Medical mistakes occurred at all levels of my care

Medical and surgical errors are very common in the hospital setting. They increase  malpractice lawsuits, the cost of medical care, patients’ hospital stays, and morbidity and mortality. As an infectious diseases specialist for over forty years, I was not aware how common these errors are until I became a patient myself after being diagnosed with hypopharyngeal carcinoma. My initial cancer was successfully removed, but a local recurrence occurred twenty months later. I underwent pharyngo-laryngectomy with flap reconstruction after attempts to remove the cancer by laser failed.

Although the care I received was generally very good, I realized that mistakes occurred at all levels of my care. I am sharing my personal experiences about the medical and surgical errors that occurred during my hospitalizations at three different hospitals.  My inability to speak after surgery made it difficult for me to prevent all of these mistakes. Fortunately, I was able to abort many of them.

I realized that my surgeons had failed to diagnose the recurrence of my cancer in a timely fashion although they examined me periodically after my initial surgery.  I had been complaining of sharp and persistent pain in the right side of my throat for seven months. The recurrence was finally observed by an astute resident who was the first to ask me to perform a valsalva maneuver (exhale while closing my mouth) during the endoscopic examination. This allowed visualization of the pyriform sinus where the tumor was located. I had wondered why my experienced surgeons never performed such a basic procedure. If they had done so earlier, my tumor (4×2 centimeters) would have most likely been observed and removed much earlier.

Subsequently, my surgeons, using laser equipment, mistakenly removed scar tissue instead of the cancerous lesion. A week after the surgery pathological studies revealed that the tumor was actually farther down in the pyriform sinus.  This error could have been avoided if frozen sections of the lesion itself, not just its margins, had been analyzed in the operating room. Accordingly, I had to undergo an additional surgery to remove the tumor. The prior surgery made the repeated attempt more difficult because of swelling and post surgical changes at the surgical site.

I also experienced hazardous situations because of nursing errors. One day after my laryngectomy, while still in the surgical intensive care unit, I experienced airway obstruction and reached for the call button. It was not to be found as it had fallen to the floor. I tried to call the attention of the staff and, even though I was a few feet away from the nurses’ station, I was ignored until my wife luckily arrived ten minutes later. Without a voice, I was helpless in asking for assistance and was in need of air while medical personal passed me by.

A similar incident took place on the otolaryngology floor a week later when the nurse did not respond to my call to suction my airways. I had difficulty in breathing, as mucus in my trachea obstructed my airway. The nurse came to assist me only after fifteen minutes. I learned that she was on the phone ordering supplies during all that time. There were two physicians and several nursing assistants on the floor, yet no one responded. Incredibly, even on a ward dedicated to people with airway issues, there were many distractions that prevented physicians and nurses from paying attention to their patients’ immediate needs.

The most serious error after my major surgery was prematurely feeding me by mouth with soft food far too soon. Early feeding by mouth after laryngectomy with free flap reconstruction can lead to failure of integration by the flap. Only my persistent questioning brought this to the attention of a senior surgeon who discontinued the feeding after it had gone on for 16 hours. The error occurred because the order to start feeding was intended for another patient and was erroneously transcribed into my chart.  I wonder what would have happened if I would not have continued to question the feeding and when (or if) the error would have been eventually discovered.

Some of the errors by nursing and other staff included:  not cleaning or washing their hands, not using gloves when indicated, taking oral temperature without placing the thermometer in a plastic sheath, using an inappropriately sized blood pressure cuff (thus getting alarming readings), attempting to administer medications by mouth that were intended to be given by nasogatric tube, dissolving pills in hot water and feeding them through the feeding tube (thus irritating the esophagus), delivering an incorrect dose of a medication, connecting a suction machine directly to the port in the wall without a bottle of water, forgetting to rinse the hydrogen peroxide used for cleaning the tracheal breathing tube (causing severe irritation), not connecting the call button, and not writing down verbal orders.

All of the errors made in my care make me wonder what happens to individuals without medical background who cannot recognize and prevent many errors.  Fortunately, despite the errors made in my care, I did not suffer any long-term consequences.  However, to prevent medical errors I had to be continuously on guard and vigilant, which was a very exhausting chore, especially during the difficult recovery period.

My family members were instrumental in preventing many errors, highlighting the value of a dedicated patient advocate. My experiences taught me that it is essential that medical personal openly discuss with their patients the mistakes that were made in their care. Since errors in patient care weaken patients trust in their caregivers, admission and acceptance of responsibility by the care providers can bridge the gap between them and reestablish the lost confidence. The establishment of a dialogue facilitates the discovery of the circumstances leading to the mistake which assists in preventing similar ones in the future. Open discussion can reassure the patient that their care givers are taking the mater seriously and are taking steps to make their hospital stay safer.

Avoiding discussing the errors with the patient and their family increases their anxiety, frustration and anger. This can interfere with the patient’s recovery and contribute to malpractice lawsuits.

The way a patient can contribute to the prevention of medical errors is to be proactive and take these steps: being informed and not hesitating to challenge and ask for explanations about his/her care, become an “expert” in their medical condition, have a family or friends serve as one’s advocate in the hospital, get a second opinion when making an important decision such as deciding on the course of treatment, and educate the medical caregivers about their condition and needs (prior to and after  surgery).

