Two decades ago, an anesthesia catastrophe at a Wisconsin hospital killed a pregnant woman named Joy.
The young mother-to-be was undergoing a scheduled C-section, but a series of mistakes by the nurse anesthetist led to a tragic end, leaving the baby brain damaged and the family devastated.
There was another victim that day. Dr. Gary Brandeland didn’t make the mistake, but Joy was his patient. Her death sent him on his own downward spiral of grief and gave him a first-hand view of how doctors and hospital workers react to medical errors.
Dr. Brandeland, now an emergency room physician in Minnesota, has chronicled the tragedy in a moving article in a 2006 issue of the journal Medical Economics. What’s so fascinating about Dr. Brandeland’s story is that it explores the emotional toll medical mistakes have on doctors and nurses who witness them, and looks at the economic factors that he says often are ultimately responsible for medical errors.
After the recent publicity surrounding the medical mistake that almost killed the twin babies of actor Dennis Quaid, I spoke with Dr. Brandeland about how medical mistakes affect the people who care for patients.
When medical mistakes happen, a lot of people blame the health care worker involved. Is that entirely fair?
The greatest common risk to patients is the understaffing of nurses. A nurse may make a critical mistake, and a patient might die. She has to live with the error, but the real culprit, the root cause often is that she or he was understaffed and overworked and a mistake was made. The hospital doesn’t pay for it on a personal level. They just get a new nurse.
I’ve seen excellent nurses who make mistakes when things get overwhelming. They are minor, and fortunately I haven’t seen a death due to a medical mistake since this tragedy happened. But I think we’re at a critical point right now where health plans and insurance companies are trying to trim costs and are cutting back on quality. Instead of the individual, I think the anger should be at the hospital structure if in fact there is a history of understaffing at that institution.
This wasn’t your mistake and you weren’t sued or blamed in any way, yet you write about the enormous personal and professional toll the tragedy took on you. Why did this affect you so much?
Everyone in the operating room is going to feel somewhat responsible. The patient came to me as someone who was going to safely help her have a baby, and the end result was this disaster. In the end, I was the one who talked to the family. I was closer to them because I’d seen them for nine months.
Have you ever been the victim of a medical mistake?
I was a patient in 1998 at a world famous medical center. The nurse came in to give me a pill. I had a heart condition and I recognized right away that it was wrong and I would have died. She came back and sort of laughed and said, “Oh, I guess the doctor wrote the orders on the wrong chart.” I would have left there with a toe tag if I had taken that pill.
How did the death of Joy change your view of medicine?
I became overcompulsive and less tolerant of any sort of mistakes at all. I felt more concern about people who were working for me, such as the nursing staff, and the mistakes that could be made. When there is a mistake, you go through almost the stages of grief. You second guess yourself. I also developed a profound sadness. I can’t describe it in words. I think about people who have lost a loved one, I think of families who have lost troops in Iraq and other tragedies where someone is killed in a car accident. It’s a sadness that doesn’t go away.
I highly recommend that you take the time to read Dr. Brandeland’s complete essay, click here.
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From 1 to 25 of 148 Comments
The doctor makes some interesting and even contradictory remarks that are worth taking a much closer look at.
He says most mistakes occur due to understaffing of nurses. (I would, in fact, concur with this, based on everything I have experienced and heard from other patients and families.) Not all, but many.
Yet, he then goes on to recount an experience in which a nurse laughs off what was almost a fatal mistake—one in which, btw, she would have been directly complicit.
This is distancing, it is a defense, and it is denial. Denial of reality, of the facts.
And this is the kind of denial you hear about *constantly*—–in fact in these TPP blog posts, where many, many people have posted stories of terrible medical incompetence both in and out of hospitals, but mostly due apparently, at root, to understaffing of nursing and associated hospital support personnel.
It’s my experience that nurses and other medical personnel, including occasionally doctors, can be the biggest codependents on the planet. That means they are in the habit of trying to control (often long before they become nurses–so many come from alcoholic families it’s not funny), they are taught they must control, they find on the job that they can’t control, and so eventually they begin to try to cope by denying what is happening and sometimes even begin to blame the patient. Sometimes that lack of ability to control–ie to keep on top of the illness and keep the patient stable and comfortable–has a lot to do with being overworked.
