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Patients who have suffered injury are encouraged to talk with their doctor to seek any needed follow-up care or additional health recommendations.

By Kevin Kunzmann & Jenna Payesko, MD Magazine.

Submerged between the pool walls, he learned to quiet his racing mind, harness the power of every cell in his thrashing arms and legs, and wring out every last ounce of energy that his racing heartbeat through his body. He was an athlete coming into his own, and quickly grew into a young man who could fly past his father in long-distance runs while sporting a smile.

In college, Alex channeled that drive towards the Air Force Reserve Officer Training Corps (ROTC) program at Baylor University. He was getting stronger by the day and became hell-bent on reaching the ranks of an Airman like it was the next pool wall. So when he collapsed in the middle of a run in the dry Texas heat one August day, his family was alarmed. For 5 days, his father, John T. James, Ph.D., sat by his bedside at a local hospital as his son endured test after test.

He received a cardiac MRI, a cardiac catheterization, an exercise stress test, and an electrophysiology test. Some of the tests caused Alex to develop a painful hematoma. One even left him bleeding from the groin. The attending cardiologist, an older man, cleared and released him after 5 days. His instructions in discharge papers were few—simply avoid driving for 24 hours.

With no one to tell him otherwise, Alex ran again on September 15, 2002. He collapsed again, but this time paramedics had to defibrillate him 3 times to restart his heart. He fell into a coma, and within 3 days, the driven, promising young athlete was dead.

James sat by his bedside, as any parent would, and wondered how this could happen. The then-chief toxicologist for the National Aeronautics & Space Administration (NASA) has a doctorate in pathology from the University of Maryland School of Medicine. He understood the procedures his son went through and set out to learn where they had gone wrong.

James told MD Magazine the details surrounding Alex’s death spurred physicians to suggest that his 2 surviving sons be tested for genetic conditions. Because of that, James worked his way into receiving Alex’s full medical records from his first collapsing incident. He pored over them, running notes by the responsible physicians and asking them about the reasoning behind their clinical decision making. He performed a cross-analysis — finding entries in Alex’s ROTC journal about persistent leg cramps from that summer, which implied he was suffering from dehydration.

James was sure that something just wasn’t adding up. Alex’s lead cardiologist never prescribed him a potassium replacement. In fact, his disregard for the low potassium levels meant the cardiac catheterization was unnecessary. A radiologist told James the cardiac MRI was conducted by technicians who were unsure of proper operating procedures for the machine’s new software. Moreover, the cardiologists had failed to diagnose Alex with an acquired heart rhythm condition, despite the fact that he had clearly scored well above the threshold for diagnosis. And atop these series of mistakes, James couldn’t find a single note suggesting that Alex should avoid exercise during his recovery.

“If he was effectively discharged and told not to run, I believe he’d be alive today,” James said.

The ‘if’s of medical errors are an insurmountable amalgamation of clinical anomalies: a physician doesn’t treat for potassium levels, a nurse administers therapy to the wrong patient, a technician doesn’t check for pre-existing conditions prior to a test. They are standout lapses in health care system efficiency, amplified by their repercussions and the efforts of those like James to bring them to light.

The conversation surrounding medical errors is typically limited to their extraordinary cost implications, both in terms of hospital budgets and human lives. There’s no doubt that understanding their burden is important, but efforts to prevent medical errors before they happen is a more ambitious and noble goal.

The Third-Most What?

One statistic has become famous among health care professionals in just 2 short years. A 2016 analysis of death rate data from an 8-year period by researchers at Johns Hopkins Medicine found 251,454 annual deaths in the US were the result of medical errors. By that count, it surpasses all but the nation’s 2 leading causes of death—heart disease and cancer—according to the Centers for Disease Control and Prevention (CDC).

It’s easy enough to say that medical errors are the third leading cause of death— several physicians have uttered the phrase in previous interviews with MD Magazine. And the fact remains that the Johns Hopkins study was pivotal because it answered a long sought after question about the frequency of medical error involvement in patient deaths. However, the CDC, which compiles an authoritative list of the most common causes of death in the US annually, is limited by its reliance on the International Classification of Disease (ICD) code. The ICD does not account for human and system factors in its mortality reports, and as a result, there is no federal metric for medical errors’ death toll.

Researchers worked to improve on the landmark former Institute of Medicine (IOM) report on errors in health care in 1999, in which the organization concluded that 44,000-98,000 annual deaths were caused by medical errors. In the years following the IOM report, multiple studies pushed that projected total up to 130,000-575,000 annual inpatient deaths caused by medical errors. The Johns Hopkins study had refined the results of 4 such studies to arrive at their estimates.