Medical mistakes should be prevented as much as humanly possible. Ignoring them can only lead to their repletion. I am sharing my personal experiences in the hope that they will encourage better medical training, contribute to greater diligence in care, and increase supervision and communication between health care providers and their patients. It is my hope that this manuscript will contribute to the reduction of such errors and create a safer environment in the hospital setting. It is also my hope that if mistakes do happen, medical care takers will openly discuss them with their patients.

Itzhak Brook is a professor of pediatrics, Georgetown University School of Medicine and author of the book My Voice: A Physician’s Personal Experience With Throat Cancer and In the Sands of Sinai: A Physician’s Account of the Yom Kippur War. He blogs at My Voice.

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  • azmd

    What a discouraging set of experiences. Unfortunately, they are not unique at all, nor will they continue to be. Medical science has evolved exponentially and continues to do so. We are at a juncture where the level of complexity of even routine daily tasks and the volume of knowledge to be mastered by clinicians at all levels is beyond the point where consistently perfect or even excellent execution is possible given current volumes of patients. All of the errors you described above could probably have been avoided if your doctors and nurses were not intolerably rushed, caring for more patients than can realistically be managed.

    Better training, improved processes and communication and more supervision might help, as you mention. But at the end of the day, medical workers need to have adequate time to accomplish the tasks they are expected to do, if they are to do them well.

    • Noni

      I completely agree. I couldn’t help wondering with every mistake he cited how much was due to the overburdening of health care workers. It’s terrifying, really.

      • azmd

        The problem is that the healthcare system apparently assumes that we are all robots, with an infinitely expandable number of work hours available to us. It seems that no consideration at all is given to how much time would be required to adequately complete the growing number of tasks included in a medical worker’s day. I don’t believe I have EVER, while sitting in a committee meeting in which some new task was being added to someone’s list, heard the words, “Wait, are we sure that the nurses/techs/residents/attendings have time to do this?”The result is that there is an ever-expanding body of work which is being done in a slipshod manner, or not at all.

        For example, the number of specific items I am now expected to complete for an admission evaluation would take an hour to an hour and a half to obtain, assuming a completely cooperative patient who answered concisely and accurately throughout the exam, which in my line of work is rarely the case. There are five separate questions that relate to quantifying alcohol consumption alone. This is even before I review with the patient what I believe his or her diagnosis to be, and discuss medication options and every possible side effect that they might cause.

        Of course we are not allotted two hours for an admission, so the admission write-up is always incomplete to some extent. This is not such a big problem, except that it breeds a culture of slipshod work, because in order to survive and get through your day in under 18 hours, you are constantly letting things slide. And when the culture becomes about letting things slide, inevitably, some things will be let slide that shouldn’t have. Strangely, we in the medical field appear to have some sort of cultural aversion to commenting on this phenomenon.

        • Guest

          I know where I live providers (nurses and physicians) are exploited under constant threat of “if you don’t do it we’ll replace you.” I live in a desirable area and there’s no doubt that if we don’t do it someone else will. And when they burn out or become annoyed someone else will replace them. Why should the hospital care about quality as long as the work gets done and they retain their current profit margin?

          Practitioners are treated better in underserved areas, but who wants to live or work there? And if they don’t comply, they can be replaced (hopefully) by a locums.

          It’s a terrible trend occurring in healthcare that bodes poorly for quality.

          • azmd

            Unfortunately, the immediate reaction of patients when things go wrong, as we see above, is to assume that their care providers had the resources in place to do better. Sometimes that’s true, sometimes it’s not. The nurse who failed to answer Dr. Brook’s call button because she was on the phone ordering supplies was probably doing so because it had become part of her job after the hospital cut back on unit clerical staff. We are at the point where staffing cuts are affecting patient care noticeably. But what’s getting noticed in many cases is not that we’re short staffed, but just that we’re not doing as good a job as we used to.

          • MM

            I think most patients, when things go wrong, don’t care about excuses as to “why” they might have gone wrong. They only know that the medical system to which they’ve entrusted their care, and the people they are completely dependent on to not harm or kill them, are putting them at risk. Whether it’s individuals’ fault or “the system’s” matters not very much. If a hospital stay injures or kills you, you’re still injured or killed no matter how many excuses those who inflicted the damage can come up with.

            It’s the job of everyone involved in a patient’s care to work out how not to negligently harm him or her. All the patient cares about is not falling prey to hospital-inflicted harm.

            If you let a patient suffocate because you’re too busy fiddling around on the computer, “Sorry, I was just following orders” isn’t good enough. If you think management has put so much work on your plate that patients’ lives are at risk, you need to either speak up or leave.

          • azmd

            I would refer you to my comment above about healthcare workers not being robots, and I would invite you to think about your own workplace, if you have one. Many American workers are finding themselves in the position of being asked to do more work than is reasonably possible to accomplish in a day, and finding that it imperils their livelihood to “speak up,” as you suggest that we do.