Docs don’t seem to do it as much simply because they aren’t charged in hospital with the minute-to-minute responsibilities that nurses are. Docs are actually more off the hook when it comes to that. But docs do deny, usually by distancing from how much discomfort a patient is in, or how severe are the ’side effects’ to the main symptom the doctor was focusing to treat or suppress.
I focus on denial because, as the doctor who wrote the essay notes astutely, it’s all about the denial of the medical administrators and insurance companies about how many personnel hours are really needed to give high quality care.
— norcal girlAtul Gawande makes a compelling case for the use of checklists and other systems in medicine. Had there been a checklist–i.e., check for breath sounds. Check for pulse ox, this tragedy could have been prevented. I feel for the doctor, but unless I read the article wrong, he was actually in the OR during the surgery. Perhaps his prolonged suffering stems from the fact that he never thought to check her respirations or oxygen sats himself. I am sure he has been through 20 years of what ifs.
— AbbyThis is a frightening and tragic tale, and I find it disturbing from several systems perspectives. Besides the one about oversight, why on earth was Dr Brandeland - who wasn’t even the primary OB on the case - talking to the family alone??? As a physician who handles acute emergencies, I sometimes have to give devastating news to families and I never do it alone; I always bring in support personnel and members of the team. Further, I try to document that I was there and what I said (I have very little doubt that the reason Dr. Brandeland was not named was because he was the one that was there).
— Chet MThe other sad aspect of this that merits comment is the fact that the hospital will likely settle the lawsuit; everyone will run for legal cover, and the system of delivering care will not change in any meaningful way. But it so obviously does. Pt died because of no anesthesiologist? I submit this could have been avoided by a $2.00 device that changes color on exhaled carbon dioxide, and the will to mandate its use on every patient
From 1990 - 2008, I have taken care of both of my parents and then my husband, all of whom had serious medical conditions. All of whom are now deceased. In each case the patient was cared for at a Harvard teaching institution. In each case the patient had a personal physician with whom they had a long-standing relationship and, in two cases, the patient had a prominent, highly-recommended surgeon. The patients had the best health insurance, they were not old, they were educated, they spoke English, they were interested and compliant and they had a family member involved in their care on a daily basis. There is not enough space to recount the life-theatenting (and perhaps life-shortenting) errors that occurred. Only once did we receive an unsolicited apology. (However, I receive fund-raising solications from these institutions.) The mistakes were made by physicians, nurses, physical therapists, and staff. I do not believe my experience is unique, or even unusual. I tell friends to never enter the healthcare system alone. This is much easier said than done, but it is crucial.
— MariaI’ve been reading quite a few books by physicians about what it’s like to work in the medical field lately, and the more I read, the less trust I have in hospitals. I realize the people who staff them are only human, but it seems like, for whatever reason, they make far too many avoidable mistakes that have grave consequences. It’s scary!
— HeronNever got sued for malpractice because when mistakes occured I immediately told the patient and the family what went wrong, the steps being taken to correct the error, kept honest complete charts and didn’t send a bill.
Re Maria’s comment (#4) I avoid getting care university teaching hospitals because most times care is delivered by house staff. Better to see top university physicians at the private hospitals with no house staff they use for private patients.
— MARK KLEIN, M.D.I take issue with Dr Klein’s implication that university teaching hospitals are more prone to error. As residents, we are told again and again that asking for help is NOT a sign of weakness, and is never the wrong course. Published rates of errors have shown again and again that teaching hospitals generate fewer medical errors and better overall patient outcomes. Adding a resident corps adds to the number of eyes seeing and examining a patient and their concerns, which can only be useful.
— Pediatrics ResidentMedical mistakes are a serious issue, with incidences of hundreds of thousands annually. I’m very concerned about the tone of Dr. Brandeland’s answers, which appear to find only the nurse as making the mistake. As with any group, there are individuals who are prone to error. However, my observation is that nurses, as a group, are professional and complete the tasks at hand.
