medical errors

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My Father, Your Mother/Child/Cousin? Medical Mistakes Affect Millions Nationwide

Betsy Lehman, a former Boston Globe health columnist, died as a result of a massive chemotherapy overdose. (Courtesy of the Lehman family)

Betsy Lehman, a Boston Globe health columnist, died 20 years ago as a result of a massive chemotherapy overdose given in error. (Courtesy of the Lehman family)

By Richard Knox

Some years back, my 78-year-old father suddenly collapsed with kidney and liver failure. He had no prior kidney or liver disease. Several doctors told us what happened.

The catastrophe was caused by his use of a medication called Pyridium for several months. It was prescribed to relieve bladder pain caused by radiotherapy treatments for Dad’s prostate cancer, which was localized and thought to be curable.

Albert L. Knox, late father of journalist Richard Knox, relaxing in New Hampshire in the mid-1980s. (Courtesy of Richard Knox)

Albert L. Knox, late father of journalist Richard Knox, relaxing in New Hampshire in the mid-1980s. (Courtesy of Richard Knox)

The package insert for Pyridium warns it shouldn’t be taken for longer than two days and elderly patients taking it should be monitored carefully for signs of liver and kidney failure. In Dad’s case, the prescription was renewed three times over a two-month period by two different doctors — who did not order any kidney or liver function tests.

It was a clearly avoidable error. “This has been an eye-opener to me,” one of his doctors told me during a conversation in the intensive care unit where Dad lay dying.

That was in 1989. Five years later, Boston Globe health columnist Betsy Lehman died of a chemotherapy overdose at Dana-Farber Cancer Institute — a medical error I documented extensively for the Globe. That tragedy, perhaps the nation’s iconic medical mistake, is credited with launching a national movement to prevent medical errors.

I’d like to think these kinds of preventable mistakes are a thing of the past. But new data from the Harvard School of Public Health, released this week, shows that’s not the case. The Harvard survey indicates that one in every four Massachusetts adults has experienced a medical mistake in the past five years, or is close to someone who has. Half of these have caused serious harm. That translates to hundreds of thousands of medical injuries in a state that prides itself on having the very best medical care.

“We do a staggering amount of harm every day.”
– Dr. Ashish Jha, Harvard

But there was also more promising medical-error news this week. Federal health officials reported a recent 17 percent reduction in “hospital-acquired conditions” such as infections, falls, trauma and bedsores. That’s 1.3 million fewer injuries and 50,000 fewer deaths since 2010, says Health and Human Services Secretary Sylvia Burwell.

Hospitals Are Killing Tens of Thousands Fewer People” was how the Washington Post billed it – a headline that managed to sound both cheerful and not-so-reassuring.

These are big numbers, on both sides of the ledger. So what’s the upshot? Do they mean American patients are safer than they were when Betsy Lehman died? Or at greater peril?

One thing’s clear: Whatever the exact numbers, they reflect a big problem that profoundly affects millions of American families.

Something like 1,000 Americans die of medical errors every day, according to one credible recent estimate. “We do a staggering amount of harm every day,” Dr. Ashish Jha of the Harvard School of Public Health testified last July at a U.S. Senate subcommittee hearing. John James of Patient Safety America, an advocacy group, recently estimated that 440,000 Americans die every year from such tragic mistakes. Nonfatal errors are 10 to 20 times more common, James says, which would mean something like 8 to 10 million medical mistakes a year.

That makes medical errors the nation’s third-leading cause of death, after heart disease and cancer, Vermont Sen. Bernie Sanders noted at last summer’s hearing.

“When you talk to people, it seems everyone has a story — everyone, whether it’s themselves, a family member, a friend,” says Barbara Fain, director of the Betsy Lehman Center for Patient Safety and Medical Error Reduction, a Massachusetts state agency whose name memorializes my Globe colleague.

Twenty years after her death, many are now asking if that movement has worked. The new federal numbers signal substantial progress toward safer care. But the new Harvard study — and a number of other recent studies — suggest that Americans are just as likely to suffer from medical errors as they were when Al Knox and Betsy Lehman died.

Which picture is right? Continue reading

After High-Profile Death, Medical Errors Still Harm Hundreds Of Thousands

Betsy Lehman, a former Boston Globe health columnist, died as a result of a massive chemotherapy overdose. (Courtesy of the Lehman family)

Betsy Lehman, a former Boston Globe health columnist, died as a result of a massive chemotherapy overdose. (Courtesy of the Distel-Lehman family)

By Richard Knox

Two decades after a Boston Globe reporter died from a preventable medical error in one of the nation’s top hospitals, hundreds of thousands of patients in Massachusetts are still suffering as a result of medical mistakes.

