Terra Sumstine, MDLinx | August 26, 2019
In today’s high-tech, patient-centered healthcare environment, with computerized patient records and charts, it’s hard to believe that medical mistakes are the third leading cause of death in the United States. Medical mistakes resulting in death can range from unrecognized operative complications to mix-ups involving the doses or types of medications patients receive.
Read on for some real-life examples of medical errors and their profound effects on patients and healthcare providers.
Medication mix-up
In March 2011, a 51-year-old Oregon man underwent cardiac bypass surgery, during which he was resuscitated after receiving cardioversion. The surgeon requested the patient be given 150 mg of amiodarone to stabilize the heart rhythm. The anesthesiologist administered three vials of medication, which he believed contained 50 mg each of amiodarone. However, due to an error at the hospital’s pharmacy, each vial actually contained 900 mg of amiodarone. The patient suffered permanent brain damage as a result of the overdose, and will require around-the-clock medical care for the rest of his life. The man received $12.2 million in damages.
Surgical errors
Rhode Island. In 2007, there were three reports of wrong-site brain surgery within less than 1 year at the same hospital—Rhode Island Hospital, a prestigious teaching hospital for Brown University. The operations were performed by an experienced brain surgeon, a doctor in training, and a chief resident; these errors occurred because the staff involved did not follow “Universal Protocol” to reduce medical errors.
In the first case, a third-year resident failed to mark the place where he was supposed to put a drain in the patient’s head. In the second case, a surgeon incorrectly marked which side of the patient’s head would be operated on for the removal of a blood clot. In the last case, the hospital’s chief neurosurgery resident cut into the patient’s scalp on the wrong side.
In the first two cases, the surgeon cut all the way through the patient’s skull, and in the third case, the surgeon stopped just after cutting into the scalp. In all three cases, the doctor closed the incorrect surgical site and then operated on the correct side. All the patients recovered from surgery; however, one patient died several weeks later from an unrelated cause.
After the third mistake was reported, the hospital was fined $50,000, ordered to improve procedures, and required to report to the state every instance in which a doctor does not follow the rules. The hospital also took unspecified corrective action against the staff involved in these incidents.
Minnesota. In another case of surgical-site error, a surgical team removed the wrong kidney from a patient with kidney cancer in 2008 at Methodist Hospital in St. Louis Park, MN. The mistake likely happened weeks before surgery when the wrong kidney was listed as cancerous on the patient’s medical chart, according to hospital officials. The hospital publicly announced the mistake, apologizing to the patient and family, and took corrective action. The patient’s health has not been disclosed, but state reports indicate that another surgery was attempted to remove the tumor and save the kidney. The urologist involved in the surgery received a reprimand and was restricted to outpatient or office-based procedures.
Michigan. In 2012, an 81-year-old woman died 2 months after receiving unnecessary brain surgery. The patient went to a hospital in Oakwood, MI, for jaw surgery to relieve pain due to temporomandibular joint (TMJ) disorder, where hospital staff incorrectly put her name on another patient’s medical scan records. The patient was then taken to an operating room where surgeons drilled five holes into her brain and removed the right side of her skull before the medical staff caught the error.
Following the incorrect procedure, the woman was placed on life support, and died shortly thereafter. The hospital did not disclose the mistake to the family or to the state of Michigan, only admitting to the error 2 years later during the lawsuit proceedings. The family was awarded $21 million in damages in 2015; however, this was overturned in July 2018, after an appeals court found that the lower court had allowed the jury to consider damages based on ordinary negligence instead of medical malpractice.
Iowa. In another case of unnecessary surgery, a pathologist mixed up tissue sample slides from two patients in January 2017, resulting in a central Iowa man receiving debilitating surgery for prostate cancer that he apparently never had. The pathologist said that the barcode scanner used to match patient slides with patient records inadvertently scanned a barcode from another patient’s form. The patient’s urologist read the pathology report, told the patient he had prostate cancer, and removed the prostate. Another pathologist examined tissue from the prostate after it was removed and found no evidence of cancer. The patient, having suffered from incontinence and other sequelae from the surgery, was awarded $12.25 million in damages.