We should remember that hospitals are organizations and thus, have a management structure. Patients have the expectation that “hospital management” has appropriate processes in place to execute medical activity in an efficient manner. They also expect that “hospital management” has “weeded out” employees (whether nurses, doctors, technicians) who cannot meet the hospital standards. All management teams, whether for a hospital, business, sports, etc. have challenges. If it is understaffed…..increase staffing; if it has too few “qualified” employees….increase pay and bring in more qualifed employees. The list goes on, but this is what MANAGEMENT is paid to do. In the specific instance, it’s completely unfair to leave the blame completely in the lap of nurses.
Similar to most articles and studies, this discussion is about “observable” medical mistakes. One “unobservable” medical mistake which may affect many baby boomers as they age, is the risk of temporary or permanent cognitive impairment, i.e., memory loss, due to the improper use of anesthesia during major surgery, e.g., hip replacement, knee replacement, cardiac. Although the problem is well documented, there appears to be no follow-up with patients on the specific issue of the anesthesia-induced cognitive impairment. The hospital moves on and, unfortunately, the patient is sometimes, perhaps often, then erroneously deemed to have “alzheimers” or some other form of dementia, which is then “treated”. This is clearly a “medical mistake” which flies “under the radar” and is never publicly discussed. It is a mistake because it doesn’t have to happen.
The vast majority of health professionals, including doctors, nurses, technicians, etc. appear to strive toward minimizing mistakes. In business, one concept of quality is the measurement of “cost of quality”. This is a quantitative number, in dollars, of the cost of “not doing it right the first time”. MANAGEMENT must make this work throughout the entire organization. Don’t single out nurses….don’t single out doctors. Management must get EVERYBODY on board and have a consensus toward “doing it right the first time”.
— Phil, NebraskaRecently two of my children had appendicitis in the same year.
— Just a dadThe first a student went to an emergency room and was and later released. His appendix burst and he was back in that hospital. The hospital failed to give him a scan that would have caught the problem. He had renal failure and they still said it’s probably the flu. Flu test kits are about $8 and most doctors have them. We stayed there 24/7 and realized his catheter was a problem. The nurse overlooked this. He would not have received as good care had we not been there.
The second case was my youngest daughter. She went into her doctors’ office with pain in the right location but again it was dismissed as the flu. She was suffering and it was her birthday. I got home that night from a business trip. The next day we went back to the doctors’ office and had a different doctor. She said it could be the flu but wasn’t sure. I said give her the flu test. She did and it wasn’t the flu. We then went to a clinic for blood tests and a hospital for an ultrasound. It took the technician five minutes to identify it was appendicitis. She had the operation and then was in the hospital for a couple days. During that time she was given an IV tube for water, sugar and meds. Her arm was quite swollen. The nurse said she is allergic to the meds and changed it just to water and sugar. The arm was still sore and swollen. Finally I asked her to take it out and she said no it should stay in. I said get the doctor. It was in the night and up came the night doctor. I said, she can eat and swallow why not let her just drink and give her a pill if needed. It’s cheaper for you and will take away the swelling. It was done and she was better. Was the nurse overworked? Yes. Did the failure to identify the real problem, the appendicitis, result from an overworked nurse, not really except for the I.V. and the catheter issues.
I am a consultant and have worked some with hospitals and medical supply companies. The issue with the Quaids was a failure on multiple levels. It has happened before in one case I know, a premature baby died as a result of an adult dosage of a drug mistakenly administered to this infant. The nurses are often the last line of defense but recall in the article the doctor wrote the drug order on the wrong chart. Doctors make many prescription errors, pharmacists send the wrong drug at times, and nurses fail to detect the problem. It is a multiple step issue. Often two or more errors have occurred.
There is new technology that can eliminate most of these problems but often the hospitals won’t invest. In the Quaid’s case it is more shocking as this is a rich hospital.