            The difference between medical workers and other workers is this: the work we do is cognitive work and at a certain point, an individual’s brain can only process so much before overloading. And when a medical worker’s brain overloads, patients are at risk. It’s everyone’s problem, and everyone should be aware and speaking out about understaffing in our healthcare institutions, because everyone is affected. As a patient, if you take the stance that “I don’t care why it’s happening, I don’t want to hear excuses, I just want it fixed,” you are not part of the solution, you are part of a problem that affects us all.

          • MM

            If you’re having trouble with a light switch at your house, and the electrician you hire to fix it, instead does something wrong which fuses your entire electrical system and then causes your house to burn to the ground, with your child in it, are you going to accept his excuse that he was just so busy, his boss is working him too hard, “mistakes will be made”, so suck it up?

            If screwing up in your job can cause fear, pain, injury, loss and death, then make sure you do your job well or cop the consequences, like everyone else has to do.

          • azmd

            No, but that individual electrician would not be penalized for making that mistake, would he? His company would be sued, not him. If there were disciplinary consequences for careless work, they would typically apply to his employer, not him. It is still unusual, fortunately, for individual employees to go to jail or be fined for making honest mistakes on their jobs. In any system, if a mistake is made, the most effective response is to try and understand the context in which the mistake was made, and then fix systemic problems.

            The healthcare system is one of the few where consequences for error tend to fall preferentially on the individual worker rather than on the employer. The obvious result is that healthcare employers have very little motivation to pay attention to whether their workers have a work environment in which their jobs can be safely and effectively performed. We are seeing the outcome of that paradigm, and it’s not a good one.

            I myself have family who have been harmed by medical errors, most recently my father. However, rather than “taking names and kicking butts” of individual providers I am working with my family to help them understand that such mistakes are the unfortunate but largely unavoidable consequence of having a broken healthcare system, and to try to see if there’s a productive way they could be part of a conversation about fixing the systemic problems that indisputably exist.

          • MM

            “No, but that individual electrician would not be penalized for making that mistake, would he?”

            Oh hell yes he would.

          • wahyman

            Even if he explained that they were very, very busy and he had so many demands on him, and he was distracted by his personal life, and didn’t really think anything bad would happen? Still responsible?

          • Auramyna

            If an electrician had too many things to do today, he could put some off for tomorrow (or next week/month even). As a nurse, we cannot do that. Healthcare staff do the best we can under the circumstances we’re given to prevent harm to our patients. One error can mean someone dies or is seriously harmed, or an end to our career; there is a lot more at stake than in other professions. So you can bet we are trying as hard as humanly possible to get it right the first time.

            The great majority of nurses go into the profession due to the desire to help and care for people. I would hazard to say that many more errors are made due to being spread too thin than from incompetence. Having said that, I do think it behooves nurses to check on their patient more regularly and answer call bells promptly when airways are at stake. If nurses are working in a team, they will use their initiative and answer a call bell if that patient’s nurse is tied up elsewhere.

            And senior managers do not listen. Maybe if they worked on the floor or could remember a time when they did, they would understand more staffing is needed.

            Whoever designs the staffing algorithms is whack.

          • Noni

            You don’t seem to understand.

            A nurse, doctor, tech, and support staff can take good care of 2 critically ill patients at a time.

            The hospital, in an effort to maintain profits while reimbursements are being cut, tell said team of people, now you must take care of 4 critically ill patients at a time instead of 2.

            Also, while you are doing that, we had to let some clerical workers go, so take care of the 4 critically ill people and enter all their orders, reconcile their medication lists, and fax med requests to the pharmacy.

            Also, to prevent reimbursements from being decreased further, log into a computer for each patient you are taking care of and enter P, Q, R, S, and check off boxes A, B, C. Make sure and comply with the rules that you have asked each patient about whether or not they own firearms, do they feel safe at home and does that home contain lead based paint.

            If you complain, there are 10 people out there ready to do your job.

            Do you see now why medical errors might be common? The horrible thing is that we all have the risk of being patients, and the real way we can change the system is by choosing hospitals and centers that do NOT overwork their staff as is so commonly found nowadays. This is nearly impossible to do in rural areas or if specialized services are needed.

            Staff complaining accomplishes nothing and has accomplished nothing. Whistleblowers are fired. Most of us can’t just leave. We have families to support. I wish it were that simple.

          • MM

            “Staff complaining accomplishes nothing and has accomplished nothing. Whistleblowers are fired. Most of us can’t just leave. We have families to support.”

            So you’ll risk killing me or my family, just so long as you and your family are all right.

            There’s something wrong with your moral compass. This is why people are scared to death of you lot.

          • Noni

            LOL, is it your opinion that we went into medicine to be stretched beyond our abilities and to put patients at risk? That we revel in what healthcare has become – dangerous, stifling, and unsafe?

            Don’t forget that every medical practitioner is also at risk to become a patient themselves. I am just at much at risk for being harmed by the medical system as you are. There’s nothing wrong with my moral compass; I’m simply pointing out that I, like you and most other people, don’t have the luxury of just leaving my job.

            What this author hopes to accomplish is that by sharing his story he can help other patients find ways to navigate the medical system and protect themselves. Changing the system? The government got their hands into controlling and manipulating the system long ago. Now, they are working on legislation to improve some aspects of it (improving price transparency and limiting facility fees).

