Medical Error

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Miscommunication A Major Cause of Medical Error, Study Shows

(Getty Images)

(Getty Images)

By Irene Noguchi

It seems almost unbelievable, but medical errors may be the third leading cause of death in America, after heart disease and cancer. That’s according to an analysis from Journal of Patient Safety. Could the key to change be in better communication? A new study from UC San Francisco and eight other institutions, says yes. Researchers found that improving communication between health providers can reduce patient injuries from medical errors by 30 percent.

The team found that a highly risky period was when patients are transferred or “handed off” between medical providers. Critical information gets passed between doctors, nurses and pharmacists.

When there’s a shift change or a patient moves to another hospital, “there’s an opportunity for communication failure,” says Daniel West, professor of pediatrics and vice-chair at UCSF Benioff Children’s Hospital. Continue reading

Rarely Mentioned Medical Mistake: Patients Harmed by High Rates of Misdiagnosis

By Sandra G. Boodman, Kaiser Health News

(Getty Images)

(Getty Images)

Until it happened to him, Dr. Itzhak Brook, a pediatric infectious disease specialist at Georgetown University School of Medicine, didn’t think much about the problem of misdiagnosis.

That was before doctors at a Maryland hospital repeatedly told Brook his throat pain was the result of acid reflux, not cancer. The correct diagnosis was made by an astute resident who found the tumor  —  the size of a peach pit  —  using a simple procedure. The experienced head and neck surgeons who regularly examined Brook had never tried it. Because the cancer had grown undetected for seven months, Brook was forced to undergo surgery to remove his voice box, a procedure that has left him speaking in a whisper. He believes that might not have been necessary had the cancer been found earlier.

“I consider myself lucky to be alive,” said Brook, now 72, of the 2006 ordeal, which he described at a recent international conference on diagnostic mistakes held in Baltimore. A physician for 40 years, Brook said he was “really shocked” by his misdiagnosis.

Misdiagnosis “happens all the time … This is an enormous problem.”

But patient safety experts say Brook’s experience is far from rare. Diagnoses that are missed, incorrect or delayed are believed to affect 10 to 20 percent of cases, far exceeding drug errors and surgery on the wrong patient or body part, both of which have received considerably more attention.

Recent studies underscore the extent and potential impact of such errors. To cite just two examples: Continue reading

Doing Things Right: Why Three Hospitals Didn’t Hurt My Wife

Michael Millenson and his wife, Susan. (Photo: Michael Millenson)

Michael Millenson and his wife, Susan. (Photo: Michael Millenson)

By: Michael Millenson

My wife was lying in the back of an ambulance, dazed and bloody, while I sat in the front, distraught and distracted. We had been bicycling in a quiet neighborhood in southern Maine when she hit the handbrakes too hard and catapulted over the handlebars, turning our first day of vacation into a race to the nearest hospital.

The anxiety when a loved one is injured is compounded when you know just how risky making things better can get. As a long-time advocate for patient safety, my interest in the topic has always been passionate, but never personal. Now, as Susan was being rushed into the emergency room, I wanted to keep it that way. “Wife of patient safety expert is victim” was a headline I deeply hoped to avoid.

“Wife of patient safety expert is victim” was a headline I deeply hoped to avoid.
In the weeks after the accident, we spent time at a 50-bed hospital in Maine; a Boston teaching hospital where Susan was transferred with a small vertebra fracture at the base of her neck and broken bones in her left elbow and hand; and a large community hospital near our suburban Chicago home. There were plenty of opportunities for bad things to happen — but nothing did. As far as I could tell, we didn’t even experience any near misses.

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Something’s Been Bugging Me

By: Pat Mastors

Editor’s Note: Pat Mastors is CEO of Pear Health, LLC. She formed the company after her father’s death, due to complications following a surgical procedure. CBS correspondent Andy Rooney’s death earlier this month prompted her to write this in his voice.

Andy Rooney, the CBS News Correspondent, died following complications from minor surgery. (Flickr: Stephenson Brown)

Andy Rooney, the CBS News Correspondent, died following complications from minor surgery. (Flickr: Stephenson Brown)

“I died last week, just a month after I said goodbye to you all from this very desk. I had a long and happy life – well, as happy as a cranky old guy could ever be. 92. Not bad. And gotta say, seeing my Margie, and Walter, and all my old friends again is great.

But then I read what killed me: ‘serious complications following minor surgery.’

Now what the heck is that?

Nobody gets run over by a ‘serious complication.’ You don’t hear about a guy getting shot in the chest with a ‘serious complication.’ Sure, I didn’t expect to live forever (well, maybe only a little bit), but I was sorta going for passing out some Saturday night into my strip steak at that great restaurant on Broadway. Maybe nodding off in my favorite chair, dreaming of reeling in a 40-pound striper. You know, not waking up. This whole ‘death by complication’ thing is just so, I don’t know … vague and annoying.

But then I read what killed me: ‘serious complications following minor surgery.’ Now what the heck is that?
Here’s something else that bothers me. This note I got a few days ago from a lady who says she’s a fan. She talked to a reporter at a national newspaper the other day. Asked the reporter, basically, what kind of complication ‘did me in’? The reporter said, ‘No idea what killed him. Unless someone dies unusually young, we don’t deal with the cause of death.’

Continue reading