My first mistake could have been fatal

Recently, our three-year-old wandered into our bedroom around 4 a.m. waking me up, saying he was scared. As I did the previous few nights when he did this, I muttered a curse word to myself and picked him up to carry him back to his room. Upon lifting him, a wrinkle in the routine emerged — he was naked below the waist. At some point, before he entered our room, his pajama pants and pull-up were removed.

A mystery had arisen. Yes, the game was afoot.


Rewind 10 years.

I am three months into intern year as a pediatric resident. I am taking call every fourth night on the inpatient pediatric hematology/oncology ward, working 30-hour shifts, covering a floor with 30+ patients by myself, routinely having 10-15 new patient admissions per call. At this point, I was still considering a career in this heme/onc (how life changes).

At 6 a.m., roughly 24 hours into my shift, I sat alone in the doctor work area, before any colleagues had arrived, checking results of morning labs for patients on the floor. A critical value popped on screen when reviewing one of my own patients. His magnesium level was dangerously high, and dramatically higher than the day before.

High magnesium levels (“hypermagnesemia”) can have mild symptoms ranging from mild GI upset to severe issues such as respiratory failure. This patient was in a chronic, maintenance mode with his illness and had no particular reason for this change. The nursing staff had not seen the result, and the lab did not call to notify us directly. It could have been a false lab value, but my gut told me it was real — and I was fairly sure I knew why it might have happened.

The root cause analysis would have to wait, as I first had to check on the patient. I took off towards his room (running, really), worried he wouldn’t be breathing and no one would have noticed.

I burst into the room and flipped on the light. I promptly woke up his mother, who was always at his side (he was only about five years old). I also woke him up and received a dirty look — I already had the sense before that morning he didn’t like me, and bursting into his room early in the morning didn’t further endear me to him (a hospital is a terrible place to sleep in the best of circumstances). I stammered a small apology, found his nurse, had her disconnect his TPN (total parenteral nutrition — intravenous nutrition for those unable to take food in their GI tract), which I suspected to be the cause of his electrolyte abnormality.

I knew the TPN was the cause, because as soon as I saw the high Mg+ level I was sure I had written his TPN order incorrectly and caused the problem. The pharmacy made a new bag of TPN that was started up at night for our patients. Every order had to be written in the morning (all orders on paper). And even if the composition of the TPN was identical to the previous day, we had to write a new order.

In the section where I had to specify the concentrations of various electrolytes (sodium, potassium, magnesium, etc.), I had transposed a number from another row into the magnesium concentration area. This led to the patient’s TPN being created with a much higher concentration of magnesium than was appropriate. No one noticed my error. The pharmacy made the TPN as ordered, and the nurses started it up before bedtime, the way they always did.

It turns out his Mg+ level, though high, wasn’t high enough to cause him serious harm — he was fine, which is why he was able to give me such a dirty look. It was also plainly obvious that a similar mistake with a different number written down or a different electrolyte mistake could have had significant consequences. Had it been the TPN potassium or sodium concentrations I changed, the consequences could have been dire.

I disclosed the error to the entire team during morning rounds, flagellating myself for the error. They assured me it was a mistake anyone could have made, the patient came to no harm, and that was essentially the end of it. I did go back and tell the family directly about the error. The mother didn’t have much to say. The son gave me another annoyed look, but not much different than his baseline look at me.

As far as I know, no changes to the TPN ordering process resulted from my error. I don’t know if this happened to anyone else or if anyone was ever harmed from it. It’s been a decade since then — I know the culture of that hospital has changed. Not only would such an error be hard to commit there, but if one did, a huge effort would be made to prevent one from happening again.

Medicine still has a long way to go to improve our culture of safety and reduce medical errors — they are still a leading cause of patient injuries and death. Thankfully, the culture of medicine is changing, though at times it seems like change the direction of an iceberg by pushing it by hand.

It’s not all bad — we’ve actually made great strides. The root cause analysis is now a common thing in hospitals. A systematic attempt to identify not just the final step that preceded a mistake, but an effort to discover all steps on a path that allowed the mistake to happen. Then changing the system to prevent that error or similar errors from occurring, ideally creating a system that does not even allow a person to make certain types of errors.

I am fortunate that my “first” mistake (I may have had some earlier ones I never knew about) did not cause serious harm — lives have been shattered and careers ruined over such things. There’s no whitewashing the fact that we are a service industry that was built on the idea that doctor knows best. Mistakes were often considered a result of lack of effort, knowledge or commitment without thought given to systematic ways to prevent harm. The culture is slowly shifting, but the iceberg takes a long time to change directions.


Back to my half-naked toddler.

Befuddled, I carried him back to his room, looked around and could not find his pajama pants or pull-up. I asked him where they were — he claimed not to know. He did, however, kept telling me that he needed his book. I had no idea what book he meant.

He was not holding a book in our room, and there was no book on the way to his room. I told him there was no book, we were going to put a new pull-up on him, and he was going back to bed. He insisted there was a book, but finally told me it was in my bathroom. I told him he was mistaken, as he had not been in my bathroom. He continued to insist that’s where it the book was located.

I finally gave up arguing and went to my bedroom and into our master bathroom. On the floor of our bathroom was a kid’s book, his pants, and his pull-up. Curious and befuddled, but too tired to care, I gave him all the items and tucked him back to bed. My wife appeared to have slept through the entire event, so I decided in the morning a root cause analysis was in order.

The next day I informed my wife of the overnight events. As it turns out, she actually did wake up before I did. She heard a noise, listened for a couple minutes, thought it was coming from our room but not seeing anything or being able to localize it and decided it came from outside.

The noise she heard, though she didn’t know it at the time, was our son. He had entered our room carrying a book, entered our bathroom, removed his pants and pull-up, peed in the toilet, left everything behind then came to my bedside to tell me he was scared.

She had fallen asleep before he woke me up, and I had no idea he was had already been in our room before then. She did not know that he was the noise from our room until I filled in the rest of the story, and it made me realize I had not woken up as soon as he entered our room, the way I normally do (and thought I did this time). It turns out that our son, who normally enters a room like the Kool-Aid man, had finally learned how to enter the room quietly.

Mystery solved.

So what action plan was taken to prevent this from happening again? Well, chaining him to his bed and locking him in his room didn’t work (Kidding! Do NOT call child protective services). We haven’t figured out a solution. Twice in the past week we discovered him at 10:30 p.m. asleep on the hallway floor outside his brother’s room. He’s just a wandering spirit that cannot be contained.

Despite having several years experience at both doctoring and parenting, I still have a great deal to learn. Unfortunately, there are probably more mistakes in my future, though hopefully not as many as in my past.

“Rogue Dad, MD” is a physician who blogs at his self-titled site, Rogue Dad, M.D.

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