            The ACA, however, is actually going to make the horror show described here much worse. Hospitals are not going to tolerate their profits decreasing as the ACA plans to do. Hospital administrators and lobbyists have no moral compass, and they are the ones in control.

          • Mengles

            You really are sick in the head.

          • azmd

            “If screwing up in your job can cause fear, pain, injury, loss and death, then make sure you do your job well or cop the consequences.”

            This punitive and one-dimensional attitude towards medical workers and our healthcare system can only ensure that bright, compassionate and caring people will choose to enter other fields than medicine and nursing over the long term.

            What we are already seeing is that the personality type that can most successfully survive long-term in a system where unreasonable demands for productivity and smooth delivery are the norm is more oriented towards sociopathy, i.e. someone who has the ability to make sure his own needs are met while manipulating those around him to think well of him. I don’t know about you, but that’s not what I want my future healthcare providers to be like when I get old.

          • Mengles

            Thank you for ensuring that no compassionate person would ever want to do medicine. If you want perfection, you should ask God for healing then.

          • wahyman

            “Too busy to be safe”, available as a button for staff or via embroidery on their uniforms.

          • Guest

            Correct. That is exact point of this article and the comments. If you want that to change, rather than attack the staff (who are here complaining that this is the reality in medicine anymore), attack the hospitals and administrators and DEMAND change (note not one of them is here defending their staffing practices). Why would they?

          • southerndoc1

            ‘ Whether it’s individuals’ fault or “the system’s” matters not very much.’
            If you just want to complain, you’re correct, it doesn’t matter very much.
            If, however, you want to see things get better, it matters a great deal.

          • Guest

            Go to a Nurse Practitioner then.

  • Noni

    Thank you for sharing this, and I am so glad you have not suffered any long term sequelae from the series of medical mistakes. Knowing full well how health care workers are stretched thin and overworked nowadays, I take full precautions when any family member is admitted to the hospital. However, no one can stay all day and night in some parts of the hospital! I can’t imagine how terrifying it must have been to have had no voice and needed assistance.

    I hope you share this blog with the hospital where you stayed, particularly with the CEO. These are the types of things the media should hear about. I don’t know that actual change could occur, but perhaps a family member or advocate could be permitted to spend the night with every patient. I realize the difficulty with regards to ICU patients or on the floors housing the immunocompromised, but no one should be healing in such a terrifying environment.

  • MM

    Wow, thank you for that link. I’m definitely going to have a look at that this afternoon. Appreciated!

  • southerndoc1

    You get what you (i.e., your insurer) pay for.
    If you don’t like it, hire a private duty nurse next time.

    • LastoftheZucchiniFlowers

      A private duty nurse in the SICU?

      • southerndoc1

        Especially in the ICU.

        • VanessaObRN

          especially in the operating room – what I have seen….:o

          • wahyman

            Is southerndoc1 saying this is the expected level of care without a private nurse? If so, one should avoid his practice!

          • southerndoc1

            It’s the expected level of care in hospitals run by BigCorpMedicine, i.e., just about all of them.
            But I’m more than glad for you to avoid my practice.

          • wahyman

            So this is what you expect to happen to your patients? And do you just let it?

            PS Please identify yourself for avoidance purposes.

          • southerndoc1

            “And do you just let it?”
            The bean counters don’t ask for my permission when they cut staffing yet again as the census increases.
            But I do work my butt off to keep my patients out of the hospital.

          • wahyman

            And when they are admitted?

          • southerndoc1

            I tell them to keep a family member or friend at the bedside continuously.

          • wahyman

            Would a family member or friend detect all of these errors?

          • southerndoc1


          • wahyman

            Are we then back to your acceptance that such things are going to happen to your patient, but it isn’t your responsibility?

          • southerndoc1

            Yes, I am completely powerless to have any effect at all on hiring and staffing decisions at any of the hospitals to which I admit or refer.
            Seriously, we can go on playing twenty questions or you can just tell me what you think I should do, because I honestly don’t know what it is.

          • Mengles

            wahyman’s solution is that you should be able to do at the snap of a finger like healing the Earth and parting the oceans, etc.

          • wahyman

            Or at least work on the problem rather than throw up your hands.

          • VanessaObRN

            southern doc,you’re slipping. this is the first time I’ve seen you on the defensive.
            Usually you’re the big bully here.

          • wahyman

            For one you should show some element of caring. Saying that this is just the way it is–and what did you expect–is not inspiring. Then you should pursue the issue with the hospital administration, perhaps along with your colleagues if you won’t do it alone. Then there are the licensing, CMS and accreditation people.I thought of all the players the docs had some clout since they generate the patients. Or instead you can write snarky blog comments

          • EE Smith

            There are more patients than doctors & nurses, Wahyman. If instead of “writing snarky blog comments”, each patient affected by suboptimal staffing levels were to write to the same people you’re suggesting Southerndoc and his colleagues do, expressing their concerns, that might make more of an impact.

            Patients and the medicos caring for them actually want the same thing. Doctors and nurses are not your enemy.