Still, clinicians have publicly argued that the numbers are what they are—estimates. Aaron E. Carroll, MD, a professor of pediatrics at Indiana University School of Medicine and a columnist for the New York Times, called the 2016 study results “more controversial than you think.” He noted that, of the 2.5 million annual deaths in the US, about 700,000 are hospitalized patients. If medical errors were accountable for 251,454 hospitalized patient deaths annually, then more than a third of all deaths at US hospitals are due to errors.

Carroll reasoned that even the best researchers are facing complex factors when trying to track which events cause death — and which are just correlated with death. “When someone dies in a car accident, it’s clear what caused the death,” Carroll wrote. “Same for a drug overdose, homicide or suicide. But when an 86-year-old with dementia and cancer dies and also had been given a drug in a slightly-too-high dose a few weeks earlier, is it the error that killed her or the underlying disease and age?”

In an interview with MD Magazine in May 2017, Tatsiana Singh, MPAS, PA-C, countered that the numbers that call medical errors the third leading cause of death are “gross underestimates,” because the majority of studies are based on medical chart review. “And that’s missing the fact that a lot of medical errors and mishaps do not get documented and never make it into the patients’ charts, and really are never detected,” Singh said.

Singh, a clinician at the Indiana State University Sycamore Center for Wellness, cited research showing that anywhere from 10% to 30% of autopsies find misdiagnoses. This alone does not include instances of incorrect surgical operations, delayed diagnoses, and miscommunication between different attending health care workers.

James, who published his own evidence-based estimate of hospital care’s association with patient harm in 2013, agreed the “third-leading cause of death” label is the incorrect way to measure the issue. He’s of the opinion that adverse events are common in hospitalized patients who are already very ill, and their deaths could be attributed to both their diseases and the incomplete care they received.

James’ study concluded that an estimated 210,000 preventable adverse events occur annually that at least contribute to the death of a hospitalized patient — a rate of approximately 1% of all deaths. A physician wrote to James shortly after reading the study, and asked if he really thought the rate could improve to better than just 1%.

“He’s got a point. It’s not going be easy to improve,” James said. “But it can be done.”

Airing Out Errors

In hindsight, James wished he followed the feeling in his gut. When his son was hospitalized, he was immediately skeptical of the facility. He was uncertain of the lead cardiologist’s capabilities too, and was later vindicated when he discovered the older physician had been grandfathered into an outdated standard of board certification that absolved him from having to earn continuing education credits.

The last email the cardiologist sent to James was a list of potassium-rich foods he believed his son would like. He remained respectfully skeptical, but now regrets holding onto his doubts. “I hate to tell people to be mistrusting of their doctor, but you have to be smart about your care,” James said. “You need to make sure your doctor treats you as part of a team.”

To ensure they’re doing their part to prevent medical errors, physicians must engage with individual patients, James said. He pointed to clues in Alex’s health history — his diet, his level of fitness — that would have indicated a diagnosis different from the one he was given. He believes physicians could benefit greatly from allocating more resources to learning a patient’s background. “Patients need to be better educated and treated equally, and doctors need to treat them as a partner in their care, and not try to just convince them on a therapy,” he said.

James has become a leading advocate for improved patient rights. He emphasized that a patient’s medical information should be more fully and immediately available, and that more focus needs to be placed on educating patients on their wellness and any means by which they’re treated. His organization Patient Safety America backs legislation supporting these changes, and his monthly newsletter to about 600 people — many of which are physicians — educates the public on recent clinical developments and how they could affect patients.

Much of his message is pro-communication and pro-transparency, both between physicians and patients, and between at-fault health care providers and their administration. He likened an ideal medical error reporting system to that practiced by the Federal Aviation Administration: aggressive in both finding the error and publishing it to ensure it doesn’t occur again.

Some find the issue to be that such transparency is taboo in US health care. Anthony Montgomery, PhD, associate professor of Work and Organizational Psychology at the University of Macedonia, told MD Magazine that learning in the medical field is akin to “treading in the deep end.” Medical students are immediately introduced to a culture that “doesn’t like mistakes, doesn’t like to admit there are mistakes, and doesn’t like errors.”

Kevin R. Campbell, MD, told MD Magazine at the time of the 2016 study that the very nature of “transition of care” enables the most common medical errors. Combined with the shortcomings of electronic medical record (EMR) programming, errors are the byproduct of an incomplete system. “System errors are the most common type of errors – these occur when the care systems and algorithms that are created within and between institutions are non-standardized and based on regional preferences,” Campbell said. “These inconsistencies can result in gaps in care. Safety measures and protocols are often inadequate to prevent error.”