A new survey finds that one in every four Massachusetts adults reports a mistake in their own medical care or that of someone close to them over the past five years — a rate that translates to more than a million people. Half of them say they or someone close to them suffered serious harm as a result.

The numbers come from a study commissioned by the Betsy Lehman Center for Patient Safety and Medical Error Reduction. It’s a state agency named for the Globe health columnist who died as a result of a massive chemotherapy overdose 20 years ago Wednesday.

The Lehman Center launched a renewed effort to reduce medical errors at an event Tuesday at the John F. Kennedy Presidential Library. The center, a state agency, was founded in 2004 but closed its doors in 2009 for lack of funding.

But now the center is up and running again, with $900,000 in annual state funding derived from a tax on medical institutions and health insurers.

The arresting new numbers on the impact of medical mishaps come from a Harvard School of Public Health poll, one of several studies commissioned by the Lehman Center and released Tuesday.

“If you translate our poll findings into absolute lives and numbers, approximately 1.2 million people in the commonwealth either experienced a medical error or had someone close to them experience a medical error over the last five years,” says Robert Blendon, who conducted the survey.

Prevention Efforts Fall Short

Blendon says the results suggest about 600,000 people suffer “serious health consequences” as a result of medical errors. Half the respondents told the Harvard researches the errors involved misdiagnosis, while many also report they got the wrong operation, drug, dosage, test or treatment. Other frequent errors involve infections that occurred as the result of patient care, and wrong or unclear instructions about followup care.

It’s strong evidence, experts in patient safety say, that the national movement to prevent medical errors has fallen far short of its goals.

At the same time, federal health officials on Tuesday released new data that suggest the national rate of medical errors has begun to decline. The report, by the Department of Health and Human Services, says the declining rate means that 50,000 fewer Americans died because of medical errors between 2010 and 2013 than otherwise would have.

‘It Could Happen To Anyone’

Lehman’s fatal overdose, detailed in the Globe by this reporter, helped launch a national movement to prevent medical mistakes. It’s cited in the very first sentence of a landmark 1999 report on medical errors by the National Institute of Medicine.

“When Betsy died it came as a great shock to everyone that something like that could happen,” says Barbara Fain, executive director of the Lehman Center. “One of the lessons is that if this could happen to Betsy, it could happen to anyone.” Continue reading

Why I Left Medicine: A Burnt-Out Doctor’s Decision To Quit

By Diane Shannon
Guest Contributor

When I introduce myself as a physician who left clinical practice, non-physicians ask me why I left. They’re generally intrigued that someone who sacrificed many years and many dollars for medical training would then change her mind. But physicians, almost universally, never ask me why I left. Instead, they ask me how. They call and email me with logistical questions, wanting to learn the secret of how I managed the transition out of clinical medicine (read “escape”).

Earlier this month I attended a conference on physician well-being at the Massachusetts Medical Society where I heard an alarming statistic: the suicide rate among women physicians is more than two times that of women in the general population.

Diane Shannon, plagued by constant worry about patients, and fear of medical errors, gave up her career as a physician. (Courtesy)

Dr. Diane Shannon — plagued by constant worry about her patients and fear of medical errors — walked away from a career as a physician. (Courtesy)

It may be dramatic and self-serving to frame my career change as a way to avoid suicide, but I can attest that medicine was not conducive to my health. As an internist, working in adult outpatient clinics around Boston, I had trouble leaving my work at work. I’d go for a run and spend the entire 30 minutes wondering if I’d ordered the right diagnostic test. I suffered from chronic early morning wakening, even on my weekends off. I startled easily. I found it impossible to relax. I worried constantly that I’d make a mistake, like ordering the wrong dosage of a medication, or that a system flaw, like an abnormal lab report getting overlooked, would harm a patient. I no longer remembered the joy I’d felt when I first began medical school, and I couldn’t imagine surviving life as a doctor.

I no longer believe it was weakness or selfishness that led me to abandon clinical practice. I believe it was self-preservation. I knew I didn’t have the stamina and single-mindedness to try to provide high-quality, compassionate care within the existing environment. Perhaps, due to temperament or timing, I was less immune than others to the stresses of practicing medicine in a health care system that often seemed blind to humanness, both mine and my patients’.

That’s not to say that I don’t miss practicing medicine. I do. I miss engaging in meaningful interactions and being of service, reassuring an elderly woman that we could make her emphysema easier to endure, bearing witness to a cancer patient’s grace in the face of death, supporting a college student facing an unexpected pregnancy. I miss spending my days in deeply meaningful work. Continue reading

Please Discuss: Should Doctors Who Make Mistakes Be Punished?

