Top medical experts explain why even good doctors and hospitals make mistakes.

By Father and Son Prank Mom at Airport With 'Welcome Home From Prison' Sign
October 05, 2005
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When Jodi Gonzalez took her 15-month-old daughter, Delaney, to UCLA Medical Center for surgery to repair a cleft palate, she was certain she had done all her homework. After a nationwide search, the Gonzalezes wound up just 45 minutes away from their Simi Valley home because the UCLA doctors were among the best in the field -- a few months later they successfully separated conjoined twins. Jodi, a nurse herself, felt confident about their choice.

Around noon on February 4, 2002, a nurse brought a jovial Delaney -- who was getting piggyback rides from her dad, Danny -- to a pre-op room for anesthesia. The operation was supposed to take about 90 minutes, and the Gonzalezes headed to the waiting room. Three hours passed before a doctor informed them that Delaney was out of surgery; he also said her airway was swollen and she needed a breathing tube. "He told me that she'd still go home tomorrow as planned," says Jodi.

Five hours later, the Gonzalezes were given the green light to see their daughter in the Pediatric Intensive Care Unit. When Jodi entered the room, she observed what she'd later learn was the beginning of a series of critical mistakes: A nurse allegedly bumped Delaney's breathing tube by accident. The nurse called for a resident to check the tube. During the next several hours, the resident, who had recently graduated from medical school, gave orders for three chest X-rays to make sure the breathing tube hadn't been misplaced. The resident misread all three X-rays and thus insisted that the tube was in place -- despite the fact that Delaney's stomach was hard, a sign that air was being pumped into her belly instead of her lungs.

At 3:15 a.m. -- when Jodi was in the lounge and Danny was home with their older son -- Delaney's heart stopped. It took 45 minutes to revive her. "A supervising physician, who arrived just three minutes before Delaney coded, told us her condition was serious. But we didn't come to grips with how serious," recalls Jodi. "The next day, our older son, sensing trouble, said, 'Delaney's dead and you're not telling me.' We replied, 'No honey, she's very sick, but she's not dead.' We didn't think Delaney was going to die. Your child can't die -- it's inconceivable."

Over the next two days, while doctors conducted tests on Delaney, the Gonzalezes prayed for a miracle, singing "Itsy Bitsy Spider" and playing with her Gloworm by her bedside. But the test results showed that Delaney was brain-dead -- and had no chance of recovery. On February 7, the Gonzalezes decided not to continue with life support. "They disconnected the machines, and I held her," Jodi recalls. "She died in my arms."

The Gonzalezes sued the hospital, settling out of court for $250,000 -- the maximum malpractice verdict allowed in the state. Last March, the California Department of Health Services cited the hospital for violations that led to Delaney's death. Among them: A radiologist failed to review chest X-rays that did confirm the breathing tube was misplaced; nurses mistakenly gave Delaney repeated

doses of Fentanyl, a medication that can depress breathing, despite doctors' orders that it not be administered if her respiratory rate slowed to less than 14, which it did; and -- the most horrific of all -- nurses disconnected a breathing monitor they believed to be faulty and never hooked her up to another one.

Unfortunately, medical mistakes aren't infrequent. At hospitals and doctors' offices across the country, they occur every day, every hour even -- and the finest institutions are no exception. The worst cases make the headlines. Last February, a teenage girl received an organ of the wrong blood type at Duke University Hospital, and in August a premature baby suffered burns in an overheated incubator at the facility. The following month, Children's Hospital Boston was cited by the Massachusetts Department of Public Health for critical errors in four cases, three of which were fatal.

So it's not surprising that when researchers at Children's National Medical Center in Washington, DC, reviewed discharge records from hospitals in more than 20 states, they found that one in 35 pediatric patients -- or 10 kids for every 350-bed children's hospital -- experiences a medical error. And those are just the errors that get noted on charts -- many don't. "Because of underreporting, we're unaware of the magnitude of medical errors," says study author Anthony Slonim, M.D.