To better alleviate EMR inconsistencies and remove outlying incentives in the payer-run system, James advocates for the implementation of a single-payer system. He said he empathizes with burdened physicians stretched thin with loads of administrative tasks, and hopes a simplified process could bring the medical error rate below 1%.

“Patients, physicians, and nurses need to get together and say we’ve had enough of how this is being done in this country,” James said. “We’ve got a lower life expectancy than others, and we’re spending too much money. It’s got to stop, but it’s going take clinicians coming together and getting legislators on the same page as them.”

APRIL 12, 2018

“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 asked, doctors, nurses, and pharmacists 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.

I was the nurse in charge of the evening shift at a small hospital. I was enthusiastic and experienced—a top graduate of a prominent nursing school. I had come on duty at 3 p.m. and met 85-year-old Mrs. Owen,* who had been admitted by Dr. X, her longtime family physician, because she had a suspected bowel obstruction. She was alone.

Around 5:30, her condition worsened dramatically. She was in increasing pain, and I became convinced she needed emergency surgery—obstructions can be deadly. I called Dr. X at home immediately. He was a highly regarded doctor, and his photo was displayed in the lobby along with those of the hospital’s other physicians. I passed it every day on my way to work.

But despite my concern, Dr. X said surgery could wait until the morning. He told me to increase her pain medication, but the drugs didn’t help, nor did anything else I tried.

Over the next five hours, I called Dr. X three more times, asking that he come to see her or at least call in a consulting physician. I always got the same instructions delivered in an ever more irritated way. And because nurses never questioned doctors, I bit my lip and followed orders.

Toward the end of my shift, Mrs. Owen was so weakened by her pain she could barely speak. She motioned me over to her bed and whispered, “When is my doctor coming?”

“Soon,” I lied.

That word has echoed in my head for quite some time. Mrs. Owen died the next morning. Whether she had a heart attack, stroke, or ruptured colon, we’ll never know, because an autopsy was never ordered. Dr. X completed the paperwork just as if he’d done everything right, and no one questioned him.

I could have, though. I could have submitted a report, carefully documented and supported by my supervising nurse. But I didn’t. Challenging a doctor may not get a nurse fired, but it’ll often get her or him publicly chastised, reassigned to a different floor, or moved to the graveyard shift. I’d seen it happen.

After Mrs. Owen died, I could no longer stand to look at Dr. X’s photo in the lobby. But this is more than a complaint against one man—bullying and disrespect occur every day in every hospital throughout America. Most of the time the behavior is petty and hurts only the workers involved, but sometimes, as I witnessed firsthand, it can take the life of an innocent person.

As nurses’ unions have been saying for many years, hospital patient-to-nurse ratios sometimes get too high to keep people safe. We don’t have a shortage of nurses, though, just a shortage of nurses who are willing to work under current hospital conditions. More respect will bring them back.

We also need whistle-blower protections to safeguard nurses who speak up for the safety of patients. If I had had such assurances of protection and support, I wouldn’t have thought twice about challenging Dr. X.

Each nurse must take it upon herself or himself to stand up to and report physician intimidation and abuse. Nurses are not second-class citizens in the health care system. In fact, in the increasingly busy and sometimes heartless hospital world, we are the patient’s primary protector.

—Sunnie Bell, RN, is a Certified Diabetes Educator and was National Diabetes Educator of the Year in 1995.

I’ll never forget her—in fact, I still have dreams about the look on her children’s faces after she died. Her name was Claire,* and she came into the ER where I was working as an emergency physician. She had an old neck collar on upside down and was complaining of neck pain and a bad headache. She was about 60 years old, and I thought she might have a mental handicap because she had difficulty describing her symptoms. Her son and daughter were with her, and they also seemed a bit slow.

This ER was always busy, and the administration had been pressuring us to move patients through more quickly. I examined Claire briefly and saw no obvious worrisome signs. X-rays of her neck showed nothing wrong; I assumed she had slept wrong or pulled a muscle. So I discharged her with some pain medication and picked up the next chart in the bottomless stack.

The next morning we received a call from an ambulance transporting a female who had suffered cardiac arrest. She was brought into the resuscitation room, where we continued CPR. I didn’t recognize her at first, but then I noticed a familiar-looking son and daughter sobbing in the hallway. I looked at the lifeless patient and almost broke into tears myself. In my rush the day before, I hadn’t listened carefully to Claire’s complaint of severe headache. Now it seemed clear to me that I’d overlooked a symptom of an impending stroke.

We did everything we could, but I knew our efforts were hopeless.

