After a recent firsthand experience and the subsequent literature review I realized that medical errors are far too common, and way too easy to occur- and worse still most of them though preventable have serious adverse effects.
I work in a nursing home, under a physician’s supervision every week. The facility we work at is exceptionally busy, with an overwhelming patient load. The home is large, and has several hundreds of inpatient senior residents, in addition to an adjacent outpatient clinic. My preceptor handles a patient load that is larger than most of his colleagues’. The other staff, including the nurses and medical assistants, are frequently inundated with work, and due to the high volume of patients, it feels as though the medical office is grossly understaffed regardless of how many people are working there. Since it is an inpatient facility, most of our patients require constant monitoring and care. Even on the outpatient side, the scheduled appointments rarely occur on time, with the clinic typically running up to two hours behind schedule on most days. My preceptor is usually operating under hectic, highly stressful conditions, and is managing multiple patients at the same time. Consequently, many of his instructions to his student-apprentices, medical assistants, and nurses are abbreviated and conveyed in a way that is not always clear. Additionally, he becomes frustrated when he has to explain things more than once, or is asked too many clarifying questions regarding his patients. While he has been treating his patients for decades and is familiar with them, most of his staff do not share that comfort with each patient’s medical history and treatment.
In the middle of the chaos of morning clinic the other day, the doctor quickly asked me to go to the room where we typically administer injections, and instructed me to give the patient sitting there a pneumonia (Pneumovax) vaccine. Usually, the medical assistants administer vaccines, but my preceptor said they were overloaded with work, and told me to do it. I did as he instructed.
Fifteen minutes later, the nurse asked me which vaccine I had given to the patient I saw earlier. I told her, and she seemed very confused. It turned out that the doctor had also asked the nurse to give that patient a vaccine, but a different one: the influenza vaccine. The nurse and I asked the doctor what she had intended for us to do. The doctor was very flustered and started to get frustrated. He had accidentally asked me to do something that he had already asked the nurse to do. His intended instructions to me had been to give the pneumonia vaccine to a different patient, sitting in a different room (one where we typically do not administer vaccines or draw blood from patients). But it had not occurred to him to clarify his instructions to those around him, since in his mind, he knew which vaccine was to be given to each patient, and he also knew exactly where they were located.
Of course, he started to get annoyed (and understandably so) when he realized that he would have to contact both patients regarding the mix up and call one of them back for an appointment to actually get the originally-intended influenza vaccine. This would obviously involve more paperwork and cause a hassle for him. Luckily, it turned out that the patient I gave the pneumonia vaccine to was due for it anyways, since she was an elderly, frequently-hospitalized patient, part of the at-risk population for nosocomial pneumonia. Furthermore, there are limited side effects to this vaccine. The issue ended up being resolved, after causing some unnecessary extra stress in our clinic.
Later, I thought about what had happened. A similar mix-up regarding something other than vaccines, such as bloodwork or giving strong medications for example, could have potentially resulted in an enormous error in patient care, one with lasting consequences! This happened because the doctor did not take the time to explain what he wanted done, and which patient he wanted us to care for. He gave duplicate instructions. But also, none of us reconfirmed the patients’ identities and matched the course of treatment (vaccines) using more than one patient-identifier with each patient, as we have all been trained to do.
In the end, this wasn’t necessarily attributed to a mistake in one step of the process, or any one person accidentally overlooking a detail. There were several things leading to the error. But the main point underlying all of this is that everyone in the clinic is so overworked. Physicians and health care workers who practice in such conditions are prone to a greater number of errors. And such mistakes happen all the time in medicine. The wrong medications are given, and then corrected with other counteracting medications, many times before the patient experiences any unintended consequences. Mistakes are made on unconscious patients during surgical procedures, and they are usually fixed and covered up right then, and written off as a “minor complications” of the procedure. Physicians and medical students frequently work under sleep-deprived conditions.
The Institute of Medicine (IOM) in 1999 issued a report “To Err is Human” (Kohn et al., 1999) that claimed 44,000 deaths a year occurred in hospitals because of errors and that the figure might be as high as 98,000. This estimate […] sent a shock wave through the medical and administrative community intensifying their concern about patient safety. Examples of errors included adverse drug events, improper transfusions, surgical injuries and wrong side surgery, suicides, restraint related injuries or deaths, falls, burns, pressure ulcers, and mistaken patient identities. The types of errors may be diagnostic, i.e., delay in diagnosis, not getting an indicated test, the use of outmoded tests or therapy and not acting on results of monitoring or tests; treatment, i.e., errors in performance of an operation, procedure or test; errors in dose or method of using a drug, avoidable delay in treatment or responding to a test; preventive, i.e., failure to provide prophylactic treatment and inadequate monitoring or follow-up and other, i.e., communication and equipment failure. Errors occur primarily in intensive care units, operating rooms and emergency departments […]. The cause is a lack of system, not a “bad apple” problem.” (Kramer 2010)
Some facilities, such as the clinic I work at, are just flooded with patients to see, medications to give these patients, lab tests to perform, and procedures to do, all the while adhering to time and reimbursement guidelines for scheduled appointments. The physician I work with is an excellent clinician. And the staff members at the clinic are extremely competent caregivers. But in my time spent there, I do always wonder why the working conditions have to be like this. Why does my preceptor continually choose to increase his patient load, in spite of already having a completely full schedule? Part of it must be that there is increased pressure from external key players in the health care policy battle to see more patients, in shorter periods of time, and for lower rates of reimbursement. Even this relatively insignificant error that occurred here was something that should never have happened in the first place, if protocols had been adhered to. If we all took a step back to reflect, and decided that we will practice medicine in a way that is more conducive to the interests of both patients and their physicians, we would have fewer errors, healthier patients, and healthier doctors.
Kramer, M. (2010). Sleep Loss in Resident Physicians: The Cause of Medical Errors?. Front. Neurol. 1:28, 1-10.
About the Author : Manasa Bhandarkar is a medical student in Boston, Massachusetts, in the United States. She is a student in the MD and MBA dual degree program at Tufts University School of Medicine. Her interests lie in medicine, health care reform, operations management, and global health.She blogs at: http://manasabhandarkar.wordpress.com/
Suggested Reading : Wrong Site Surgery
Editor’s Note: This is a guest post and the views expressed in the article are solely that of the author. The incidents about patient experiences stated in this blog are completely fictional and any resemblance to any person(living or dead)and/or incident is purely co-incidental.