Preliminary results from a pair of studies suggest that the rate of errors in doctor's offices is also alarmingly high. As with hospitals, in doctor's offices "there's a lot of slippage in our systems for processing patients, test results, and other aspects of care," says Lucian Leape, M.D., author of one of the yet-to-be-published studies.

Four years ago, Dr. Leape served on the Institute of Medicine's committee that authored To Err Is Human, a 312-page report that blamed 44,000 to 98,000 adult and child deaths and more than 1 million injuries annually on medical errors. The report concluded that mistakes weren't the fault of doctors and nurses but rather of a system that lacked proper safeguards. What's happened since? Some progress has been made -- for instance, the American Academy of Pediatrics (AAP) has issued a policy statement and co-authored a fact sheet for the public on avoiding pediatric medical errors -- but there's more work to be done, says Dr. Leape: "Medical errors in children are an immense problem, and parents are a critical part of the system. We have to educate them about how they can help."

The Halls of Silence

In order to implement safeguards, hospitals must figure out why medical mistakes occur under their roofs in the first place. Are residents overworked? Is equipment faulty? Does the staff need more training? A major barrier to pinpointing problem areas: getting doctors and nurses to discuss mistakes so everyone can learn from them. "The doctors where I practice barely talk to one another about anything," says a pediatrician in Pennsylvania who requested anonymity. "There's no way to deal with errors or problems."

Why are some healthcare workers giving their colleagues the silent treatment? "In many places, we're still pointing fingers at doctors and nurses and blaming them for errors," says Richard Gorman, M.D., a pediatrician in Ellicott City, MD, and chair of the AAP's Committee on Drugs. So if admitting to an error is going to hurt a doctor's career, most are understandably reluctant to talk openly. Adds Dr. Slonim: "Once you start assigning blame, the reporting goes underground."

Complicating matters is the risk of lawsuits. Most hospitals have an internal peer-review process, where doctors and sometimes nurses critique what went wrong or nearly went wrong in recent cases. And their discussions are usually prohibited by law from being introduced in malpractice litigation. "Once a week, we sit down as a group and figure out how a mistake happened. Then we brainstorm ways to put safeguards in place to prevent it from recurring. When everyone is forthright, it works beautifully," says Steven Selbst, M.D., vice chairman for education at the Alfred I. duPont Hospital for Children in Wilmington, DE.

The problem is, some doctors and nurses are still ashamed or afraid to speak up. "Often medical personnel hide behind malpractice as a reason for not talking," says Carol Ley, M.D., the St. Paul, MN-based board chair of the National Patient Safety Foundation.

And if doctors and nurses are reluctant to be as honest as possible about a blunder or even a near miss within an internal hospital review, they're completely terrified to reveal a mistake to a patient's family. It's not just about a big malpractice judgment -- higher insurance premiums and a tarnished reputation can play a part, as can feelings of genuine remorse. "Nothing is worse for a doctor or nurse than contributing to a medical mistake -- especially on a child," says Dr. Selbst. "You feel terrible about it. You have to work hard to find the words."

However, Dr. Selbst notes that physicians are more likely to tell families about mistakes now than they were just a few years ago. A growing number of hospitals are encouraging it, and the doctors at these institutions are seeing that when families are told about an error, they can be forgiving. "From what I've seen, if doctors try to cover up mistakes, families are more likely to sue," Dr. Selbst says.

That's what George and Gina Meder are doing to the physicians who operated on their 3 ½-year-old daughter, Andie, in December 2000 at an outpatient surgical center in Waterbury, CT. Because of chronic ear infections, Andie needed a 15-minute procedure to have her left ear tube replaced and adenoids removed. At the end of the operation, the surgeon bumped her breathing tube and the anesthesiologist never checked to see if it had been dislodged. The state report notes that the surgeon left the anesthesiologist to attend to Andie while he went to tell the Meders that the operation went well and they could see their daughter in about 15 minutes. But a few minutes later, Andie coded. Doctors were able to get her heart beating again and transferred her to Waterbury Hospital.

