Medical Errors

Medical Errors: Wrong Side Surgery & Other Errors

Wrong side surgery

Make no mistake: Surgery patients need to be proactive
The Providence Journal-Bulletin (Providence, RI) January 27, 2002, Health & Fitness; Pg. N-01
Surgeon operated on the wrong side of a man's brain.

USA TODAY, December 6, 2001, LIFE; Pg. 10D
Since 1998 - three years after the problem became nationally known and a focus of patient safety initiatives
-- there have been 136 reports of wrong sided surgery.

Doctors Face Sharp Penalty for Wrong Cut
The Palm Beach Post July 24, 2001; pg. 1A
Doctor fined $10,000 last month by the state Board of Medicine for mixing up two patients. He performed a procedure on each one that should have been done on the other.

Errors detailed in kidney removal
Boston Globe June 1, 1996, Saturday, METRO Pg. 1
A surgeon at Quincy Hospital who removed the wrong kidney failed to check X-rays that would have revealed the error.

Neurosurgeon Suspended after Wrong Side Brain Surgery
The Washington Post ; July 25, 1995; PAge Z05
The chief of neurosurgery at a famous New York hospital has been suspended from his duties after he operated on the wrong side of a patient's brain for a malignant tumor.
The patient, has been left with severely impaired vision and no awareness of her left side.
A recent report in U.S. News & World Report ranked the hospital as the top cancer center in this country.

Hospital Told to Halt Surgeries after Amputation of Wrong Foot
New York Times. April 8, 1995, Saturday, Section 1; Page 7; Column 2
Florida State Regulators ordered a hospital here where doctors amputated the wrong foot of a diabetic man in February to suspend elective surgery. In issuing the ruling, the Florida Agency for Health Care Administration noted a series of mistakes in the last three months, including the amputation, the death of a man who was mistakenly taken off a ventilator and an arthroscopic surgery on the wrong knee.

Wrong procedure

A 67-year-old woman mistakenly underwent an invasive cardiac electrophysiology study.
Ann Intern Med 2002 Jun 4;136(11):826-33 ; Chassin MR, Becher EC.
Among all types of medical errors, cases in which the wrong patient undergoes an invasive procedure are sufficiently distressing to warrant special attention. Nevertheless, institutions underreport such procedures, and the medical literature contains no discussions about them. This article examines the case of a patient who was mistakenly taken for another patient's invasive electrophysiology procedure. After reviewing the case and the results of the institution's "root-cause analysis," the discussants discovered at least 17 distinct errors, no single one of which could have caused this adverse event by itself. The discussants illustrate how these specific "active" errors interacted with a few underlying "latent conditions" (system weaknesses) to cause harm.
The most remediable of these were absent or misused protocols for patient identification and informed consent, systematically faulty exchange of information among caregivers, and poorly functioning teams.

Medication Errors

OVERVIEW:

To Err Is Human: Building a Safer Health System (2000) Page 41.
    It has been estimated that for every dollar spent on ambulatory medications, another dollar is spent to treat new health problems caused by the medication. One estimate places the annual national health care cost of drug-related morbidity and mortality in the ambulatory setting as high as $76.6 billion in 1994.98
    One recent study conducted at two prestigious teaching hospitals found that almost two percent of admissions experienced a preventable adverse drug event, resulting in an average increased length of stay of 4.6 days and an average increased hospital cost of nearly $4,700 per admission.103 This amounts to about $2.8 million annually for a 700-bed teaching hospital, and if these findings are generalizable, the increased hospital costs alone of preventable adverse drug events affecting inpatients are about $2 billion for the nation as a whole.
    A study of all patients admitted to a large teaching hospital found that adverse drug events complicated 2.43 admissions per 100.104. The occurrence of an ADE was associated with an increased length of stay of 1.91 days and an increased cost of $2,262.
    The increased risk of death among patients experiencing an adverse drug event was 1.88.

The Costs of Adverse Drug Events in Hospitalized Patients. JAMA 1997, 277(4):307-11
In review of 4108 admissions to a teaching hospital, 60 patients experienced a serious preventable ADE. Estimated costs attributable to preventable ADE’s were $4685 pere event. For a 700-bed teaching hospital, the projected annual cost for preventable ADEs was $2.8 million.

A Lesson from Ben; Ben Kolb dies after being given the wrong medication during a routine ear surgery
NBC News Transcripts, Dateline NBC (10:00 PM ET) January 1, 2002
Seven year old dies when he receives epinephrine injection instead of lidcocaine.

10 Common Prescribing Errors Consultant; 41(6) p. 766 May 1, 2001
Sound-alike Drugs; Lack of Drug Knowledge; Dose Calculation Errors; Decimal Point Misplacement; Wrong Dosage Form;
Wrong Frequency; Use of Abbreviations; Drug Interactions; Renal Insufficiency; Incomplete Patient History

Hospital Says Two Died in Nitrous Oxide Mistake
New York Times, January 17, 2002; Section B; Page 1
Two women at a hospital in New Haven died in one over the last week after getting nitrous oxide instead of oxygen

Medical-Errors Issue Got High Profile Push
The Boston Globe, December 13, 1999, NATIONAL; Pg. A1
Dissussing death of 39-year-old Boston Globe health columnist died following a massive chemotherapy along
with other high profile malopractice cases.

