medical error

got this from my mail box today.

It's every patient's worst nightmare. And every word of it is true.

Sixty-seven-year-old Joan Morris lay sleeping in her hospital bed,
recovering from brain surgery at one of the nation's most prestigious
academic medical centers. One floor below her, 77-year-old Jane Morrison
was also asleep, awaiting an invasive, somewhat risky cardiac procedure,
in which the heart is deliberately stopped and re-started.


By 9 a.m., due to 17 separate errors on the part of the medical staff,
Morris was the one on the operating table with a catheter in her heart
while Morrison, the intended patient, was still sleeping in her room.

So begins Chapter 1 of "Internal Bleeding; The Truth Behind America's
Terrifying Epidemic of Medical Mistakes," by doctors Robert M. Wachter and
Kaveh Shojania (Ruggedland publishing; 2004). Through gripping
storytelling and painstaking investigation, the book details the
circumstances behind 20 serious medical mistakes at U.S. hospitals,
getting to the heart of just why they happened, and offering some detailed
solutions on how to prevent more. Wachter's conclusion, after a year of
touring the country hearing from doctors and hospital administrators who
have read his book:

Mistakes are even more common than people think, and there is much work to
be done to quell the "epidemic."

"They say they've had every single one of the errors reported in the book,"
says Wachter, who will visit Boulder Tuesday to present a public lecture
on medical errors. "They are so incredibly ubiquitous."

Wachter became interested in the subject after the publication of the now-
famous 1999 Institute of Medicine report declaring that as many as 98,000
American hospital patients die annually due to medical mistakes. As a
physician at the University of California San Francisco Medical Center,
ranked one of the top 10 hospitals in the country, Wachter was no stranger
to those mistakes, and he believed they often had more to do with a
complete "systems failure" than the human failing of one individual.

"It struck me that too many patients were being harmed or dying even in
excellent hospitals," he says. "It became clear to me that we were not
approaching the problem the right way."

In writing the book, Wachter interviewed doctors, nurses and medical staff,
and pored over paperwork to dissect, down to the most minute detail, how
mistakes were made. Some accounts use real names of patients and
facilities; others omit them for privacy reasons. Among those discussed:

Willie King, a 51-year-old father of three from Tampa Florida went into
the hospital to have his right leg amputated due to complications from
diabetes. Doctors amputated his left.

Jesica Santillan, 17, died in 2003 at Duke Medical Center after receiving
a heart-lung transplant of the wrong blood type.

A 68-year-old woman was recovering nicely from elective cardiac bypass
surgery when she unexpectedly had a grand mal seizure, lapsed into a coma,
and died. It turned out the ICU nurse, instead of flushing the woman's IV
line with the blood-thinner Heparin, had given her a fatal dose of insulin.


A Texas man, whose doctor intended to prescribe 120 tablets of the heart
medication Isordil, instead received the much more powerful drug Plendil.
He suffered a massive heart attack and died.

After repeatedly setting off the metal detector while trying to board an
airplane, a woman returned to the hospital where she had recently had
stomach surgery to discover doctors had left a crowbar sized metal
instrument inside her.


Horrifying as such cases are, they can not be solved with the instinctive
act of blaming one person and firing them, Wachter says. Instead, in an
age when equipment, medication options, and staff structure is more
complex than ever, errors are almost to be expected, so stop-gaps must be
put in place to catch them before they do harm.

"Complexity has outstripped the ability of even incredibly bright, hard-
working, compassionate people to get it right all the time," he says.

The biggest challenge now, Wachter says, is "changing the culture" of
medicine, to make it easier for a receptionist or an orderly, for instance,
to speak up and tell a doctor when they believe they are making a mistake.
And for them to feel comfortable reporting even near-misses so that
systemic changes can be made to assure the mistake doesn't happen again.

Have things improved since the 1999 report? "I think we are doing a little
better," Wachter says. "Certainly we think about it and focus on it and
talk about it more than we once did." But no follow-up study has been done
so its hard to know for sure.

One thing he does know:

"We are still harming and killing too many people."

well, my personal experience is that
1. wrong medications being given,
2. baby swapping
3. needle in the baby back
4. skull fracture in new books