The technology requires the doctor to enter the drug order in a handheld. It would check against the patient record and stop a wrong drug. Then the nurse scans the drug when she picks it up, this stops the grabbing of a wrong drug or dosage, then the patients bar coded wrist bracelet is scanned and this stops the drug going to the wrong patient. It also stops a drug from being administered that the doctor just changed and the nurse or pharmacy didn’t know about yet.
My take on this, if you can, stay with your loved one and question everything.
There is a nursing shortage in this country and it is getting worse. Furthermore, insurance companies are more and more squeezing as much profit out of the system as possible, and fewer and fewer people actually have insurance that pays a reasonable amount to the health care providers. The few nurses that I know are totally overworked and stressed out from overwork. Not only is too much expected of them when they are on the job, but many of them work too long hours and never fully recover from their work on their days off. There is no way mistakes are not going to happen in such a system. The whole system has to change, otherwise it will continue to go downhill and we will have a 3rd world medical system.
— ceciliaAccording to many reports, studies and literature evaluations, between 400,000 and 1,000,000 Americans die every year due to the medical care received (MCR).
— healthinfoThe infrastructure and financing promote illness, disease, death and profits, not wellness and health.
Just ask anyone who has experienced MCR recently, even those whose lives they feel have been saved.
Or reflect on the fact that the cigarette and drug industries are again reported as financing studies to promote expensive, somewhat dangerous and often unnecessary so-called early diagnostic tests that do not promote primary prevention (do not or stop smoking), but do lead to a lot of MCR, often with little gold standard proof that they primarily prevent, cure or eliminate the need for never ending treatment.
The front line health care providers see this every day, often are victims themselves of overwork and stress, but for economic reasons (need a job)show up and remain mostly quiet.
Before we start down the road of expanded insurance coverage, we need a new solution and restructured infrastructure to support affordable wellness and health. The cost of illness and disease will then be reduced naturally despite cries for more supply side economics to help us through our woes.
For a slide presentation on this subject, e-mail healthinfo@delhitel.net and put Infrastructure Presentation in the Subject line and your name, phone and affiliation in the text section.
Nursing shortage is only an excuse; it is rarely the critical factor. The issues are more with incompetence and poor attitude of many nurses, and systemic problems. Many nurses spend more time ‘documenting’ nonsense than actually doing and thinking about patient care. Attitude of “It is only a job” is reflectd by how jobs are done. Going back to some well publicized cases of nursing errors years ago in Auburn, NY and in Springfield, OH when the same errors were repeated by the same person, you’ll agree that the issues were incompetence and attitude. There is more of a shortage problem when the people in the system are less capable.
There are many other problems in the system. I simply express my opinion on the nusing factor from my personal experience.
— jet3936I am an attorney.
No matter what hours I may work, no matter what may be afflicting my in my personal life, there is one thing I am reconciled with: If I make a mistake and my client suffers (either financially, or by being sent to jail) I expect to be sued and punished. I deserve it.
That is what entering a true profession means; it means that I have no right to make a mistake.
— DAs a nurse, I have a few comments on medical errors (at least from a nursing perspective).
Hospitals are very understaffed, as most people are already aware. Patient loads are at times ridiculous. For example, as a bone marrow transplant nurse I would have to draw labs for all patients at 5am. Sometimes I might have up to 5 BMT patients on a shift. Add in the extremely high number of meds all of the patients are on, and the emergencies that regularly come up with that patient population, and some shifts there was no possible way to get everything done on time. Not only that, the hospitals are so short-handed that as a new graduate I was hired to work on a floor that a few years ago I would have needed at least one year experience before being hired. Brand new nurses are hired directly into ICU’s now. That is a scary thought. When I hired in I was told it would be a year and a half before I would be BMT trained - instead it was 6 months. I was told it would be 2 years before I was charge nurse trained - it was 1 year. At times I felt completely overwhelmed, but I was told I had no choice in how quickly I advanced. My preceptors said good things about me, and therefore I was fast-tracked. As a brand new nurse, I was terrified of making a mistake that would seriously harm somebody. Thankfully that never happened.