Lab errors

Hospital Admits Fatal Lab Errors; Incorrect Drug Doses Blamed for Deaths of 2 Men
The Washington Post, August 19, 2001, A SECTION; Pg. A02
932 patients given incorrect Coumadin doses due to erroneous laboratory tests.

Med mal reform is bad medicine
Business Insurance February 24, 2003
   Linda McDougal, the Wisconsin woman whose doctor mistakenly performed a double mastectomy on her even though she was cancer-free, has decided to become the poster child against medical malpractice tort reform.
   At the risk of sounding like a liberal, I'm with her.
   The tort system's fundamental moral purpose is to punish those who harm others, and, where feasible, to force them to pay restitution to their victims. Capping doctors' malpractice liability for noneconomic damages at $250,000-which is less than one year's salary for most of them-effectively removes the deterrent the tort system is meant to create.

Other Errors

Porous Safety Net Allows Lethal Medical Mistakes   USA TODAY,   October 11, 2000, Pg. 1A
   An overworked nurse infuses the wrong type of blood into a patient.
   An experienced pharmacist puts the wrong drug in a child's medicine bottle.
   A less experienced surgeon blows a heart procedure that is performed more frequently, and flawlessly, down the street.

Determining Negligence an Inexact Science in Pennsylvania Malpractice Cases
Centre Daily Times; January 14, 2001
"According to a fairly recent Harvard University study, only one of 16 meritorious malpractice cases gets brought."

Serratia marcescens Bacteremia Traced to an Infused Narcotic New Engl. J Med May 16, 2002
Repiratory therapist infects 26 patients by drawing narcotic from intravenous lines.

Unexpected hypoglycemia in a critically ill patient (Insulin given instead of Heparin)
Ann Intern Med 2002 Jul 16;137(2):110-6
Administration of the wrong medication is a serious and understudied problem.
At approximately 8:15 a.m., Ms. Grant's (a pseudonym) ICU nurse heard coughing, entered her room, and found her moving her head and extremities in an uncontrolled manner. The nurse administered labetalol because the patient's systolic blood pressure was greater than 200 mm Hg. The ICU team arrived almost immediately, diagnosed a generalized seizure, administered intravenous lorazepam followed by midazolam, and emergently intubated the patient for airway protection. Serum electrolyte and arterial blood gas levels were measured, and computed tomography (CT) was done to rule out intracranial hemorrhage. Approximately 30 minutes after initiation of these diagnostic and therapeutic maneuvers, the laboratory notified the ICU team that the patient's serum glucose level was undetectable.
At 9:15 a.m., a nearly empty 10-mL vial of regular human insulin (100 U/mL) was found on the medication cart outside the patient's room. This finding, in conjunction with the persistent hypoglycemia despite aggressive glucose replacement, suggested that the patient's sudden deterioration had resulted from inadvertent administration of insulin.

ABO Blood typing mismatch:

A report of 104 transfusion errors in New York State. Transfusion. 1992 Sep;32(7):601-6.
Of 104 incident reports in the 22 month study period, there were 54 ABO-incompatible transfusions.

Donor Mix-Up Leaves Girl, 17, Fighting for Life New York Times, February 19, 2003 Section A; Page 1
Jesica Santillan, A 17-year-old girl, is in critical condition after mistakenly being given a heart and lung transplant from a donor with the wrong blood type at Duke University Hospital in Durham, N.C.
The donor had Type A blood, and Ms. Santillan Type O.

Suit Says Transplant Error Was Cause in Baby's Death New York Times, March 12, 2003 Section A; Page 23
     A year-old baby died in August at Children's Medical Center in Dallas after a surgical error destroyed her liver and doctors tried to save her with a transplant but mistakenly gave her a liver of the wrong blood type, according to a lawsuit filed on Monday.
     The case is the second to come to light in recent months in which a child died after a transplant team failed to take the most basic precaution of making sure an organ donor and recipient had compatible blood types. The Duke case revealed that the most sophisticated medicine at an elite institution could be undone in a moment by a simple human error.
    In the last 15 years, although thousands of transplants have been done, only about a dozen mismatches have been revealed to the public or reported in medical journals. But the number may be an underestimate.

BLOOD ERRORS - Blood Mix-Up Caused Death
Newsday (New York) NASSAU AND SUFFOLK EDITION May 6, 2002, Pg. A06
Twice within six days during April 2000, the lawsuit says, Ying Lung Chiu Wong of Chinatown was transfused with the wrong type of red blood cells and plasma. Shortly after the second incorrect transfusion, Wong died.
A Newsday investigation, published last month, found that between 1995 and 2001, 441 hospital patients died following transfusions, including 78 who received the wrong blood.

The state-of-the-art computer was programmed to prevent mistakes
The Boston Globe December 11, 2000, METRO Pg. A1
The machine beeped again and beamed a more urgent message: "Does not match . . . Do Not Use!" But the technician in the blood bank overrode the alar

How Many Medical errors? .
What kind of errors?, Wrong Side Surgery, Not Following Guidelines, Reducing Errors,
Doctor Discipline