Hospital Errors - Frightening and Maddening!

[Rumpus]

Latest medical scandal in the Boston newspapers:

Three pateients, two with the same surgeon, had back surgery. All three had the surgery performed at the wrong location. The surgeon and the assistant had different methods of counting the vertebrae.The errors were discovered when follow-up x-rays were done when the pateints complained of continuing pain.

Unfortunately, that is one of the most common surgical errors. Its not as easy to discern when the vertebrae is exposed and often even top surgeons make that error. I am guessing because it was at BI that it made the paper. Its known as an excellent institution.

 

[left210]

did you file a lawsuit?

We are looking at our options. Our biggest is concern is that this never happens again. The RT was fired from that hospital but is still working at another hospital doing the same thing. Also, we are fighting that the ICU dept go back to having a 24 hour monitor tech so that when alarms ring they are not tuned out. They used to have a 24 moniter tech but cut them out due to budget cuts and just the other nurses and staff all listen for them but not one person is responsible.

 

[KPeveler]

The last time I went to the ER they sent me home twice still with the presenting symptom, gave me the wrong med for the initial problem, and then finally had to admit me.

I found out two days later after the pain meds finally wore off that they had EVERY SINGLE ONE of my medications wrong. And I BROUGHT THE BOTTLES with me. I even watched them copy the names and doses into the computer (I could not see the computer screen). I found out they were giving me 1/4 of my seizure med! No wonder I had such problems!

Also, my doctor seriously hurt me due to complete ignorance of my current diagnosis (I have a chronic genetic illness) and then when I collapsed as a result of his injuring me, he did not even respond to the page.

I don't think the staff could have messed up much worse!

 

[Kellydelly]

Been a nurse for 26 years and have never worked in a hospital that has "protocols" based on a diagnosis code. If there is a protocol, the surgeon/doctor has to sign to initiate them and discontinue them. No protocol is started without a physician approval.

I agree, the surgeons and doctors write the orders, and the respiratory therapists and nurses, and aides carry them out! I think the surgeon/doctor dropped the ball, not the rest of the staff.

 

[DonkeyGreatness]

I agree, the surgeons and doctors write the orders, and the respiratory therapists and nurses, and aides carry them out! I think the surgeon/doctor dropped the ball, not the rest of the staff.

The surgeon wasn't the one who disregarded a patient's concerns and told them they were confused.

 

[lsyorke]

It sounds like the surgeon "signed off" on the orders without catching the error and the orders existed.

That's what I wanted pointed out. The surgeon being angry sounds great for him, but the reality is that HE is responsible for what is ordered and he didn't change the orders.

The therapist should have known the diagnosis.

 

[Luv Bunnies]

In thinking through the whole situation, the problem could certainly have been caused by the surgeon. Even if the staff entered the wrong diagnosis code, the surgeon should have caught it on one of his visits. And why were all of those breathing treatments ordered in the first place? I doubt we'll ever really know.

The worst part was my dad being labeled as confused and argumentative when he was simply pointing out the truth. I don't think any staff member should ever say that to a patient's face. That's what the surgeon was really ticked off about. And yes, he may have realized he made a mistake, but he was still rightly concerned about the way my dad was treated.

The good news is that my dad was able to spend Christmas at home and is feeling a little better each day. He has a retired nurse (my mom) to take care of him and he knows I'll go over there and get on his case if he doesn't follow her orders!

 

[teacherforhi]

Not as a serious as the OP's father, but when I had knee surgery this past June, every single person who came to me pre-op asked if I had any allergies. I told EVERY one of them I was allergic to two things: Ceclor and strawberries.

Guess what was on my first meal tray after surgery? They then had the nerve to tell me I hadn't told them. My mom went off on the director of food services. (I wasn't feeling up to it myself.) But in retrospect, thank goodness it wasn't a fatal allergy. Something like peanuts can turn up anywhere and aren't always obvious. At least I can see a strawberry and not eat it.

 

[ols386]

When my dad was in the hospital a couple of years ago, he was on oxygen (as he was on oxygen 24/7 for emphysema). We noticed that for some reason he was having even more trouble, than usual, breathing. Come to find out, the nurses were gradually turning down his oxygen as they thought he was to be weened off of the oxygen. Some how or another, there were orders on his chart to gradually ween him off of oxygen. The doctor said he never input that order onto the chart, but someone certainly did. We never did figure out how that happened. Dr/nurses may have known, but they sure didn't share it with us.