Also, due to patient overflow, at times we would get patients that we were not trained to manage. I was trained in oncology and BMT patients, so some of the overflow patients were difficult. Thankfully the medical interns and residents were great, and would come up and explain what had been done to the patient, and what needed to be done by the nurse.
The other MAJOR issue was mandating. At the hospital I worked at, we could be mandated for up to 16 hours. I felt ok for the first 14, but after that I would literally by tripping over my own feet. If we said we were too tired we were threatened with patient abandonment.
One more comment for Pediatrics Resident - I agree with you. I would feel very comfortable taking my children to a university hospital with residents. As a nurse, I loved having the interns/residents there 24 hours a day. I have worked at hospitals without that luxury, and believe me, the attendings do not like to be “bothered” at night. The residents are far more responsive to concerns during 3rd shift, and also knew when to call the attending.
— ElizabethRe: Dr. Klein’s comment about academic medical centers
I wouldn’t be so quick to rule out going to an academic medical center. Yes, much of the care is delivered by residents. Yes, they are tired and overworked. However, I’ve been in situations where residents caught errors on the attendings’ part. In my opinion, it’s better to have more than one perspective on a case, which won’t always happen when there are no house staff. Also, if something happens at night, at least there are doctors around. I believe federal regulations only require the emergency room to have an M.D. present 24/7. So without residents, a patient could be out of luck if they needed a procedure only a physician could perform.
Mistakes are going to happen whether or not residents are present. It will require a systems-level change to start reducing the error rate. The Toyota Production System model, which stresses real-time problem solving by the entire health team, is one way to address the issue of medical mistakes at the systems level. I’m sure there are others out there, too.
Also, your comment seems a wee bit hypocritical. We were also residents once, remember?
— Rebecca D., M.D.It’s all about money. Hospitals are supposed to turn a profit. The corporations and CEO’s that own them demand this. The health care workers suffer.
The patients suffer more.
It’s time to take profit out of medicine. Doctors and nurses should earn a good living. People should be hired for some administrative tasks. There should be cleaning staff and food staff. Even the corporations that make the technology and medications should be regulated.
No one else should make money off of health care.
— rini10D the Attorney’s comment was interesting. No right to make a mistake? That’s a pretty tall order. Even the aviation industry recognizes that that’s not possible, and their mistakes can certainly be catastrophic! If you refuse to believe you can make a mistake, you’re never going to learn from it. Some of the new health care quality initiatives stress the fact that it takes an entire team to make a mistake; the person at the end of the chain isn’t the only one who made the mistake possible.
— Rebecca D., M.D.I was in the ICU after being diagnosed with pulmonary emboli (blood clots in my lungs). I was on multiple medications including a very dangerous clot-buster. I was told repeatedly by my doctors not to let anyone stick me with a needle for any reason, not even finger sticks. These orders were placed prominently on my chart. I had to constantly remind nurses and lab people about this, and at one point had to use the call button repeatedly even after asking the person to check my chart. She assumed that since I was young, I was just trying to avoid a needle. I received otherwise excellent care, but this issue was troubling.
— AnonymousOur son had two bone tumor surgeries at a large teaching hospital. My husband and I counted a minimum of four incidents that were a serious threat to his health or life. For example, we walked in one day and he was flushed and shaking. I told the nurse that he must have a fever. She argued with me saying she’d just taken it. I insisted she do so again and it was over 103. Two of the most disturbing incidents we did not even count as health threats. During both admissions he was screaming out in pain and the nurses/residents said it was normal or made fun of him, saying he was being a “baby.” (He was 19.) Both times we finally demanded the anesthesiologist be brought up to examine him and both times the doctor discovered our son’s epidural had come out. One of the anesthesiologists blew up at the assembled group of residents and assistants calling them “incompetent” in front of us. I literally become physically ill whenever anyone mentions that place. You can bet that for any care from cancer surgery to cyst removal we now go to small local hospitals.
— DianeMedical care is better now than it has ever been, as evidenced by increasing lifespans. Mistakes have always been made, but now they are more visible in this litiginous society.
