Never Go to the Hospital Alone: And Other Insider Secrets for Getting Mistake-Free Health Care from Your Doctor and Hospital

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The Truth About

Health Care Safety:

No Better than

Bungee Jumping

"Living at risk is jumping off the bridge and

then checking to see if the bungee cord

is attached to your ankles . . ."

– ANONYMOUS

Imagine that you have settled into your easy chair on a relaxing Sunday afternoon. You were so buried in work at the office the week before that you lost track of the news. To catch up, you pick up the Sunday paper and read, in giant type on the front page, the headline:

Deadly Carnage: 8 Airliners Crash This Week,

over 1,600 dead

Stunned by what you have just read, you wince when you remember that you have to get on an airplane the next morning and fly across the country to attend a business conference.

Though fretful about your safety, you attend your conference anyway. The continuing crashes are the talk of the gathering. Everyone is worried. You consider renting a car and driving across the country to get back home, but at the last minute you decide to fly anyway and are relieved to make it safely.

The weekend comes, and once again settling in to your favorite easy chair you scan the front page of your Sunday paper, only to read:

Air Disasters Continue: 8 More Airliners Crash

This Week, over 3,200 dead in two weeks

FAA considers shutting down all airlines

You are scheduled to fly with your family the next morning for a week’s vacation in Florida. Will you go? Or will the fear of being an airline accident statistic keep you and your family home?

For the sake of argument, let’s say the government and the FAA allow this carnage to continue for three full years. (No, that would not actually happen.) Passengers nervously continue to fly because they have no other option. What would be the net result? In three years, 238,337 people would be dead and 1,248 airplanes destroyed—almost the total aircraft fleets of several airlines put together. With that level of destruction, would you ever set foot on a commercial airliner again? Would anyone?

Of course not. And yet we do keep going to hospitals, despite some shocking facts. How many patients die per year due to medical mistakes?

How many patients die per year

due to medical mistakes?

Some 238,337 patients have died due to medical error in our nation’s hospitals in the last three years, according to a recent study on medical mistakes, Patient Safety in American Hospitals. This works out to approximately nine patients per hour, 228 per day, 1,600 per week, 6,400 per month, and 79,445 deaths per year. These totals are staggering but largely unknown by the public. Medical mistakes in hospitals and doctors’ offices are one of the leading killers in this country, exceeding automobile accidents, breast cancer, and heart disease combined.

Now compare these numbers with the deaths in the U.S. caused by airline accidents. Since 2002, and at the time of this writing, there has been one passenger death for all of the major U.S. airlines combined. Now, I am not saying that passengers are the same as patients, or that airliners are the equivalent of hospitals. Health care is far more complex than airline travel. Nevertheless, using this comparison to explain the magnitude of the loss of life helps frame the scope of the problem. It really puts things in context, doesn’t it?

How serious is the problem

of medical mistakes?

The study on patient deaths from preventable medical errors paints a very stark picture of the dangers involved in being treated by the U.S. health care system. The nation was first alerted to the severity of the problem in 1999 when the Institute of Medicine (IOM), an arm of the National Academy of Sciences, published its report on the state of U.S. health care. The report was called To Err Is Human, and it startled those who were paying attention when it divulged that close to 100,000 patients die every year due to preventable health care mistakes.

What types of preventable errors are being made? A review of headlines in just one newspaper over the past year reveals mistakes like these:

• A technician improperly sets up a ventilator hose using an instructional diagram drawn backward and deprives a nine-day-old baby of the right amount of oxygen.

• Two patients’ medical files are mixed up and a surgical team removes a healthy appendix from the wrong patient—leaving another patient with a diseased appendix that still needs to be removed.

• A nurse gives her patient two different drugs that ultimately cause the patient to die—and neither of the drugs was even prescribed by the patient’s doctor.

• A patient dies after hospital staff improperly program a computer-controlled medicine pump—despite repeated warnings from other hospital personnel that the pump was faulty, difficult to program, and prone to errors.