A patient who had an operation made things very clear…” credit=”Ian Turton/Flickr CC

The latest “Invitation to a Dialogue” feature in The New York Times opinion pages stems from a question posed by the former chief of Beth Israel Deaconess Medical Center, Paul Levy. It begins:

The tendency to assign blame when mistakes occur is inimical to an environment in which we hope learning and improvement will take place. But there is some need to hold people accountable for egregious errors. Where’s the balance?

Read the full invitation here; brief responses are due by Thursday to letters@nytimes.com, and the dialogue will be published in the paper’s Sunday Review. If you send your response to the Times but it is not chosen, please consider sending it to us by clicking on “Get in touch” below, and we can post our own compilation.

My two cents: Doctors have incredibly hard jobs and when one messes up — makes an honest mistake of the type I described in this recent post on misdiagnosing ectopic pregnancy — I don’t think they should usually be punished. It’s a powerful argument that punishment will merely lead to cover-ups rather than improvement. However, from the patient’s perspective, I think I have the right to know about these errors, by name, and what disturbs me is that there is so little accessible information on the most important aspects of medical quality — including which doctors mess up more than others.

Readers? Background reading:
True Transparency: Doctors Who Admit Errors, And How To Help Them
Oops! Mass. General Surgeon Openly Admits Performing Wrong Surgery

Study: A Few Bad Apples Dominate Patient Complaints About Doctors

(Wikimedia Commons)

(Wikimedia Commons)

It’s tricky. Patients want to be able to shop for high-quality doctors — or at least avoid the bad ones — but the quality information they can access remains spotty at best, even in these days of Yelp and Angie’s List.

Here in Massachusetts, we also have the Massachusetts Health Quality Partners, which gather data on patient experience — as featured recently in the Consumer Reports ratings of physician practices in the state. But a recent Health Business Blog tour of the existing quality-shopping resources found it still coming up so short that the headline is “The still-early state of online doctor reviews.”

Of course, if we could all know more about the official complaints against doctors and hospitals — and not just the tiny trickle that end up being made public — that would certainly help. So here’s an interesting idea just out from the journal BMJ Quality and Safety: What if the first three complaints about a doctor could be kept confidential, but once the fourth rolled in, the patient concerns had to be made public?

Doctors named in a third complaint had a 38% chance of being named in another one within one year.

Here’s the rationale: a new study of Australian doctors found a striking phenomenon of “frequent fliers”: “Half of all formal patient complaints made in Australia to health ombudsmen concern just 3% of the country’s doctors, with 1% accounting for a quarter of all complaints,” it found.

Wouldn’t you love to know exactly which doctors comprise that 1 percent, especially when you’re in the market for a new one?
From the press release:

Doctors complained about more than three times are highly likely to be the subject of a further complaint – and often within a couple of years – the findings show.

The problem is unlikely to be confined to Australia, warn commentators, who point out that while regulators often know about these problem doctors, patients usually don’t.

The researchers base their findings on a national sample of almost 19,000 formal patient complaints filed against 11,148 doctors with health service ombudsmen (commissions) across Australia between 2000 and 2011.

Over 60% (61%) of the complaints concerned clinical aspects of care, while almost one in four (23%) concerned communication issues, including the doctor’s attitude and the quality or quantity of information provided.

Most (79%) of the doctors involved in complaints were men, and over half of all those complained about (54%) were aged between 36 and 55.

When the distribution of complaints was analysed across all doctors in practice, this showed that 3% of practitioners accounted for 49% of all complaints made; and 1% accounted for a quarter. Continue reading

Hospital Chief On Apology To James Woods For Brother’s ER Death

The news is nearly two years old, that Kent Hospital in Warwick, R.I. settled a suit by actor James Woods over his 49-year-old brother’s Emergency Room death.

But it is still quite something to hear the hospital chief involved, Sandra Coletta, say out loud before an audience of hundreds that she apologized for what happened and that “Quite honestly, I did nothing other than what my mother taught me.”

The issue of medical apologies is particularly relevant right now in Massachusetts, where the next wave of health reform is expected to include legal changes to help spur more of them.

Coletta spoke in Boston last night at the 10th annual dinner of MITSS, Medically Induced Trama Support Services, a widely respected group that aims to support patients, families, and staffs after things go medically wrong.

‘I can’t tell you how to say you’re sorry. I can just tell you to do what feels right in your heart.’