 

[Disney Doll]

Your dad can contact the medical records department of the hospital and request a copy of his entire chart. This would enable you to see who actually wrote/entered the order for weaning.

 

[ols386]

Your dad can contact the medical records department of the hospital and request a copy of his entire chart. This would enable you to see who actually wrote/entered the order for weaning.

Thanks for the info. He is since deceased (but not because of that incident or anything like that).

He actually was released from the hospital and moved to a rehab/nursing home facility not long after that, as insurance would no longer pay for hospitalization. We knew that he would not live for much longer as all of his medical problems (that he had been dealing with for 14 years) were mounting and it just became too much for him. He's at peace now.

 

[Rumpus]

That's what I wanted pointed out. The surgeon being angry sounds great for him, but the reality is that HE is responsible for what is ordered and he didn't change the orders.

The therapist should have known the diagnosis.

True. It was "ectomy" vs "otomy". Ironically, computerized medical records are supposed to prevent errors. If the post op diagnosis had been hand written, along with post op orders, it might have never happened. I can envision a code generating a list of particular orders for a particular physician of which he signs for. Unfortunately the code generated orders for the wrong surgery. Fortunately, the patient was over treated but wasn't given anything harmful, only his feelings were hurt.

 

[Disney Doll]

I an an RN and I work with the IT department and as a regular staff nurse at my hospital and one of the biggest battles we fight is reminding people that the computer does not take the place of critical thinking, being careful and paying attention to what you are doing.

Properly utilized, the computer can be a godsend. The orders entered are clear, concise and legible (no trying to figure out MD's chicken scratch anymore) but the onus is on the ordering MD/PA/APRN to choose the correct order or group of orders. The onus us secondarily on the nurses/therapists/pharmacists who check and/or carry out the orders to question anything that seems unusual and to step back and research if a patient says "This seems wrong" or "The dovtor told me this but you are doing that".

As a nurse, I can tell you that no one goes into work trying to injure or harm someone. It's not a goal of ours. Yes, there are bad healthcare people, just like there are bad teachers, lawyers, bankers, cops, firemen etc...but the majority of healthcare workers TRY to do good things for people. But we are human, and mistakes will be made and one just hopes that the mistake does not cause undue harm. It is pretty much every healthcare person's nightmare to harm a patient. Generally, when an error occurs, it is because a system boke down, not because a worker had decided to intentionally harm someone.

At my hospital, we are contantly looking at ways to improve systems so that we lessen the number of errors...in the past few years we have done a good job of using checklists etc. so that every person does the same process the same way (ie- a pre-operative checklist to make sure all aspects required to be in place prior to surgery are in place). Healthcare is taking a lot of cues from aviation, where there are very few errors despite being a high risk field.

I always get sad when our "human-ness" gets in the way of successfully helping a patient.

 

[bonoriffic]

I went in for stomach surgery. A nurse came into the waiting room and called for "Mr. Smith". Being a Mr. Smith who was to have surgery at that time, I stood up and followed her. She gave me a gown to change into and some sort of iodine gel and what looked like steel wool. She told me to cover my chest with the gel and scrub until it hurt. I got dressed but didn't like the look of that medical grade steel wool. I refused. Several back and forth with the nurse, and she finally said, "Sir, you are having heart surgery".

Turns out there was another Mr. Smith that day, who wasn't there yet. Good thing I questioned things.

Fast forward to recovery, and despite my meal order having the check box for surgical diet and listing what I couldn't have... I always got the wrong meal. It was quite cruel to know I couldn't have solid foods for weeks and the hospital kept giving me hamburgers.

 

[Rumpus]

I went in for stomach surgery. A nurse came into the waiting room and called for "Mr. Smith". Being a Mr. Smith who was to have surgery at that time, I stood up and followed her. She gave me a gown to change into and some sort of iodine gel and what looked like steel wool. She told me to cover my chest with the gel and scrub until it hurt. I got dressed but didn't like the look of that medical grade steel wool. I refused. Several back and forth with the nurse, and she finally said, "Sir, you are having heart surgery".