          • wahyman

            I totally agree that patient advocacy is necessary. I have personally written to hospitals about the care given to family members. But patient advocacy should not be in lieu of professional advocacy, .

          • Guest

            It seems you simply don’t want to understand. YOU have the power, as you have the money and can choose one hospital over another in the future. YOUR complaints could actually cause change. Most of us in here have voiced complaints in the past. My personal experience is not only did nothing change I was then “on the radar” and labeled as disruptive. Every health care worker you know (excepting the true sociopaths) care about people and are professional.

          • wahyman

            I do not accept that the lone patient who is a rare user of the hospital in most cases has or could exercise more power than the medical professionals who send the patient to the hospital, especially if they believe that hospital is not a good place for the patients they are sending there.

          • Suzi Q 38


  • LastoftheZucchiniFlowers

    isn’t that where our own Darth Vader (dikcheney) bought and obtained his new heart? Talk about a medical mistake! That ghoul had to suffer THREE HEART ATTACKS before he would even agree to quit smoking! But if he so much as winces – a cadre of cardiology wizards appear at his side to provide any and all interventions (for which Darth can and does obviously PAY!)

    PS – off topic to the article which is an indictment of how even the physician/surgeon gets stomped on when he/she is the patient because once in the johnny coat – one looses all power!!! If we could have surgery in our HSM custom suits and bear down on sluggish hospital staff in full power regalia – do you think we’d suffer the indignities that the author endured at the hands of HIS OWN COLLEAGUES? The patient in the hospital (esp. voiceless with a trach!) has literally, NO VOICE. That’s the bulk of his point, I suspect.

    • Guest

      Your spittle-flecked venom towards Cheney (I assume it’s because you didn’t like his politics, or just hate successful people in general and wish doctors would refuse to treat them so they could all die) is irrational and unwarranted.

      Anyone who has been involved with a heart transplant knows that there is a strict protocol that is adhered to. To imply that Cheney somehow cheated to get his heart is a slap in the face of all the dedicated medical teams that work to save peoples lives with this procedure.

      He didn’t “buy” his “new heart”, he waited 20 months on the standard waiting list for it – longer than most patients do. All protocols were followed. And he stopped smoking in 1978, after his first heart attack.

      Why would you feel the need to tell such awful lies about a stranger? Really, you sound positively unhinged.

      • LastoftheZucchiniFlowers

        I sound unhinged? Uh – read your own words, Trey. Cheney IS known to have jumped ahead in line and if you have ANY place in medicine (esp. transplant medicine) you would KNOW this. Lies are not necessary where dikcheney is concerned since actions are their own indictment. This thread, being about blunders in Dr. Brook’s medical care, shouldn’t be blighted by further swill featuring Beezelbub Cheney. His new heart was ill-gotten gain, and if you fail to acknowledge that then you are naive and silly and CERTAINLY not a medical professional in this century. Organs are bought and sold EVERY DAY – wake up.

        • Guest

          Yup. Unhinged.

          • LastoftheZucchiniFlowers

            guest, trey, pee-little-ton, schizo-bot much?

  • JockatCRICO

    One of the most powerful motivators for patient safety improvement is front line clinicians, and their clinical leaders, hearing specific details about what happened in their setting with their patients. When the person sharing those harrowing details is a colleague or a peer, it blunts any tendency to dismiss the narrator as uninformed or unfamiliar with medical care and helps keep focus on the root cause. Anyone who experienced any of the errors Dr. Brook did should seek an opportunity to be heard by the right audience; but clinicians who experience errors in their own diagnosis or treatment have an added obligation to speak up and confirm they’ve been heard

    • LastoftheZucchiniFlowers

      I believe that Dr. Brook has worked and continues to work tirelessly within his own specialty organization to reduce medical errors via educating his fellow physicians and surgeons by highlighting that it was ONLY because of his inside knowledge that some of the mistakes were picked up. How do lay people manage to navigate the terrible labyrinth which is hospitalization with major surgery and recovery WITHOUT these insights? The fact is that they DON’T and the hospital is still the antechamber to the tomb. To paraphrase Atul Gawandi, we can all do better.

      • southerndoc1

        Dr. Brook is good at identifying problems, but misses the cause and cure by a country mile.
        He thinks the problem is poorly trained individuals who are not adequately supervised and lack diligence in performing their jobs; most of the medical professionals here realize that the problem is well-trained, dedicated staff being torn in a thousand directions by job responsibilities are impossible for a human being to perform adequately.

  • rbthe4th2

    I was harmed from some medical mistakes a doctor made. I made several polite complaints. I said maybe the doctor is overworked, I think he’s great but maybe he and/or his office staff could use some help. My perception is that these are good people and maybe you need to give them a hand up instead of a smack.
    I got fired from the whole practice and lost care. I’m at a bad stage too for getting that and no care in the area.
    I let others know my story. Speaks volumes about the ego of the doctor involved (and its known to be big) and the hospital administration. I’m not into suing people or companies into oblivion, but how else do you get change with actions like this?
    We had another lady in the area a few years ago, she and a few others were se*ually harassed. They told the lady (the only care in the area) that she could only be seen on an emergency basis. She had complained about it, asked them to fix it, so they said no care for you. The doctor surrended his license. All perfectly legal. Same company/hospital.
    It is stories like this, where doctors don’t truly police their own, along with “let me sue doctors for a broken fingernail because he’s a millionaire” mentality, that make it virtually impossible today to get a discussion going on fixing problems in healthcare.