Connecticut. In May 2015, a 60-year-old woman underwent surgery at Yale New Haven Hospital to have part of her eighth rib removed due to a painful precancerous lesion, but instead had her seventh rib removed in error. Radiologists had marked the eighth rib with metallic coils and dye to identify the surgical site; however, the wrong rib was still removed. When the patient complained of continuing pain after surgery, she had another x-ray that showed an intact eighth rib along with the metallic coils. The woman had a second surgery the same day to remove the correct rib. The patient sued the hospital, and the case was settled.
Tiny patients, big mistakes
Pregnancy mix-up. An IVF clinic in Los Angeles, CA, made an “unprecedented” mistake involving three families trying to conceive. The clinic implanted two embryos in a woman from New York. The woman and her husband are Korean American, so when she gave birth to two baby boys in March 2019, it was a shock when they discovered that neither was of Asian descent.
Through some detective work, the couple learned that the two babies did not share the same DNA: one of the babies belonged to a couple from California, while the other belonged to a different family, which has chosen to remain anonymous. After a legal hearing, the New York couple relinquished custody of both boys to their biological parents in May 2019, leaving the New York couple childless. Both couples are now suing the IVF clinic for malpractice.
Switched at birth. In June 2018, two women with the same last name gave birth at a local hospital in Logan, WV. While the babies were in the nursery, one of fathers, Arnold Perry, came to pick up his son. In the bassinet where he’d last seen his son was a baby, with the last name Perry marked on the card. Since the wrong room number was on the basket, he queried the nurse on duty. She told him that the boy was his son, and crossed out the room number listed, rewriting the new number with a Sharpie.
Later, when new mom Heather Perry went to the nursery to retrieve her son, she found him missing. Hospital staff then checked ID bracelets and determined that the infants had, indeed, been switched. Both babies were reunited with the correct parents, and no lawsuits have been filed.
Baby brain damage. In January 2005, a doctor administered what she thought was oxygen to a newborn who was having difficulty breathing. After 41 minutes, the mistake was caught, but the damage was done: the baby actually had been breathing in carbon dioxide. He suffered severe brain damage and now requires around-the-clock nursing care. He can feel pain and respond to his parents, but his life expectancy is believed to be less than 30 years. The family was awarded $16.5 million in damages.
Fatal toddler overdose. In February 2006, a toddler who had numerous surgeries and chemotherapy to treat a massive abdominal tumor was finally declared cancer free, but sadly died a few days later after an accidental IV overdose of sodium chloride. The doctors had encouraged the parents to complete the little girl’s last round of chemotherapy, but on the morning of the last day of her chemo session, a pharmacy technician mistakenly filled her IV bag with approximately 20 times the recommended dose of sodium chloride. The little girl fell subsequently fell into a coma and died 3 days later.
The case prompted a new state law that now requires all Ohio pharmacy technicians to pass a specific examination (previously, only a high school diploma was required). The case also resulted in jail time for the pharmacist who was supervising the pharmacy technician who made the error. Rather than sue, in 2008, the little girl’s father founded the Emily Jerry Foundation to focus on medication safety, better training for pharmacy technicians, and procedures to improve the healthcare system.
More than 250,000 people in the United States die every year from medical errors, according to experts from John Hopkins University School of Medicine, who published their findings in the BMJ.
In a corresponding open letter to the CDC, these authors urged the federal agency to add medical errors to its annual list reporting the top causes of US mortality: “We suggest that the CDC allow clinicians to list medical error as the cause of death, and, in the interim, the CDC should list medical error as the third most common cause of death in the US after heart disease (611,105 deaths per year) and cancer (584,881 deaths per year) and replacing respiratory disease (149,205 deaths per year).”
They added: “Appropriately recognizing the role of medical error in health care has enormous implications for medicine … Currently, deaths due to medical error result only in internal discussions in confidential forums such as a hospital’s internal root cause analysis committee or a department’s morbidity and mortality conference… Reducing costly medical errors is critical towards the important goal of creating a safer, more reliable health care system.”