10 Medical
Errors That Changed the Standard of Care
We learn most from our painful mistakes. Mistakes can injure
patients and land physicians in legal and professional trouble. Studying these
mistakes and learning how to prevent, monitor, and respond to them, however,
has changed the standards of care. By working to eliminate common medical
errors, physicians can protect patients, protect themselves from lawsuits, and
help lower the cost of their professional liability insurance premiums.
In 1910, when Abraham Flexner researched the state of US
medical education, only 16 of the existing 155 medical schools required more
than a high school education for admission. Germ theory was still disputed.
The practice of medicine in the United States is now much
more standardized, thanks in large part to changes to standardization of the
qualifying examinations for US-trained physicians and to medical malpractice
law.
Today's standards of care are now mostly based on scientific
evidence. In the past 20 years, courts have held physicians and hospitals to
national standards of care rather than accepting local variations in the
practice of medicine.
In 1976, Dr. Jim Styner, an orthopedic surgeon, crashed his
small plane into a cornfield in Nebraska, sustaining serious injuries. His wife
was killed, and 3 of their 4 children were critically injured. At the local
hospital, the care that he and his children received was inadequate, even by
standards in those days. "When I can provide better care in the field with
limited resources than what my children and I received at the primary care
facility, there is something wrong with the system, and the system has to be
changed," Dr. Styner said.
His family's tragedy and the medical mistakes that followed
gave birth to Advanced Trauma Life Support (ATLS) and changed the
standard of care in the first hour after trauma.
Dr. Styner helped produce the initial ATLS course. In
1980, the American College of Surgeons Committee on Trauma adopted ATLS and
began disseminating the course worldwide. It has become the standard for
trauma care in US emergency departments and advanced paramedical services.
The Society of Trauma Nurses and National Association of Emergency Medical
Technicians have developed similar programs based on ATLS.
Judy was 39 years old when she went to the hospital for a
hysterectomy. After she died on the operating table, autopsy revealed that the anesthesiologist
had placed the endotracheal tube in her esophagus, not her trachea.
Today, anesthesiologists measure a patient's carbon dioxide
levels -- which are much higher from the trachea than from the esophagus --
through use of an end-tidal carbon dioxide monitor.
In 1982, ABC's 20/20 ran a segment titled "The
Deep Sleep: 6000 Will Die or Suffer Brain Damage." This program
highlighted several cases of medical mishaps that resulted in serious injury or
death. The American Society of Anesthesiologists responded with a program to
standardize anesthesia care and patient monitoring and in 1985 created the Anesthesia
Patient Safety Foundation.
Standard practices now include the use of pulse oximetry
and end-tidal carbon dioxide monitoring for anesthetized patients. The new
standards have markedly reduced the frequency of anoxic brain injury and other
major complications. The push for electronic monitoring systems for patients
under anesthesia caused anesthesia-related deaths to plummet from about 1 in
10,000 to 1 in 200,000 in less than 2 years.
Sally and Ed looked forward to the birth of their first
child. Sally's labor was long, so her obstetrician added oxytocin to speed
things up. Unfortunately, administration of oxytocin led to unrecognized fetal
distress, and their newborn daughter suffered severe brain injury and cerebral
palsy.
Fetal monitoring to test both uterine contractions and fetal
heart rate (FHR) is now the standard of care, with a 30-minute response time
from recognition of fetal distress to delivery. The purpose of FHR monitoring is to follow the status of
the fetus during labor so that clinicians can intervene if there is evidence of
fetal distress, as reflected by an FHR above or below the normal range of
110-160 beats/min or an FHR that does not change in response to uterine
contractions.
Electronic fetal monitoring (EFM), also called FHR
monitoring, was first developed in the 1960s. Since 1980, the use of EFM has
grown dramatically, from being used on 45% of pregnant women in labor to 85% in
2002, according to the American Congress
of Obstetricians and Gynecologists (ACOG). "When EFM is used during labor,
the nurse or physicians should review it frequently," state ACOG
guidelines.
Bill had a seizure and crashed his car into a tree, crushing
both legs. Arteriography revealed that his right leg was salvageable but his
left leg was not. Unfortunately, the x-ray technician mislabeled the films,
mixing left for right, and the orthopedic surgeon first amputated Bill's right
leg.
Preventing wrong-site surgery became one of the main safety
goals of the Joint Commission for Accreditation of Healthcare Organizations
(JCAHO). Establishing protocols became an
accreditation requirement for hospitals, ambulatory surgery centers, and
office-based surgery sites.
JCAHO mandates standardization of preoperative procedures to
verify that the correct surgery is performed on the correct patient and at the
correct site. Guidelines include marking the surgical site, involving the
patient in the marking process, and having all members of the surgical team
double-check information in the operating room.
Despite these efforts, wrong-site surgery occurs about 40
times a week nationwide, a JCAHO survey found.
The biggest pitfall is inadequate
information about the patient. The solution is a carefully standardized
method of collecting information.
Tom was 12 years old when his appendix burst and he was
taken to the local pediatric hospital. Three days after the appendectomy, he
developed another high fever. One week later, the surgeon performed a second
procedure and found that a surgical sponge had been left inside.
Postoperative sponge and instrument counts have been routine
for decades. There is no single standard,
although nursing and surgical organizations have developed best practices for
sponge, needle, and instrument counts.
Different ways of counting sponges may be used in the same
operating room even during the same case,
says the Association of Operating Room Nurses. This lack of standardized
practice creates opportunities for errors.