Turns out there was another Mr. Smith that day, who wasn't there yet. Good thing I questioned things.

Fast forward to recovery, and despite my meal order having the check box for surgical diet and listing what I couldn't have... I always got the wrong meal. It was quite cruel to know I couldn't have solid foods for weeks and the hospital kept giving me hamburgers.

I and my family members have had surgery in the recent past, and we have been asked by everyone that we interfaced with, our full names, DOB, and what we were having done so often that it almost became annoying. Better annoying than the wrong patient, but I think that hospitals and surgical facilities are bending over backwards to be sure that mistakes don't happen. The dietary department is another thing. The order can be sent correctly but they do seem to make more mistakes than other departments. Nurses cannot always check to be sure that the right patient is getting the right meal. Dietary hands out the trays.

 

[It'sWDW4me]

I had a friend who tried for 6 years to get pregnant. Her and her DH were thrilled when she finally was pregnant -- a miracle baby (as they said) because they had been through fertility without success.

Fast forward 4 or 5 months into the pregnancy. Friend goes in for routine ultrasound. Her DH had to work, so she went alone. OBGYN doc (not a tech, but actual doc) does the ultrasound and says there is no hearbeat & no movement. Checks again and says the baby passed away. Doc suggests she make an appointment to have a D&C done in two days. Friend and hubby are distraught.

The next day, friend says she still feels pregnant. No movement, but still had nausea (which she had throughout pregnancy). Calls doc and tells him. Doc says hormones are still in her body so she still has pregnancy symptoms.

The morning of the scheduled D&C, friend and hubby decide not to go to D&C appointment and instead go see another doc to get a second opinion. Second doc does ultrasound and baby is alive and well and heartbeat is strong. Friend finishes pregnancy and has a baby boy. She never was able to get pregnant again (this was 12 years ago). Imagine had she gone in for that D&C! My sister works in for a company that insures hospitals & doctors and says the machine tape from the D&C would have indicated that the fetus was alive, but they would probably not have said anything unless friend asked for the tape and had it evaluated.

This same thing happened to a coworker. Her now 8 yr old daughter was "dead" at three months gestation. Dr. wanted to perform the D&C right then and there. She and her DH got a second opinion, thank goodness.

 

[stinkerbelle's mom]

I posted earlier this week that my dad was having surgery to remove a benign tumor from his chest. Luckily, the surgery went well and he was able to go home yesterday. But, there was an incident in the hospital yesterday morning that was really scary when you consider what could have happened.

Kudos to your dad, glad he got it straightened out. Something similar happened to my mom. She was 74 then.

She is a diabetic and had to have lung surgery, they found a spot. Originally they were going to do a biopsy but the dr decided to remove the spot. Since she was a diabetic she was due to have the surgery early in the day, some emergency happened and they ended up pushing her back to late afternoon. So all day no eating or meds. When she finally had her surgery she was late getting to her room and they put her on a morphine pump for pain. I had somewhere to be that night so I got my brother to visit for a while-- my mom lives with me.

When she woke up she was very disoriented from the pain meds and not eating and kept getting sick. She didn't recognize my brother right away and kept calling him by my other bros name. That freaked him out. She kept trying to go back to sleep, but he was afraid to let her cuz he was afraid she wouldn't wake up. The nurse was assuring him she was fine, but because they didn't know my mother they assumed she had dementia. I had to get on the phone with the nurse to have her take all the meds off my mom, but ask her about an hour to a 1/2 hour before she was due meds if she wanted any. My mom refused all meds. The next day she woke up her normal self and the nurses couldn't believe she was the same person. It was a nightmare for my mom, she wanted me, my brother was "yelling" at her. When he left she couldn't remember our number and called our old number. Thankfully that's all behind us, but she know worries about being over medicated all the time.