"No one at the surgical center ever told us how serious Andie's condition was, let alone what happened to her," George says. "First, a nurse told us she hadn't woken up from anesthesia yet. Later, another nurse informed us that her heart had stopped beating but she would be okay. Then our surgeon said she'd been without oxygen for some time and may have brain damage."

The surgeon followed the Meders to the nearby hospital, where she was being prepped for a helicopter ride to Yale-New Haven Pediatric Intensive Care. "He was crying and collapsed in my arms," George recalls. "And I felt sorry for him. I even gave him a hug. But he never told me about the mistakes. Andie was declared brain-dead that night. Gina and I lived for months not knowing what transpired during Andie's last moments."

Recurring Nightmares

In fact, more than a year passed before state officials investigated Andie's death. At the time in Connecticut, the surgical center wasn't legally obligated to report mistakes, and while Andie's death certificate should have raised red flags with the state, it didn't until a reporter brought it to the attention of the state health department. Pressured by the state's patients'-rights group -- of which George Meder is now a vocal member -- Connecticut recently become one of only 21 states that require reporting of medical mistakes. All of which begs the question: If fewer than half the states insist that mistakes be reported, how can healthcare workers learn from one another's errors? "It's tough," says Dr. Ley. "We need much more sharing."

The landmark IOM report called for a federal registry of medical errors, but the project hasn't even gotten off the ground, says Dr. Leape. So what's available? Both the FDA and the United States Pharmacopeial Convention/Institute for Safe Medication Practices have voluntary reporting systems for medication errors and issue warnings to hospitals when they notice trends, the National Patient Safety Foundation posts information about medical errors on its Web site, and medical journals, trade magazines, conferences, and newspapers fill healthcare workers in on a few more.

But these efforts clearly aren't enough. In the meantime, mistakes are repeated. Case in point: In 1999, an 8-year-old boy with attention deficit hyperactivity disorder (ADHD) died after a pharmacist filled his prescription for methyl-phenidate (the generic name for Ritalin) with methadone, a powerful painkiller used to wean addicts off heroin. In 2001, the same mix-up happened to Joshua Dunbar, a first-grader in Espanola, NM. Joshua took the wrong drug for three days before he suddenly became ill; his mom, Miriam, rushed him to the ER, where he fell into a coma.

He eventually awoke, but the methadone overdose left Joshua with permanent brain damage. "Joshua's teacher told me that before the overdose, he was one of the brightest kids she'd ever met. Afterward, she was barely able to pass him to the second grade," says Margaret Branch, an attorney for the family, whom the Dunbars hired after the incident. At press time, the case was settled out of court for an undisclosed amount. This came after a mistrial in August when the court ruled that a prescription for methadone had been fabricated to make it appear as though the pharmacy had accounted for all of its methadone.

What's more, the FDA knew about four cases of confusion between methylphenidate or Metadate ER (another ADHD medication) and methadone before Joshua received the wrong drug. The agency sat on the information until October 2002, when it noted six cases of mix-ups -- not including Joshua's.

Seven Steps to Safety

While eliminating medical errors depends largely on getting members of the medical establishment to talk frankly about mistakes so they don't happen again, parents are sometimes in a position to spot red flags and intervene. For instance, Joshua Dunbar's mother didn't ask the pharmacist why her son's medication looked different from his previous prescriptions. And her reason is understandable: The boy's doctor had changed the dose. Experts advocate speaking up, however. "Whenever the appearance of medication changes from one refill to the next, question the pharmacist about it," advises Michael Cohen, president of the Institute for Safe Medication Practices, an advocacy group in Huntington Valley, PA. Other things you can do:

  1. Ask your pediatrician to print.
    A study last year found that about one in 70 prescriptions given at doctors' offices is illegible. With 7,000 medications on pharmacy shelves -- some with similar names, like the antihistamine Zyrtec and the antipsychotic Zyprexa -- it's easy to see how pharmacists could misinterpret what a doctor ordered. Cohen's advice: Ask your child's doctor to print or type the prescription and note what condition the medication is being used to treat, a step that the AAP encourages. Double-check the information with the pharmacist when you pick up the prescription.
  2. Check into your doctor's history.
    Currently, medical boards in 42 states allow you to view a doctor's disciplinary record on the Web. See Public Citizen's Web site to find information on your state.
  3. Take the pulse of the nurses.
    Snagging a prestigious surgeon is going to mean little if your child receives the wrong medication in the middle of the night. Ironically, that's what happened to Dr. Ley, the physician who's on the board of the National Patient Safety Foundation. When her 9-year-old daughter, Jacquelyn, shattered her elbow playing soccer, Dr. Ley and her husband, an orthopedic surgeon, made sure their child had the finest doctors. All went well until her third night in the hospital, when a nurse programmed a morphine pump to deliver four times the dose of medication instead of discontinuing it, as planned. Dr. Ley woke up and saw Jacquelyn wasn't breathing. "The doctors and I revived her and she's fine," she says. Dr. Ley's experience shows the importance of choosing a facility with highly trained nurses. Ask the hospital's nursing director what percentage of nurses have a bachelor's degree; studies indicate they're likely to make fewer errors than nurses with associate degrees. Also inquire about the nurse-to-patient ratio in the unit where your child will stay (1 to 3 or 4 is probably fine in a general unit, 1 to 1 or 2 in an intensive care unit) and how many hours the nursing shifts last (no longer than eight hours is preferred). A fresh nurse not only isn't as likely to make mistakes, but she also may catch a doctor's error, says Dr. Leape.
  4. Look for medication safety nets.
    The AAP notes in a policy statement that the medication error rate for hospitalized children is as high as 1 per every 6.4 prescriptions. Before deciding on a hospital for your sick child, ask if a pharmacist accompanies doctors on rounds (a step taken in less than 20% of hospitals). Even better, determine if the hospital has a Computerized Physician Order Entry (CPOE) in place. With this system, doctors enter medication orders (eliminating the penmanship problem), which get cross-checked against the patient's allergy, weight, and other medications. One study found that CPOE can cut the number of errors in half. But because of the cost and need for staff training, just 1 in 20 hospitals has the system fully implemented.
  5. Know who's in charge of your child's case.
    Three of the recent errors at Children's Hospital Boston happened because doctors mistakenly thought another doctor was in charge -- and no one took the lead. So if your child is hospitalized and needs care from multiple departments, be sure it's clear to you and to everyone else who the head doctor is.
  6. Have your child's X-ray read right.
    In other words, insist that a radiologist read it. He may spot things your physician misses. When Carrie Steinweg's 2-year-old son, Chandler, jumped off a workbench and hurt his arm, his dad took him to a local urgent-care center, where the general practitioner read the X-ray. "Chandler came back without even a bandage," recalls Steinweg. "Two days later, we got a call from the urgent-care center saying Chandler's arm was broken and we needed to take him to the emergency room immediately." Fortunately, Chandler didn't damage his arm further during those two days. Until a radiologist reviews your child's X-rays, you shouldn't consider the case closed.
  7. Get it in writing.
    If your child is having a procedure or operation where there may be confusion between her right and left side, have your physician sign where the surgery will take place to make sure the wrong side isn't mistakenly treated. With no mark for reference, a 13-year-old boy recently had a catheter inserted in the wrong kidney at Children's Hospital Boston. The mistake was caught before damage occurred.

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Copyright © 2004. Reprinted with permission from the February 2004 issue of Child magazine.

All content here, including advice from doctors and other health professionals, should be considered as opinion only. Always seek the direct advice of your own doctor in connection with any questions or issues you may have regarding your own health or the health of others.