  • azmd

    So in thinking about this critically, the writer had a series of medical encounters in which a variety of serious and not-so-serious mistakes were made. It sounds as though he came into contact with possibly as many as 40 or 50 medical providers who made mistakes. That seems like a huge number, but I am quite honestly not surprised to hear it.

    People make mistakes for different reasons. They make mistakes because they don’t care, because they are incompetent, or because they are overextended. Do we all really think that so many medical providers are incompetent or uncaring? It seems unlikely to me. The chances are much greater that they are overextended as the result of predatory staffing policies by their employer.

    I would suggest that anyone who is the victim of medical errors take it up directly with hospital administration: “I notice that the following mistake was made. I genuinely think that the nurse/doctor/tech cared about me and wanted to do a good job. I am concerned that their workload did not allow them to function at their most optimal level during the time they cared for me.”

    Just a suggestion.

    • karen3

      We did. hospital administration denied that a stage IV pressure ulcer, starvation, a black eye, being left for days without treatement for a spinal cord injury, etc, was a problem. Seems to me that the staff should be the ones taking it up with administration and leaving if the answers don’t match up with their personal ethics. If a hospital has no doctors and nurses, it won’t last long.

      • azmd

        See my reply above. The hospital is perfectly able to stay in business when it loses staff over unsafe practices. It just hires temp workers to replace the permanent staff who have left.

        • Guest

          Correct, the scabs come in gleefully and do the work. It happened at our hospital when some physicians in a private group contracted with the hospital complained about something. The hospital rewarded the hard work and loyalty of these physicians by replacing them.

    • LastoftheZucchiniFlowers

      Except that the surgeons who were his colleagues LEFT HIS CANCEROUS TUMOUR inside his body and removed SCAR TISSUE. How would you assign culpability for this?

    • nomidazolam

      The hospital administration claimed that they had no fiduciery duty to me. All the people involved in my care were “independant contractors” over which the hospital had no control.

      • azmd

        Taking an educated guess, I would say that you were dealing with a hospital whose unsafe staffing practices had resulted in the departure of a large number of their permanent medical and nursing staff, as other commenters here have suggested that we do. When that occurs at a hospital, it unfortunately does not result in changes in staffing levels or administrative personnel. The hospital just hires temp workers from agencies to replace the permanent workers it has driven away. Those temp workers are in fact “independent contractors” and because they are not familiar with the hospital’s policies and procedures, and they are also subjected to the same unmanageable workloads that resulted in their colleagues leaving, they are even more prone to make medical errors.

      • Suzi Q 38

        Is that true in all hospitals? Doesn’t the hospital have the duty to hire good surgeons?
        Did you complain? If so, how did you approach these real concerns, which department did you complain to and what happened to make sure this did not occur to others as well?

        • nomidazolam

          I complained to the nursing advocate, the president of the hospital, anesthesia associates, the so-called patient advocate (actually a lawsuit mitigation nurse) my surgeon and anybody else I could think of. The gist of it is the “independant contractors” statement and they were sorry I was UPSET, but really they had nothing to do with my treatment, that was (insert name(s) here) fault. Hospitals don’t “hire” surgeons or crna’s etc. They simply allow them to conduct business inside the hospital.
          The State Board Of Health and Welfare did cite the hospital for many violations in my case. They “recommended” certain things be changed, but as far as *I* know, nothing has been done to make people safer, as there has been no followup. There is too much money involved to pay close attention to these violations.

      • Suzi Q 38

        Such an interesting, but $#itty system.
        One without any accountability at all.
        Some doctors ask why our attitude is so different about physicians than years past. Since patients can’t really trust some of them, their credibility in our eyes is lost.

    • Suzi Q 38

      “”I would suggest that anyone who is the victim of medical errors take it up directly with hospital administration: “I notice that the following mistake was made. I genuinely think that the nurse/doctor/tech cared about me and wanted to do a good job. I am concerned that their workload did not allow them to function at their most optimal level during the time they cared for me.””

      I am going through this right now.
      I felt that my care was not good.
      I am voicing my complaints to patient advocacy, who is forwarding my concerns to each department head. The Chief of the medical staff is getting a copy of the grievance, too.

      I refused to just walk away from it without letting them know why I and anyone else I knew was not coming back.
      I told them that while my concerns were legitimate, they were my view of the events. That I wanted to hear what each individual person had to say in response. Maybe they had very good reasons for not doing X, Y, and Z.

      As for me, we are in a very large city.
      I simply would have to go to another hospital to get care. There are a hundred (exaggerating). I told the patient advocate to read all of my EMR medical reports to make sure that no one labeled me as a PITA. If so, I eventually will find out about it.

      I don’t want to be back at that hospital anyway. Why would I want to go back to a set of doctors that were so tired and stressed out that they did not provide me with good care?

