What a New Doctor Learned About Medical Mistakes From Her Mom’s Death - ProPublica

What a New Doctor Learned About Medical Mistakes From Her Mom’s Death - ProPublica

The hospital she was in is a nationally ranked hospital near Seattle. It wasn’t that we felt the place was not up to snuff or not capable of providing good care. But I hadn’t realized how hard it is to keep a complicated patient safe in the hospital. The harm is rarely caused by actual negligence. The vast majority of cases involve a lot of people doing fairly reasonable things, and somehow something just falls through the cracks.

Chaotic conditions often lie hidden until they reach a level to be seen, much like a contagion. In this hospital many of these chaotic problems are hidden or lied about, statistically then the hospital might be seen to run well without addressing them.

One day my mom fell out of bed in middle of the night. They had bed alarms to notify nurse if a patient starts to fall out of bed. But there’s also a chair alarm, and the nurses showed us that there were only enough electric outlets for one alarm at a time, and the alarms had identical cords – making it hard for the nurses to tell which alarm was plugged in. The day my mom fell, the wrong alarm was plugged in.

There are lots of easy solutions to this. They could make the cords different. Or they could have two outlets, so both could be plugged in. I certainly hadn’t thought about that as a medical student, but all of a sudden it became the most important thing in my day when my mom was in the hospital.

Medication errors were frequent. My mom was on a seizure medication that needed the dose adjusted according to her nutritional status. The physicians probably knew this, but with all the handoffs, a new doctor would come in, see the drug level was low in her blood – and without carefully observing her nutrition – and then up the dose. She was being accidentally overdosed on the medication which caused her to sleep for days. As somebody who has a life expectancy on the order of months, those days were very important to us.

The biggest error related to her chemotherapy, which was administered by a device straight into the fluid of her brain. They’d give her the chemo about once a week, and it was supposed to last an entire week. One weekend her normal oncologist wasn’t on so the covering physician administered the chemo. About a week later her normal oncologist came to us in tears. She’d discovered that her colleague had not administered the right chemotherapy drug, and the type she’d received had only lasted a day, not a week. My mom had effectively gone for a week without getting any treatment. For her this probably didn’t change her life expectancy drastically, but it probably changed it a little bit. But this event itself was really terrifying. It had the potential to make a huge difference in the life expectancy of other patients.