 

[Bastiansmom]

My MIL (age 46) is kind of a "sickly" person. She has a lot of lung/ breathing issues, back pain, and can't take a lot of medicine for these problems because she gets nauseous easily.
About 6 weeks ago she went to the ER because she had been sick for over a week and was having a really hard time breathing. They did a CAT scan or MRI (not sure which, maybe it was both) that automatically sent the results to some group (outside the hospital) that was supposed to be able to give results very quickly. She waited for a little while and finally the doctor came back and they had the following conversation:

DR: It looks like you have pneumonia related to your HIV.
MIL: What?!?!?
DR: Pneumonia related to your HIV
MIL: Are you saying I have HIV?
DR: Yeah (said it kind of mockingly in a "duh" sort of way)
DR: Have you ever been tested?
MIL: Yes, in 1995
DR: Okay

Then the doctor left. Then nurses started coming in to give MIL all kinds of HIV/ AIDS literature. MIL had to sign documents saying she received all of this. She had to sign documents saying it was okay for them to bill her insurance and tell them the diagnosis. She kept asking to speak for the doctor and they kept telling her "Just a minute," but he never came. They finally admitted her into the hospital and left her there alone until the next morning.

The next morning a doctor came in (not her doctor, but one from her dr's office) and casually asked "So what are we going to do about this pneumonia?" She was really upset, had been up all night, alone, crying, and worried about what was ultimately her death sentence. She said, " I don't care about the pneumonia, I have HIV."

DR: Who told you that?
MIL: The doctor in the ER last night told me I have HIV.
DR: That was a mistake (he then starts reading over her chart again).
DR: I am so sorry. YOU DO NOT HAVE HIV. They should have never told you that, and if you did have it, that is not they way people should be told. You should not have been left alone.

Apparently, the type of pneumonia she had is mostly seen in HIV/ AIDS patients. However, a few people with compromised bronchial systems (COPD, emphysema, etc) can get it also. When the doctor in the ER saw it was this, he automatically ASSSUMED it was HIV related. When he asked her if she had been tested, he ASSUMED it was a positive (the test had been negative).
If he had taken more that 30 seconds with her, or read her chart (she had listed her lung issues on her admin form), she would not have been in agony for those 12 hours thinking she had HIV.

How cold can someone be?
I don't think this guy should be a doctor, or at least he should have contact with patients. I'm not in the medical profession, but shouldn't a second test be run before someone is given this type of diagnosis?

BTW, she is doing okay now.

 

[sparklynails23]

OP- Are you sure they didn't remove part of your dad's lung by mistake? Maybe that was the real error.

 

[wilderness01]

I an an RN and I work with the IT department and as a regular staff nurse at my hospital and one of the biggest battles we fight is reminding people that the computer does not take the place of critical thinking, being careful and paying attention to what you are doing.

Properly utilized, the computer can be a godsend. The orders entered are clear, concise and legible (no trying to figure out MD's chicken scratch anymore) but the onus is on the ordering MD/PA/APRN to choose the correct order or group of orders. The onus us secondarily on the nurses/therapists/pharmacists who check and/or carry out the orders to question anything that seems unusual and to step back and research if a patient says "This seems wrong" or "The dovtor told me this but you are doing that".

As a nurse, I can tell you that no one goes into work trying to injure or harm someone. It's not a goal of ours. Yes, there are bad healthcare people, just like there are bad teachers, lawyers, bankers, cops, firemen etc...but the majority of healthcare workers TRY to do good things for people. But we are human, and mistakes will be made and one just hopes that the mistake does not cause undue harm. It is pretty much every healthcare person's nightmare to harm a patient. Generally, when an error occurs, it is because a system boke down, not because a worker had decided to intentionally harm someone.

At my hospital, we are contantly looking at ways to improve systems so that we lessen the number of errors...in the past few years we have done a good job of using checklists etc. so that every person does the same process the same way (ie- a pre-operative checklist to make sure all aspects required to be in place prior to surgery are in place). Healthcare is taking a lot of cues from aviation, where there are very few errors despite being a high risk field.

I always get sad when our "human-ness" gets in the way of successfully helping a patient.

Nice post and spot on.

I think the real error was with the surgeon. He should have been reviewing his orders and writing updates in his progress notes. It is easy for him to be "so mad" that it makes him look good. Healthcare is a hard field and until someone walks in our shoes, they really don't know how it all works or how hard the field really is.

I just had two surgeries and honestly they couldn't have gone smoother. I also had many procedures done prior to the surgeries. Each time I was treated with diginity and everything that should have been done was.