• A baby dies in intensive care after receiving an adult dose of a blood thinner medicine called Heparin—and he was one of 17 babies in the same hospital to receive the same type of overdose as part of an ongoing, undetected problem.

How do these sorts of deadly mistakes happen? The story of Charlie, a burn patient in a hospital I once worked with, gives us some insight into the reasons these tragic errors occur. Charlie was only four years old at the time of the accident that sent him to the hospital. Shortly after he got there, doctors inserted a catheter into a vein under his right collarbone to provide him with antibiotics. Eight days later, he began to show signs of a serious infection.

A pediatric surgeon who had been on duty for over 24 hours decided to test the tip of the catheter to see if it was the cause of the infection. When the surgeon came into Charlie’s room and told the nurse he was going to test the catheter, she saw immediately that he was very tired. Normally, when a catheter is to be removed and replaced, a thin wire is routed down the middle of the catheter tube before removing it to mark the spot where it has entered the vein. This helps guide the new catheter to that exact spot in the same vein. Charlie’s nurse asked the surgeon if he intended to run a wire. He didn’t respond. The nurse became concerned at the failure to follow standard procedures, so she asked, Well, if you are going to start a new line on the left without a wire, shouldn’t we use ultrasound to verify correct placement? Again, the surgeon didn’t answer. Fearful of the doctor’s reaction, the nurse decided not to press the issue any further.

Due to fatigue, and without the benefit of the guide wire, it took the surgeon four tries to place the new catheter. Satisfied that all was well, he left Charlie’s bedside to see other patients. But all was not well. Only three hours later, the toddler had a seizure and died. His autopsy revealed that his heart had been punctured in four places, causing blood to leak into its lining.

Charlie’s death was the result of some of the classic mistakes made in health care: improper procedures, poor performance due to fatigue, infections, ineffective communication, and poor teamwork. These types of mistakes lead to a cascade of errors that harm and kill patients.

In 2007 the State of California reported that over 145 patients had objects such as sponges, needles, and steel surgical instruments left behind in their bodies after surgery. Forty-one patients had surgeries performed on the wrong part of their body. Those were just the errors that were actually reported to state authorities in just one state. Many errors go unreported. Multiply the number of mistakes reported in only one state by 50, and then factor in the unknown numbers of unreported errors, and you begin to get a sense of the seismic proportion of the problem.

Why we don’t know the real number of

medical mistakes

The president of the Institute for Healthcare Improvement (IHI), Don Berwick, M.D., believes mistakes are much higher than disclosed in most reports. His organization estimates that as many as 15 million patients are harmed every year. Among this group are 1.5 million patients who are hurt or injured every year due to preventable medical mistakes. The problem is so widespread that a study conducted by Harvard discovered that one out of every 25 patients is injured due to negligence. That doesn’t even include the number of patients hurt or killed due to honest but preventable mistakes, having nothing to do with negligence.

Despite studies like the one by Harvard, Dr. Berwick of IHI says, It will always be true that the vast majority of incidents will never be reported. The truth is, we don’t really know how many patients are hurt or killed every year in our hospitals and doctors’ offices. Whatever the true number of medical errors and injuries, there are a lot of them. A recent review of 37 million patient records suggests that hospital errors have killed or hurt roughly twice as many patients as the number in the 1999 report from the IOM I mentioned earlier. It’s no wonder that 64 percent of U.S. doctors surveyed believe medical errors to be a serious issue for the nation.

After analyzing what we do know, an article in Safety Science magazine indicated that the safety record of U.S. hospitals is no better than that of bungee jumping or motorcycle racing.

Mistakes in our nation’s health care system have become so severe that David Gaba, M.D., Associate Dean of the Stanford University School of Medicine, says it should become a public-health issue, much like the war on drugs or the campaign to immunize children. If the public really knew how dangerous much of health care was, they probably wouldn’t stand for it, says Dr. Gaba.

Why is health care so dangerous?