After I pronounced her dead, I met her son and daughter in the small chapel near the emergency department. I started to explain—in way too technical terms—what happened. Then I paused, and tears came to my eyes.

“I’m so sorry,” I said. “I wish I had ordered a CT scan yesterday. I must have missed something. I’m so sorry.”

“That’s okay,” Claire’s daughter replied. “We know you did your best. Mom said you were a good doctor.”

I couldn’t stop my tears now.

A few days later, I went to the funeral, where I sat with Claire’s children. Even though 20 years have passed and I’m now a medical-school professor, I haven’t forgotten. I try to impress upon physicians-in-training that medicine is more than using advanced technology to move an endless flow of patients.

Every person in the exam room, regardless of social status, is a human with a family, and our duty is to act in that person’s best interest—not in the best interests of insurance companies and hospital administrators, the way I did.

We also need to ease the burden on the ER. Between 1997 and 2006, emergency department visits increased by 32 percent, while reimbursement to hospitals hasn’t kept up. We need more retail health clinics and urgent-care centers. And we need to educate people so they trust these new clinics and use them for all but the direst emergencies.

Until these things occur or other solutions are found, unfortunately what happened to Claire will happen again—and again.

—Bryan E. Bledsoe, DO, is a clinical professor of emergency medicine at the University of Nevada School of Medicine in Las Vegas.

The above story was originally published by Readers Digest.

I was a second-year medical student at the University of Pennsylvania, and on my second day of rounds at a nearby VA hospital. Penn’s philosophy was to get students seeing patients early in their education. Nice idea, but it overlooked one detail: Second-year students know next to nothing about medicine.

Assigned to my team that day was an attending—a senior faculty member who was there mostly to make patients feel they weren’t in the hands of amateurs. Many attendings were researchers who didn’t have much recent hospital experience. Mine was actually an arthritis specialist. Also along was a resident (the real boss, with a staggering mastery of medicine, at least to a rookie like myself). In addition, there were two interns. These guys were just as green as I was, but in a scarier way: They had recently graduated med school, so they were technically MDs.

I began the day at 6:30 a.m. with a “pre-round,” a reconnaissance mission in which an intern and I did a quick once-over of our eight patients; later, we were to present our findings to the resident and then to the attending. I had three patients and the intern had the other five—piece of cake.

But when I arrived in the room of 71-year-old Mr. Adams,* he was sitting up in bed, sweating profusely and panting. He’d just had a hip operation and looked terrible. I listened to his lungs with my stethoscope, but they sounded clear. Next I checked the log of his vital signs and saw that his respiration and heart rate had been climbing, but his temperature was steady. It didn’t seem like heart failure, nor did it appear to be pneumonia. So I asked Mr. Adams what he thought was going on.

“It’s really hot in here, Doc,” he replied.

So I attributed his condition to the stuffy room and told him the rest of the team would return in a few hours. He smiled gamely and feebly waved goodbye.

At 8:40 a.m., during our team meeting, “Code Blue Room 307! Code Blue 307!” blared from the loudspeaker.

I froze.

That was Mr. Adams’s room.

When we arrived, he was motionless. The resident immediately began CPR while yelling: “Wachter! What did he look like this morning?”

I stammered, then lied: “He was a tiny bit short of breath, but he was okay.”

The autopsy later found Mr. Adams had suffered a massive pulmonary embolism. A blood clot had formed in his leg, worked its way to his lungs, and cut his breathing capacity in half. His symptoms had been textbook: heavy perspiration and shortness of breath despite clear lungs, with the right interval between his major hip surgery and the onset of respiratory problems. The only thing was, I hadn’t read that chapter in the textbook yet. And I was too scared, insecure, and proud to ask a real doctor for help.

This mistake has haunted me for nearly 30 years, but what’s particularly frustrating is that the same medical education system persists. Who knows how many people have died or suffered harm at the hands of students as naive as I, and how many more will? What’s needed is this:

Students and residents should participate in teamwork training, just like commercial airline pilots do. Such training stresses the importance of speaking up when they see something they don’t understand.

What’s more, before they start working on the wards, students should do exercises with computers or actors to help them better recognize the symptoms of common clinical syndromes.

Finally, attending physicians should be up-to-date in-hospital care, and should have undergone special training to help them balance the amount of supervision needed for patient safety with the graded independence that will help trainees become practitioners.

—Robert M. Wachter, MD, is associate chairman of the Department of Medicine at the University of California, San Francisco, and author of a blog and six books on health safety and policy, including Internal Bleeding, from which this story is adapted.

The above story was originally published by Readers Digest.

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.

*Names changed to protect privacy.

The above story was originally published by Readers Digest.