Things went very wrong with James Woods’ brother, Michael, at Kent Hospital. According to news reports, Michael died of a heart attack while waiting in the emergency room, having come in for vomiting and a sore throat. The Associated Press reported in 2009:

The hospital’s chief executive, Sandra Coletta, acknowledged at a news conference with Woods outside court that mistakes were made. She said the hospital is creating an institute in Michael Woods’ honor and investing $1.25 million over the next five years to study redesigning health care and reducing errors.

Actor James Woods during the trial over his brother's death

Coletta provided an update on the hospital’s changes last night, but she also offered a window into the emotional side of the incident. She was new to her Kent Hospital CEO job when she heard of the Woods suit, she said. When she listened in on the trial, she “found out that we hadn’t done everything correctly. We had had a system failure. We had not followed a physician’s order.” But how could the hospital settle the case, without even defending itself?

“I remember saying to someone, ‘The only way I could ever settle this case is if Jimmy would stand with me and agree to change this hospital for the better. If we could combine our efforts and take the pain that he and his family had endured, and join it with us to improve the care of patients going forward. Then we could settle.’

So we asked if he would meet with us. And I met with him. And that’s really where all the headlines come: ‘She said she was sorry!’ Quite honestly I did nothing other than what my mother taught me. I think all too often in health care we evaluate, and we are counseled, and we read books upon books. But sometimes you just have to go back to your core value.

I faced a man who had lost his brother, a brother he had raised in the absence of a father. A brother who cared for an elderly mother while he was out doing his career. Someone who was very dear and close to his heart. When I met that man, I did not meet ‘James Woods.’ I met a family member who had lost a brother, because an order that was written by our emergency physician was not carried out by the staff.

‘Either you are a better actress than I am an actor, or I’m going to be coming after you.’

We did settle the case and we established the Michael J. Woods Institute, and the purpose of the institute is to redesign health care from a human factors perspective… Continue reading

What We Can All Learn From Michael Jackson’s Doctor

By Ken Farbstein
Guest blogger

Michael Jackson had what most of us think we want: Utterly personal attention from a dedicated doctor, on call all the time for him alone.

That doctor, Conrad Murray, is now on trial for manslaughter (see reports here and here) though no one thinks Michael’s death from an overdose of the anesthetic Propofol was deliberate. By all accounts, the treatment that Michael received was anything but normal or typical, but is there anything that typical patients can learn from what went wrong?

Hindsight is 20/20. Clearly, doctors shouldn’t administer Propofol on their own. This case is unique. But as a patient advocate, I try to learn from every medical error, and to extract useful guidance that patients can act on in the moment. The lessons of Michael’s death have little to do with Propofol. Much remains unclear about exactly what happened, but I see three key lessons:

•Don’t assume information about your medications has been communicated from one doctor to another.
•Keep an updated medication list.
•Get a family member or professional patient advocate to help oversee your care.

The story of Michael Jackson’s death is explored in my book, Getting Your Best Health Care:  Real-World Stories of Patient Empowerment, among case studies of other celebrities.  In particular, I examine more fully the role of his medical team. The conflicting accounts this week by the prosecutor, defense lawyer, and early witnesses make it hard to know the whole truth at this time, but useful lessons are already emerging.

‘For the doctor to proceed then without a professional assistant, a cogent patient, or a computer was like a groggy pilot flying at night with no co-pilot or flight instrument panel: flying blind.’

 

Poor communication among medical personnel

Michael’s primary care provider reportedly communicated some critical information poorly. When emergency medical technicians arrived to try to revive Michael, his primary care doctor did not inform them that he had given Propofol to Michael, according to the prosecutor.  That may have affected the way the EMTs tried to revive him.

Flumazenil was used to reverse the effects of benzodiazepines like the Lorazepam that Michael had been taking.  Miscommunication may have led the EMTs to administer the Flumazenil in a misdirected effort to counteract the effects of the Lorazepam.

The patient’s role Continue reading

True Transparency: Doctors Who Admit Errors, And How To Help Them

A patient who had a different operation made things very clear...


It’s easy to be snarky. I confess that when I posted this story last November about a Mass. General surgeon who admitted performing the wrong operation on a patient and analyzed why, my headline began “Oops!” But the truth is, of course, its incredibly courageous of doctors to admit their mistakes publicly, to break the medical omerta.

The topic is timely today because of a new Harvard study finding that most doctors will face a malpractice lawsuit at some point — and interesting work under way in Massachusetts to encourage medical apologies. The Patrick administration, too, supports making admissions and apologies easier. And the American Medical Association’s amednews.com has just posted an inspiring piece on three doctors who came clean before their colleagues, including Mass. General’s Dr. David C. Ring and Dr. Jo Shapiro of Brigham & Women’s.