A US Department of Health and Human Services study says that
this type of mistake occurs in 1 in 100 to 1 in 5000 persons. A 2008 study
published in Annals of Surgery found that mistakes in tool and sponge
counts happened in 12.5% of surgeries.
Nursing and surgical groups recommend that each member of
the surgical team play an equal role in assuring accuracy of the counts.
Recently, manufacturers have made sponges with threads visible on x-rays,
radiofrequency identification systems, and bar coding to alert staff about
missing sponges.
As a young child, Betty had been given penicillin, turned
blue, and was rushed to the hospital. She was 15 when she got strep throat, was
given penicillin, and died. No one had asked her about medication allergies.
Medical
questionnaire forms have always included a space for allergies, although this
became much more prominent after the Institute of Medicine report on patient
safety in 1999.
In 2008, the Pennsylvania Patient Safety Advisory cited more
than 3800 cases in which patients received medications to which they had
documented allergies. Breakdowns in communication of
allergy information include "documentation of patients' allergies on paper
but not entered into the organization's computerized order-entry systems, and
allergies arising during episodes of care but not documented in the medical
record or communicated to appropriate staff."
Strategies to address the problem include adding visible prompts in consistent and
prominent locations listing patient allergies, eliminating the practice
of writing drug allergens on allergy arm bracelets, and making the allergy
reaction selection a mandatory entry in the organization's order-entry systems.
Linda wasn't doing well in her first trimester. The nausea
and vomiting left her severely dehydrated and with a low potassium level. In
the emergency department, her nurse made a mathematical error and
administered too much intravenous potassium. Within an hour, Linda was dead.
In the 1980s and 1990s, patient safety groups, including
JCAHO, drew attention to the need for removal of concentrated potassium
chloride vials from patient care areas. Now, almost all US hospitals have
removed the drug from floor stock on patient care units. Potassium is now added
to IVs by the manufacturer and is labeled.
The tragic errors that gave rise to this system change were caused
by deficits in knowledge about the dangers of rapid intravenous administration
of concentrated potassium or, more often, mental slips or selection errors when
grabbing a vial of medication. Limiting access to this drug has reduced fatal
errors.
Additional safety strategies include using premixed
solutions, segregating potassium from other drugs and using warning labels,
prohibiting the dispensing of vials for individual patients, and performing
double-checks with a pharmacist.
Frank was 72 years old when he broke his right leg in a car
accident and had to recover for a few weeks in a rehabilitation facility. The
nurses didn't know that patients needed to move regularly, and Frank developed
deep decubitus (pressure) ulcers. When these became infected, Frank's leg had
to be amputated.
Each year, more than 2.5 million people in the United States
develop pressure ulcers, notes the Agency for Healthcare Research and Quality.
Bedsores can be fatal. The Centers for Medicare &
Medicaid Services no longer provide additional reimbursement to hospitals to
care for a patient who acquires a pressure ulcer while under the hospital's
care.
The primary way to prevent decubitus ulcers is by turning
the patient regularly, usually at least every 2 hours. Efforts to relieve
pressure to avoid additional sores by moving the patient have been documented
since at least the 19th century.
Nursing homes and hospitals now have programs to avoid
development of bedsores by using a set timeframe to reduce pressure and having
dry sheets by using catheters or impermeable dressing. Pressure shifting on a regular basis and the use of
pressure-distributive mattresses are now common practices.
Lillian was 68 years old and weighed 250 lb when she
underwent surgery to remove her gallbladder. The second day after surgery, she
needed help to walk to the bathroom. Lillian's nurse, Millie, wasn't strong
enough to support her and they both fell, breaking Millie's right arm and
Lillian's left leg.
Historically, schools of nursing have taught students to
manually lift patients using proper body mechanics, such as lifting with the
legs and using correct posture. However, body mechanics are not sufficient to
protect nurses from heavy weights, awkward postures, and the repetition
involved in manually lifting patients, according to a position paper from the
American Nurses Association (ANA).
The ANA supports policies that eliminate manual patient
lifting. Safe patient-handling techniques involve the use of such equipment as
full-body slings, stand-assist lifts, lateral transfer devices, and
friction-reducing devices.
There is no federal legislation or regulation on safe
patient handling, although several states have enacted such legislation, ANA
says.
When Christy was 42 years old, her doctor discovered a large
lump in her left breast. The lump should have been evident during Christy's 2
previous annual examinations if they had been complete. By the time it was
diagnosed, the cancer had progressed beyond cure.
Breast
examinations by the physician, teaching of techniques for breast
self-examination, and recommendation of mammograms are now the standard of
care.
Mammography was developed in the 1950s and became a common
diagnostic tool in the 1960s. It is a key method for detecting breast cancer
early, when it is easier to treat. In 2005, about 68% of all US women
between 40 and 64 years of age had had mammography in the past 2 years, according
to insurance studies. All US states except Utah require private health
insurance plans and Medicaid to pay for breast cancer screening.
Standards for the timing of mammography vary by organization
and by patient history. The US Preventive Services Task Force currently
recommends that low-risk women older than 50 years receive mammography once
every 2 years. ACOG currently
recommends annual mammograms for all women 40 and older.
These are but a few examples of medical mistakes that have
led to patient injuries or death -- and have led further to changes in the way
physicians in the United States practice medicine. Recognizing that all of
these mistakes could have been prevented, the federal government and various
medical academies have developed guidelines for prevention and treatment of
many diseases.
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