      At least tell me so that “buyer beware.”

  • Suzi Q 38

    Thank you for writing about this real problem.

    I think I will stay out of the teaching hospital and its staff, thank you very much. My unfortunate experience was at a famous cancer teaching hospital.
    I had strange leg weakness and numbness in my extremities that they passed off as Renaud’s. There were small but noticeable weakness and neuropathies after my daVinci hysterectomy. The doctors did not take a full MRI of the 3 parts of my spine, only an MRI or my lumbar.

    The neurologist in charge was concerned that I was going to sue his friend, the gyn/oncologist. I was not at the time. I just needed care.

    Just when I had given up, I told the gastro about my symptoms.
    You see, by then I had a gyn/oncologist, neurologist, gastroenterologist, and a urologist. I had symtoms relating to the necessity of these specialists that all led up to a severe nerve condition called spinal stenosis.

    Thank goodness that doctor finally listened. He was angry at all of his colleagues, but asked me to tell them what I needed. He told me to tell them that I needed an MRI of my cervical and thoracic spine.

    Wow. the gastro telling the neuro how to do his job.
    He is the poop doctor, not the nerve doctor.

    The new teaching hospital said that my former teaching hospital waited too long to treat me. This is most of the reason that I still have weakness and nerve problems after my anterior discectomy.

    I decided to go to the patient advocacy. I was told that my case was so complex that there will be an evaluation from each department head involved. Whoopee. I told them that I wanted to have a meeting with the Chief of Staff.

    I have low expectations from the patient advocacy. I probably will have to get a lawyer and sue the hospital for the first time in my life.

    The second hospital had better specialists, but their hospital was filthy.
    I could visually see the dirty, brown floor. The bathroom was dirty, as well as the sink and my room in general.

    I thought of Mersa and C. difficle…pseudamonas a.

    The two visiting nurses that I had two days in a row that were nowhere to be seen most of the time. Using the call button was futile.
    My room mate was a nurse, and we just laughed about the care.
    I was more mobile than she was, so we elected me to unhook my monitors and walk out to the nursing staff and “bitch” a bit.

    I finally called my family and the surgeon and told him I was getting out of there. My DRG was 4-5 days. I was discharged at my request within 30 hours.
    Probably saved my life, LOL.

    • Rayn

      I am sorry for your unfortunate experience. However, I am not sure the fault of the mistakes are because it was a teaching hospital and not a community hospital, mistakes happen in the community hospitals as well. In fact this article indicates it was a resident who found the cancer recurrence. Both teaching hospitals and community hospitals can make mistakes and we need to work to try and prevent them accordingly.

      • Suzi Q 38

        Thank you. You are right.
        Mistakes can happen anywhere.

  • meyati

    You asked about mistakes to people without medical education. I’m allergic to bandaids-even with cloth tape. My dog bit me. In the ER, 4 times I begged them not to use bandaids. In 3 days my arm was like a petri dish. I have cancer-which made it worse. I ended up hospitalized with IV antibiotics. About a week after discharge, I went to the hospital surgery follow up-I was asked how it happened and I said, “THe ER put bandaids on the bites. I am allergic to bandaids, even cloth bandaids, and they turned my arm into a petri dish.” She examined my arm-then finally got me ready to leave-she pulled out a bandaid-same brand-same size-same style.- I said, No, please don’t. I’ve decided to carry a small emergency pack of gauze, topical antibiotic ointment that I’m not allergic to, cotton sleeve Ace wrap to keep this from happening again. I tell them that I might as well be in Russia or Viet Nam-I have to carry my own dressings now. They want to cut out my mouth-most of my face because of the cancer. I’m thinking, if they can’t take care of an arm, how can they take care of my face? Since this happened, I’m asking my oncologists to let me enjoy the moments now, and would they help me when the bad times come. I know it’s against their training to do nothing, but I have an aggressive rare incurable cancer. For me, it’s Carpe Diem.

  • Susan Thompson-Dancer

    When I was in the hospital for a sigmoid colon resection, I experienced severe back pain 14 hours after surgery. The only response was more and more pain medicine. Hours later, after I was already tachycardic and hypotensive and through my narcotic induced haze I was finally able to say to the GI Surgical RN “I think I have a retroperitoneal bleed.” Nurse = blank stare. ME: “You know…where a patient is bleeding into their abdomen and lower back??” Her response = She assisted me to a sitting position and looked at my back and said “SEE…you no bleeding on your back.” Ohmyword. True story! Had to insist on someone paging the surgeon. I am a healthcare provider, my mom is in healthcare and my brother is also. We knew the words, the signs and symptoms and STILL were victims of poor care. I feel badly for the regular person in a hospital who does not know what to look for.

    • Suzi Q 38

      I hear everything your said.

      I had to go to my teaching hospital the other day and speak with the patient advocate. No high expectations, just curious as to how each specialty would respond to each of my important questions regarding my care.

      I stopped by the patient resource center and logged onto “Up-To Date,” one of my favorite medical websites. All I did was type in: “The symptoms of spinal stenosis.” and received a 10 or 15 page article listing all of my very real symptoms; the ones I had been complaining about the last year and a half.
      I sent the advocate a copy of the article.

