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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