The piece begins with a heartbreaking story of a Seattle nurse whose dosage miscalculation led to a baby’s death — and to her own suicide. (A recent study found that doctors have about double the usual suicide rate to begin with, and major medical mistakes triple their suicide risk, amednews reports.) And the piece ends with some of the efforts, in Boston and elsewhere, to help medical staffers who have made errors:

Supporting physicians when things go wrong

Few physicians talk publicly about their medical errors, but a growing number are benefiting from programs dedicated to helping doctors deal with the emotional turmoil that often comes in the wake of adverse events.

Jo Shapiro, MD, helped start the Center for Professionalism & Peer Support at Boston’s Brigham and Women’s Hospital in October 2008. There are 55 physicians and other health professionals at the hospital trained to offer emotional support to peers involved in cases of patient harm.

“When there’s any kind of adverse event that we hear about, one of us will make an outreach call to the physician involved,” Dr. Shapiro says. “We ask them simple questions like, ‘How are you doing? How are you feeling? Is there anything I can do to help you?’ ”

Continue reading

Lawmakers Approve Bill To Reduce Medical Errors

It’s hard to vote against patient safety, so it’s not a huge surprise that a bill to reduce medical errors and boost patient safety passed unanimously out of a public health committee today. Still, it’s worth noting here, via press release:

The Joint Committee on Public Health voted unanimously in favor of House Bill 1519, “An act reducing medical errors and improving patient safety” today. Sponsored by Representative Jeffrey Sánchez, co-chair of the Committee, the bill addresses systemic issues that affect patient safety by encouraging honest, open communication and evaluation of care among health care providers.

“As the dialogue about payment reform in Massachusetts moves toward basing payment on value and not volume, these issues of patient safety and quality become even more important,” Sánchez said. “We need to find the right balance so that the coordination, efficiency, and quality of health care can all be improved in this process.”

House 1519 requires the development of preventive measures to reduce avoidable errors, healthcare associated infections and other unanticipated health outcomes; requires the development of screening procedures for multidrug-resistant organisms, including MRSA; provides whistleblower protection to any person who assists in a complaint with the Board of Registration in Nursing; expands medical peer review laws to any committee formed to perform duties of a medical peer review committee, regardless of whether the committee has an affiliation with a specific hospital, nursing home, or HMO; and requires the study of the impacts of medication errors as well as medical overutilization of services, including the practice of defensive medicine in the Commonwealth. Continue reading

Rep. Jeffrey Sanchez: Make Massachusetts Patients Safer

Rep. Jeffrey Sanchez


This Tuesday, the Massachusetts legislature’s Joint Committee on Public Health is slated to hold a hearing on 33 — count ‘em, 33 — proposed bills on patient safety and quality of care. (The agenda is here.) Here, Rep. Jeffrey Sánchez, the joint committee’s House chair, writes a guest post about his own legislative offering, to be heard at the hearing along with the others.

(CommonHealth welcomes guest posts on health care topics of broad public interest. To inquire about submitting one, please click on the “Get in Touch” button below.)

In Massachusetts, we’re surrounded by some of the best health care institutions and practitioners in the world and don’t typically think patient safety is an area that needs to be addressed. But unfortunately, accidents happen.

Back in 1999, the Institute of Medicine released an eye-opening study, “To Err is Human,” which found that nearly 100,000 people die every year in the United States due to medical errors. As the report’s title suggests, these errors aren’t malicious or intentional; they are often a result of systems or a culture that make it too easy for mistakes to occur. We need to encourage systems that make it difficult, if not impossible, to make an error.

Another area that must be addressed in order to improve patient safety is the rate of health-care-associated infections. Each year in the Commonwealth, there are about 34,000 such infections. In addition to delaying recoveries and affecting quality of life, these infections have a significant financial impact, costing the Commonwealth between $200 and $400 million annually.

There are shining examples right here in Massachusetts of the type of systemic changes that are necessary to address these patient safety issues. Dr. Atul Gawande, a surgeon at Brigham and Women’s Hospital, was part of a team that developed a simple two-minute checklist for use in surgery that has seen a drop in deaths and complications of an astounding 36%. New England Baptist Hospital instituted a program to screen and treat patients for MRSA (methicillin-resistant staph) and ended up reducing all surgical site infections by almost 60%. The Massachusetts Hospital Association and the Massachusetts Coalition for the Prevention of Medical Errors are also working together to reduce the number of central line-associated blood stream infections.

These types of initiatives should be implemented across the Commonwealth. To do so, I have filed House Bill 1519, An Act reducing medical errors and improving patient safety. This bill, which is among those to be heard on Tuesday, includes: Continue reading