Health care is complex, sometimes difficult, and not the perfect science we like to think it is. Health care professionals make decisions where the stakes are high—people can die, stress is rampant, and powerful machines and potentially deadly medicines are used. As patients, we are often given potent drugs that change our body chemistry. We get stuck with large needles and sometimes have our bodies cut open and parts removed. We have difficult and potentially damaging acts performed on our bodies in complex and complicated procedures—or even in procedures that seem relatively minor. Even just having our wisdom teeth removed can prove deadly.

Health care is also dangerous because of the incontestable truth of human fallibility. Brent James, M.D., vice president of medical research at Intermountain Institute for Health Care Delivery, says, Errors will happen anytime you take a complex system and put human beings inside of it. The notion that you can train doctors to completely avoid mistakes is just false. The doctor is not perfect. She may miss a clue and make the wrong diagnosis. The nurse is not perfect. He may misunderstand the doctor’s orders for your care or forget to ask for clarification. You, as a patient, are not perfect. You may forget to take all of your medicine. All human beings are fallible; we all make mistakes. Add up all of these human failings and drop them into a system that is already complex and dangerous and you have a situation in which the very person or system you thought was going to make you well could actually kill you.

There is a science to complex health care, but less so than you think. Quite frankly, doctors will admit (in private and rarely to you) that much of what passes for the process of health care is doing things out of habit because that’s what they did 20 years ago when they were trained. Sometimes it is intuition or a best guess as to what to do or try next to help you get well. Sometimes the guess is just a gut instinct; a stab in the dark. Maybe it was informed by years of experience and a vast amount of knowledge—but it’s still a guess and certainly not scientific. Health care can sometimes be dangerous because the science of care doesn’t always provide all of the answers and it is a field that is constantly evolving.

Doctors today know more than they did five years ago and much less than they will know five years from now. The pace of change accelerates every year. Keeping up with it is difficult and exhausting. Health care professionals even have a term for this unyielding syndrome: change fatigue. So many changes so quickly, they simply can’t keep up any more. They’ve worn themselves out trying to perfect what they currently know and do while worrying that failing to keep up with advances will cost them the life or lives of one or more of their patients.

Three undeniable truths about the safety of health care in the U.S.

By now you are no doubt thinking, Health care can be very dangerous! Yes, it can be. But the intent of this book is not to alarm you out of getting the care you need. If you need help getting well, there is no better place than a doctor’s office or hospital in this country. We really do have the best health care in the world. So before you say, Wow, I am never going to the doctor again, or, I’d rather die than go to a hospital, you need to know some undeniable truths about our system as pointed out by Robert Wachter, M.D., and Kaveh Shojania, M.D., in their book Internal Bleeding (Rugged Land, 2004).

Undeniable truth #1: Most (and I emphasize most) doctors and hospitals in this country are safe. Most of the time patients will receive safe, effective, quality care. If I were overseas and became very ill, I would want to get back to America as soon as possible for my care. Even considering the fact that mistakes will be made in our health care system, I have confidence that the majority of them will be caught before they harm me. There is nowhere else I’d rather be in a hospital than the U.S. Our doctors and nurses are committed to our health; they are called caregivers for a reason. This is more powerfully true than most people know. If you had watched them in action over and over again with thousands of patients in hospitals all across the country, as I have, you would be able to truly appreciate their dedication to your health and well-being. They have sacrificed a good portion of their adult years in endless hours of education and training to learn how to heal you. They, even more than you, seek perfection in what they do.

Undeniable truth #2: The professionals who provide the care in our health system are some of the smartest, most dedicated, and most caring people on the face of the planet. None of them ever wakes up and thinks, Today, I will be careless and not pay attention, or, Today, I will intentionally make a mistake. They all seek perfection in the care they provide and want nothing more than to be able to heal you and me. They are extremely conscientious and strive for the best outcomes. As we will see, there are some who are negligent or incompetent, but thankfully, they are extremely rare. Bear in mind, though, that even if we could wave a magic wand and eliminate them from the system, we would still see errors, because even well-trained, very professional, highly educated, dedicated people make mistakes. Humans are