      I was so incredulous that the neurologist that had been treating me was so blind to it all. As I have said before, a full MRI would have answered his question.

      Why risk my future mobility to the cost of a cervical and thoracic MRI when I have PPO insurance? Please don’t tell me doing so would have compromised the ethics of overprescribing unnecessary tests. My symptoms came and went, then became progressively worse. The symptoms persisted, then escalated near the end. By then, I was spending part of my time in a wheelchair. I could no longer walk long distances.

      Instead of a “detective” for a doctor, I got a Pomeranian.
      He has got some explaining to do.

      At the very least my complaints had “merit.”

  • Mark C.

    For stroke victims or the elderly who are not able to speak well, nor understand much of the medical jargon, it is VERY important to have a relative or friend stay with them in the hospital 24×7. Take shifts as needed for breaks.

    Not only are errors more likely with patients who are less than well aware, but medical staff are more likely to ignore patients that do not have a caregiver.

    If necessary, hire someone to sit with your loved one if you cannot. I witnessed, and prevented, an alarming amount of mistakes after my mother had a stroke and was in recovery.


  • RachaelMall

    I’m currently in a situation I’d like to call limbo. Not sure if there are mistakes involved or just willful stupidity.

    to ER a month ago, diagnosed with acute bilary pancreatitis. After
    three days, docs gave up on a cause. No alcohol, calcium, high
    cholesterol, etc. And my gallbladder was FINE. Not inflamed or anything.
    Only a polyp.

    Similar symptoms recurred, neighbor inadvertently
    took to different hospital. Oh. Crap. I’m in pain, I’m there, what can I
    do but stay. Several days later, I direly regretted that decision.

    After a few days of testing, Wednesday afternoon, four different people, two PA’s, two physicians, took turns egging me into a laproscopic chlolecystectomy. Coxing, wheedling, waxing. All they did was make my instincts scream so loud they were deafening. I couldn’t put my finger on it, but I knew something wasn’t right.

    The next morning, here comes a PA, then the other one, still pushing. Then the one gives me the sucker punch I’ve sensed coming: She informed me due to a baseball sized cyst, they CAN’T do the laproscopy, they have to do open the surgery. Three months recovery instead of a week? Oh, hell no.

    I loudly protest, asking to pop the cyst or wait til it shrinks. PA responds don’t worry, the surgery is simple (like hell!), I’ll try to get you on the schedule. I said EXCUSE ME MISS, you’re not answering my questions. She darted out of the room. Great listening skills, lady.

    I immediately page my nurse, demanding to halt the surgery until I get some common sense answers. She promises the surgeon is coming to see me.Six hours later, no surgeon, not even that obnoxious PA.

    And I was sitting there fuming for six hours, I realized while those four were trying to coax me into the laproscopy, the KNEW they could not because of the cyst.They’d had the results a day before they ever started pushing. OK, now I’m mad. Really mad.

    Morning finally. The surgeon was gracious enough to grace me with his presence for a whole 45 seconds. Promises to consult with GI with cyst and he’ll be back, Don’t all men say that?;)

    Anyway, the next person I see was some case manager for insurance. (Huh?) She says I’m sorting it all out, they know you’re iffy on surgery. Are you going to have the surgery?

    Right there, she pushed that last button before I go ballistic. Though I shouldn’t have, I became verbally combative with her. Then again, she deserved because she kept trying to talk me into the OPEN surgery. AAAH!!!! I asked her what kind of idiot would have open surgery that takes months to recover from when all they have to do is wait for the cyst to shrink? She just didn’t know, of course. Then she dramatizes and says oh if you wait the gallbladder could burst. (After these dim wits told me I could wait another SIX months.) So i replied I would rather this thing burst before I let them needlessly slice me open like an apple. At least an open surgery would then be justified! I need them to sit an answer m questions. She promised a PA would come back (she didn’t) and asked AGAIN if i was sure about surgery. I just stared at her like she was Jupiter. She saw she was getting no where and literally stomped off. I’m serious…she stomped off, all kinds of mad. OK…At this point, I’m ready to jump out a window and run for my life.

    About an hour later, here comes one of the docs that pushed for a laproscopy he knew couldn’t be done. I told him point blank: I feel really jerked around and mistrustful of you people. Why won’t you answer my questions? So he mutters something inaudible like oh dear, ok, and then says more clearly “Well, no surgery”? Me: Not if you want to unneedlessly slice me open like an apple. He says OK, well, we can do outpatient, we send you home. You like to go home?” I said in that case, you may as well. I wanted to punch him. Great listening skills, buddy.

    Not sure what went wrong or why other than they got mad they couldn’t trick me into major surgery. And once I protested, they all refused to answer questions and just pretty much HID from me. Real professional there, folks. Maybe there’s other reasons they all hid away but really? I’m not sure if I did something wrong or what.

    On the discharge papers was a problem of “knowledge deficit”. Well, duh! Not answering questions has that affect on patients!

    And for those wondering, yes, I complained to hospital administration.Someone finally listened.

  • RachaelMall

    Why is my post in such a terrible format?!

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