and his wife, Barbra, sat in the reception area outside the room, waiting to see their little boy.
"Suddenly, we heard a lot of commotion from inside the testing room," John recalls. "We knew something was wrong." The parents later learned that a metal oxygen container had been inadvertently left in the MRI room when the machine was turned on. Attracted by the giant magnet, the container shot through the air to the core of the machine, striking the child on his head and fracturing his skull. Michael was taken to intensive care, but two days later, he died from massive injuries to his brain.
Medical errors as horrific as this one are quite rare. But the fact is that doctors, hospitals, pharmacies, and other health-care facilities make mistakes far more often than most people realize--and many of those mistakes involve children. No one knows the exact number of kids who are victims of medical mistakes. A 1999 report from the Institute of Medicine, a research group, found that an astonishing 3 to 4 percent of hospitalized adult Americans are harmed in some way by their treatment. According to the IOM, medical errors kill an estimated 44,000 to 98,000 people in the United States each year.
In the aftermath of the IOM report, the American Academy of Pediatrics (AAP) began digging for data on kids. Researchers encountered a worrisome lack of information, with no ongoing national reporting system to track medical mistakes. "A lot of what happens with children is simply unknown," says Carole Lannon, M.D., director of the steering committee on quality improvement and management for the AAP.
But there's evidence to suggest that the youngest patients may be even more vulnerable to medical mistakes than adults are. In a study published in 2001 in the Journal of the American Medical Association, researchers who pored through more than 10,000 drug orders for children at two Boston teaching hospitals found 616 medication errors-about six mistakes for every 100 kids. Just as alarming, near misses--such as faulty prescriptions caught and corrected before the medicine was given to a patient--occurred about three times more often among children than among adults.