Medical Errors

I was there the day the neurologist accidentally killed his patient.  It was during my hospital training as an  x-ray technologist. The patient had been admitted complaining of migraine headaches.  As part of her workup, the doctor performed  a carotid arteriogram, an injection of contrast material followed by a rapid series of x-rays taken to visualize the brain.

In preparation for the exam, a tray had been set up with the equipment the doctor would need; sterile gloves, hemostats, gauze pads, a syringe, and containers holding the dye and some green tinged alcohol used to clean the sight of injection.  I had positioned two rapid fire film changers holding multiple x-ray films, one under and one to the side of the patient’s head. The patient lay flat on her back, her head held by a radiolucent sponge and thrust back so that the doctor had easy access to the arteries in her neck.  (Today, a catheter is threaded into position through an artery in the groin but in those days, the injection was made directly into an artery in the neck.)

The doctor wore a lead apron to protect himself from the scatter of the x-ray exposures and my teacher and I stood behind a lead glass window. I held the trigger in my hand, ready to press the button that would expose the films. The doctor, his back to us, spoke to the patient as he prepared her for the injections.  My eyes flicked to  the exposure settings of the x-ray machine to be sure they were correct. As he made the injection, the doctor yelled SHOOT and I pressed the button. Hearing  the reassuring clangs made by the multiple exposure machines, he quickly stepped back and laid the syringe on the tray.

Almost immediately, we knew something had gone terribly wrong. Instead of lying motionless on the table, the patient  began to seize. The doctor ran to her side and tried to hold her down. We rushed to help keep her from falling off the table. And then . . . her body went limp. Her breathing stopped. Her eyes rolled back in her head. She was gone.

Shocked and confused, the doctor stared from the motionless body on the table to us. “Jesus! he cried. “What happened?”

Aghast, we searched the room for a cause. Our eyes came to rest on the syringe lying on the tray, a drop of green tinged fluid seeping out of the tip of the needle. As realization dawned, the doctor made a choking noise and  staggered against the table. “Oh my God. ” Shoulders slumping, he took off his gloves and struggled out of his protective lead apron. “I must speak with her husband,” he murmured.

Dazed, I asked my instructor, “What do we do now?”

“Nothing. I’ll take care of this. You go to lunch, and . . . ” she added. . . “don’t say anything.”

As time went by, I heard or witnessed other incidents, some of which caused the death of the patient. Surgical instruments or sponges left inside patients happened so frequently that one surgeon demanded his patient be x-rayed before being taken to the recovery room.  Miscommunication between patient, physicians and hospital personnel  occurred all the time.

In 2000 the Committee on Quality of Health Care in America reported “that between 45,000 and 98,000 Americans die each year as the result of medical errors. If the lower figure is used as an estimate, deaths in hospitals resulting from medical errors are the eighth leading cause of mortality in the United States, surpassing deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297), and AIDS (16,516). Moreover, these figures refer only to hospitalized patients. . . ” These figures were published by the Institute of Medicine.

After the report came out, hospitals took a much more serious approach to error prevention. For years, hospitals had been paying large fees to gain accreditation by The Joint Commission, one of several privately funded organizations whose goal is to monitor and continually improve the health care provided by hospitals and their personnel.  Those organizations have ramped up efforts to decrease medical mistakes.

Computers have helped prevent some communication problems but mistakes still occur and now we face a serious shortage of trained hospital personnel resulting in an often overworked staff with its incumbent fatigue-driven results. Yet, the simple practice of hand cleanliness has substantially reduced infection.

However, lest we get too complacent, like it or not there is still a ‘wall of silence” that surrounds hospitals. Fear of lawsuits prevents some doctors from admitting negligence. The neurologist of whom I spoke told the patient’s family the woman had suffered a stroke and died before anything could be done to save her. Medical staff members said nothing , perhaps out of loyalty, fear of job loss or reprisal. Blame played a part and reputations were at stake.

This too may be changing. Reporting has been made easier and in some cases, can be done anonymously. Cause of errors becomes a reason for protective procedural changes with better safety measures the goal.

I am still haunted by my decision to say nothing that day long ago. At times, my family and I need the services of a hospital and my hope is that change comes fast enough to protect us all.