By Joe Kita
"It was more than 20 years ago, but it still haunts me," says Bryan E. Bledsoe, a clinical professor of emergency medicine at the University of Nevada School of Medicine. "I made a mistake that may have cost a woman her life."
Bledsoe's oversight, which you'll read about later, has driven him throughout his career. To this day, he is an outspoken advocate for health care safety, teaching physicians-in-training to treat patients as individuals, not as numbers at a deli counter.
It sounds like an obvious message, but an overemphasis on speed is just one of the reasons that, every day, Americans in hospitals around the country are injured or die because of a medical error. "Any physician who says he or she never made a mistake is a liar," Bledsoe says.
The problem of avoidable medical error burst into the news in 1999 when the Institute of Medicine published To Err Is Human: Building a Safer Health System. Highlighting an estimated 98,000 unnecessary deaths every year, the report inspired a patient-safety movement-but over a decade later, not nearly enough progress has been made, say many experts. What's still needed: more thorough approaches to investigating errors, support systems that help doctors admit to and learn from their failings, and better methods of adopting proven solutions. In the meantime, people are still dying needlessly.
"If we don't talk about the problem of hospital error, there's no way to fight it," says Peter Pronovost, MD, PhD, a professor at Johns Hopkins University School of Medicine, whose own father died because of medical errors at age 50. "Whenever I've worked up the courage to share a personal mistake, my colleagues listen raptly. But most don't say anything, even though I know they're just as guilty. The culture of medicine still won't allow it."
But that's changing. When Reader's Digest first considered approaching health care professionals to ask them to confess their biggest mistake, we worried that few would speak up. We were wrong.
Doctors, nurses, and pharmacists all stepped forward. Each of these professionals welcomed the chance to say "I'm sorry"-and, more important, to address the weaknesses in the health care system that continue to make errors like theirs possible.
Read their stories and see if you, too, don't entertain some hope that a better, safer health care system is on the way.
"After six hours, he still wasn't waking up. What had I done?"
-- Peter Pronovost, MD, PhD
I was a young doctor doing specialty training in critical care, and I was exhausted. Partway through a 36-hour shift at Johns Hopkins Hospital, I was hungry and hadn't slept for 24 hours, but I was facing an overflowing intensive care unit and somehow needed to discharge five patients to make room for more. Mr. Smith,* who'd had esophageal surgery, was a borderline call. But because of the pressure I was under, I decided to remove his breathing tube and transfer him to another unit.
That turned out to be a very bad decision.
Before long, his breathing sped up as his oxygen levels dropped dangerously. I needed to reinsert his breathing tube. But what I didn't know was that he had severe swelling in his throat-in fact, the anesthesiologists in the operating room had had difficulty placing the tube in the first place. When I looked into his mouth and tried to identify his vocal cords in order to insert the tube, all I saw was a swollen mass of dark pink tissue, like raw hamburger meat.
I took the instruments out and started to bag him, breathing for him, but he vomited, making that almost impossible. I finally got the tube in-but quickly realized it was in his esophagus, not his airway where it belonged. Understand that when you insert a breathing tube, you give the patient medication to stop his breathing. You have about four minutes before he suffers brain damage. It took me between three and five minutes to get the tube properly placed.
I waited anxiously for the medication to wear off, which usually takes about 15 minutes. But after an hour, Mr. Smith was still asleep. After six hours, I was panicked. I explained the situation to the patient's wife-well, I sort of explained it. Fighting back tears of shame and guilt, I told her I'd had difficulty reinserting the tube, but I didn't mention that it was the wrong decision to remove it in the first place. Doctors, especially Johns Hopkins doctors, didn't make mistakes. If you did, you suffered your shame silently.
Luckily, Mr. Smith regained consciousness shortly thereafter and recovered with no ill effects. I still remember my overwhelming feeling of relief.
Many medical errors occur because hospitals lack standardized checklists for common procedures designed to minimize the chance of bad judgment. Airline pilots and NASCAR teams have them-why don't doctors? I think it's partly because it's so important to us to believe in the myth that doctors are perfect.
Before I pulled that tube, I should have had to complete a checklist that included input from the patient's senior physician and nurse. If anyone had disagreed, I wouldn't have been able to act. A simple system like this not only protects patients but also promotes honesty, respect, and teamwork among hospital staff.
A few years ago, I helped develop just such a list for doctors and nurses in more than a hundred ICUs in Michigan. It focused on a common intensive care procedure: inserting a catheter into a vein just outside the heart for delivery of intravenous liquids. It ticked off five steps everyone had to follow, and in 18 months, it lowered the rate of catheter infection by 66 percent and saved 1,500 lives.
Mr. Smith taught me a lesson I never forgot. It's time we let him teach us all.
-Peter Pronovost, MD, PhD, is a professor at Johns Hopkins University School of Medicine and the coauthor of Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.
PLUS: 15 ER Secrets
"Her name was Emily, and she was two years old."
--By Eric Cropp
It was a busy Sunday in the pharmacy at Rainbow Babies & Children's Hospital in Cleveland. The hospital's computer system had been down for about ten hours before I started my shift, and because I was teamed with a pharmacist who was fairly new to the department, I had additional responsibility. But I'd been in busy situations many times before. In fact, I had 14 years of experience and had been president of the Northern Ohio Academy of Pharmacy.
But on this day, I made the mistake of not thoroughly checking a saline-solution base that a technician had prepared for a child's chemotherapy treatment. She mixed it more than 20 times stronger than ordered, and I didn't catch it. When a nurse administered it, the high concentration of sodium chloride flowing through the child's veins made her brain swell and put her in a coma. Three days later, she died. Her name was Emily, and she was two years old.
I was eventually convicted of involuntary manslaughter, for which I received six months of jail time, six months of house arrest, three years of probation, a $5,000 fine, and 400 hours of community service. I also lost my license, career, reputation, and confidence. But most devastating of all is that I have to live every day with the memory of that little girl.
I accept full responsibility for what happened. I should have checked that solution more carefully. But there are some facets of hospital and retail pharmaceutical work that desperately need fixing if similar tragedies are to be avoided.
Pharmacy technicians need better training. Most people don't realize that techs have something to do with approximately 96 percent of prescriptions dispensed in pharmacies, according to the National Pharmacy Technician Association (NPTA). Yet 92 percent of us live in states that do not require them to have any formal training. (The tech in my case had a high school diploma.) Ohio recently adopted Emily's Law, which requires that all techs undergo training and pass a competency exam. The NPTA is currently working on a bill that would institute Emily's Law nationwide.
We should also take advantage of technology. There are lots of look-alike, sound-alike medications that come in small vials with tiny labels. A bar-code scanning system, like the ones in supermarkets, would supply an extra layer of safety.
But technology isn't enough; pharmacists and techs need better working conditions. Pharmacies can be cramped and the workload is often heavy. But studies suggest that crowding and dim lighting make mistakes more likely. So do interruptions, and the need to fill too many prescriptions. Believe me, a lot of pharmacists say a little prayer on their way home that an error didn't slip through.
Finally, I wonder what would have happened if I had talked to Emily's family right away and said I was sorry. I was advised against doing that. That's the way it is in the medical world when a mistake occurs: Hospital management may meet with the family, but the health care worker is often advised not to make a personal apology. Too much of a culture of silence still exists and must change. Doctors, nurses, pharmacists, and others need to be able to come together to confess their mistakes, clear their consciences, be supported, and, most important, work together to make the system safer.
-Eric Cropp, 42, is currently unemployed.*Names changed to protect privacy.
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