Be Wary of Deadly Mistakes in Health Care
Too often, patients are unaware that mistakes in health care are not unusual and can have extremely serious consequences.
Most people never imagine that doctors, nurses or pharmacists make mistakes. They trust their health professionals to make the correct diagnosis, prescribe the best treatment and administer it correctly.
Unfortunately, mistakes in health care are far more common than patients realize. Even those who know the health care system inside and out can suffer. One such reader shared his story:
An Insider’s Tale of Mistakes in Health Care:
“I have a master’s degree in hospital administration and have worked for 20 years in laboratory medicine, skilled nursing facility administration and direct patient care. I have also been arguing with health care professionals for 50 years about care for my juvenile [type 1] diabetes.
“During my years in administration, I have seen patients suffer injury and death due to error. Too often there is no follow up, prevention or lessons learned for health care providers; when something bad happens, they always have the same excuse: ‘the patient took a turn for the worse.’
“In my own family, my daughter almost lost her hearing due to an incompetent pediatrician. When she was 10 years old, a different doctor performed surgery on a plantar wart, but missed it by 1.5 inches. We believe the physician was under the influence of something.
A Blood Clot That Was Mistreated:
“My wife had a DVT [deep vein thrombosis blood clot] that broke loose and moved to her thigh. Her physician told her it was referred pain. A day later that phantom pain landed in her lungs as a pulmonary embolism! Even the emergency room doctor doubted she had a pulmonary embolism until the MRI came back two hours later. During that time, not a single nurse or physician so much as checked on her.
“When she was in the ICU, they discovered she has a rare clotting disorder and is hypersensitive to Coumadin [warfarin]. She could only tolerate 0.5 mg without bleeding to death.
“Back at the clinic for follow up care, the ‘clotting team’ wanted to put her on a 5 mg dose of warfarin because that was their standard protocol and the cheapest way to treat a clot. Fortunately, my wife is a medical technologist and she was able to read them the riot act. Otherwise, I fear she would have bled to death under their care.
Failing to Check on a Breast Lump:
“I can list dozens of errors in my own care. I am extremely active and have no diabetic complications after five decades, yet the primary care providers cannot see past ‘check the toes’ and ‘check the A1c.’
“I came in with a breast lump one time and the doctor was so preoccupied with checking my toes and rushing out the door that I had to call her back to check the lump, which was why I’d made the appointment. Once she realized I had a lump, she ordered a mammogram and ultrasound to help identify the lesion.
“Since I am a male, I think they wanted to dismiss it as nonsense. Fortunately for me, it turned out to be an abscess, but I had to assert myself to get any attention. Even so, the surgeon took the biopsy specimen from my nipple without using any lidocaine [local anesthetic]. What is wrong with these people?
“The public is enthralled with physicians and nurses, but they don’t realize the danger they are in and they don’t know enough to watch their own backs.”
It is worth remembering that men can develop breast cancer–and that potentially deadly mistakes in health care are all too possible. We all must be vigilant and assertive when we are receiving health care. To help with that effort, we suggest reading our book, Top Screwups Doctors Make and How to Avoid Them. If you have a friend or relative taking multiple medications this book is a must read.
Reader Reviews:
We always encourage visitors to read reviews to get a sense of how other people found one of our books or products. The overall rating for Top Screwups is 4.85 out of a possible 5 stars. Here are just a couple of recent reviews:
Faithful in Seattle says:
“We need to be our own advocate. This gives us the tools, checklists, and supporting background to be a partner with our providers. I will consult it whenever we see the doctor.”
Ellen in Dallas reports:
“I wish every doctor in the country could be given a copy of this and then made to read it. My husband is suffering from terrible after effects of five years of taking statins and years of taking a proton pump inhibitor.”
Linda in Lakeland, FL offers:
“Great book. Will refer to it many times and won’t go to the hospital without it! Thank you for this invaluable information.”
Find out for yourself why it is so important to take an active role in your health care by clicking on this link.
Filed under: General Problems
I worked in a close door pharmacy for several years where the primary core business was proving a fairly comprehensive set of pharmacy services to SNF’s (Skilled Nursing Facilities). I don’t know how many serious med errors that I caught and remedied while I was there. I know that there was at least one a day, on average. That’s was my contribution to interdiction of serious med errors. I can’t speak for the several other pharmacists employed there as to how many they caught, but I’m sure it was a similar count. I used to go to work and as I was heading out the door, I’d tell my daughter that I was “goin’ ta save lives today”. She was in grade school and thought that I was being funny in a silly way. Now that she’s in High School, I asked her if she remembered that departure tag line I used to use. She responded yes, and I explained to her that it was not just a silly thing that I’d say to her, but rather it was true. She mouthed the word silently, Wow.
I remember working the evening shift that ran until the, last new admit was out for delivery around midnight. We’d be processing a new admit order later in the evening and come across something that the prescriber had written earlier in the day and see that it was a major problem. I’d call the facility, explain the problem to the nurse, who was then supposed to cal the prescriber and get it straightened out. More often than not, the response was, “Dr. So-n-So told us to tell you that we were supposed to do whatever you (the pharmacist) told us to do and he’d sign off on it in the morning.” Now we’d (whichever of the evening shift pharmacists were on duty) always tell them what our “suggestion” was and remind them (the nurses) that we had no prescriptive authority and that they still needed to clear it with the prescriber before it was a legal order. We’d fax over the suggestion and after a bit, they’d fax the order back to us on an order sheet with writing at the bottom “T.O. – xxx, LVN/Dr. So-n-So” . That means Nurse xxx had been standing next to their fax machine, retrieved our suggestion, called Dr. So-n-So, read to him our suggestion, he had ok’d it, and the nurse had written the new order up and then dialed the fax machine and sent it to us. Did they actually call the prescriber and get a verbal authorization? I can only assume so. That I’m aware of, there were no bad outcomes with the patients and no complaints. We we’re a very competent, well trained crew and knew our stuff. Still, it gives me pause to think that the doc was willing to put his license on the line…and the nurse too if she really did not call the doc). We had received a valid order. All I can say is that God help you if you end up in a Skilled Nursing Facility (SNF).
Then there were the freshly minted Family Nurse Practitioners (FNP) that have prescriptive authority in my state. I don’t know how many times that I got a call for help from one of them They had no idea what to do for a particular patient and problem. I’d get as much data as I needed to make a competent clinical decision and “make my recommendation”. The order would come over from the facility with the FNP’s signature on it and the order verbatim to what I had suggested. It’s kinda scary to think what flies as OK in those places. I’m grateful that I spent a fair amount of my own time reading and studying the kinds of things that I needed to know in order to be able to write competent prescription orders. I did this so that I would recognize mistakes in the clinical judgement more readily. I never thought that we’d be prescribing de facto, yet that is exactly what we were doing. The authorized prescriber was signing off on it, but the only thinking process on their part, in a fair number of cases, was making sure to get the recommendation from pharmacy transcribed accurately onto the order. Again, no bad outcomes and the patient was cared for adequately. This is one area, SNF’s, that seems to not come up whenever I read these stories about medical errors and injury and death. We did a good job for our patients. I don’t know that every pharmacy and pharmacist could say this. I’m glad that I got out of that kind of practice setting a while ago.