Though we should strive for perfection, mistakes will continue. The best way to minimize their impact is to question everything you don’t understand as a patient or a patient’s health care proxy. Don’t be afraid to look over a doctor’s or nurse’s shoulder and ask questions.
The more you understand, the more likely you are to catch errors. PLUS, the doctor or nurse is more likely to be on his/her toes, since he/she knows someone’s watching.
— jackThanks to Dr. Brandeland for sharing such a heart-wrenching story.
I think the vast majority of health care professionals feel terrible when they make a mistake. They don’t always show it the same way - when I had a medical injury that required surgery to fix, the physician trivialized it, distanced himself and took out his anger on me - but knowing how bad I myself feel when I screw something up, I can’t imagine that nurses and physicians would be any different.
I think the real problem is a medical culture that is either too afraid or too deeply in denial to confront its systemic imperfections.
#16: “It’s time to take profit out of medicine.” Well, uhh, profit is what allows a hospital or clinic to invest in new technology, add services, add staff and so on.
I don’t think there should be obscene profits (however that’s defined) in medicine, nor should the profits be lining the pockets of shareholders and CEOs. But hospitals and medical groups most definitely need to be able to operate at more than the break-even point.
— Perrin J.To my critics–First off I switched from getting care at a top California teaching hospital to seeing the best people in their private offices and their local hospitals.
This is what triggered the switch. Got referred to one of the world’s top specialists for an unusual muscle problem. He recommended a biopsy at a particular muscle site to increase the chances the visual pathology report and tissue histochemistry would be defintive. Got admitted to the famous university medical center for the biopsy.
A 2nd or 3rd year quite arrogrant surgical resident breezed into the outpatient surgery center to do the biopsy. Insisting on taking the muscle from an area the consultant told me might not be productive. I refused to let her operate insisting Dr. Big himself do it himself. Ended up waiting hours for him to come to do it right. The information proved extremely valuable.
After that started seeing the Great Ones at their private offices. My medical care has been a lot better since.
— MARK KLEIN, M.D.I wouldn’t even know where to start on this one, but I can assure you, it’s not always the nurses’ fault. We have commented before–there are nice, thinking nurses and there are angry distracted ones. The doctors are in charge of the care. The hospitalists sometimes won’t even come in your room or face you, but they sure will dish out the drugs! Surgeons have little stickers put on the “right” organ or limb to cut–those can come off. People are afraid to speak up in the operating room if they see something amiss. Another popular medical blog about running a hospital recently posted about how bad a doctor felt about removing the wrong kidney in a patient. I am sure the doctor did feel horrible, who wouldn’t–but that patient, what was he or she supposed to do? Gosh, down to NO kidneys, now what?
— StarI can’t even comment on this one–it would be bad for me…. I am conemplating malpractice on treatment I got–but was assured this morning by a lawyer’s wife that it wouldn’t change anything to sue.
“Exploring the hidden toll medical erros take on the health care workers who witness them.”
Perhaps the above non-medical “erro” should be fixed.
— AnonymousThe most important errors are:
- diagnosis errors;
- interpretation errors (e.g. missing something on an image);
- medication errors (dose, allergy, contraindication, not appropriate);
- anesthesia errors;
- surgical errors (wrong organ or limb).
The most common are diagnosis and medication errors. We can’t do much quickly or easily about diagnosis errors, but we can prevent almost all medication errors!
However, this requires investing in clinical information systems which capture medication orders from the doctor, check them against patient age, weight, history, lab results, other meds, and allergies, and ask for confirmation. Then every patient and every vial of medication must be barcoded, swiped, and confirmed before administration.
However, hospital managers and doctors still refuse to accept that healthcare is a business, not a cottage trade, and needs to be run like any other business, with modern metrics, quality control and improvement, risk and defect management and mitigation, production processes, workflows, and service-line cost accounting.
In any other industry or business, errors and defects create costs, and are measured and aggressively controlled by investment in quality and outcome improvement processes.
Frustratingly, doctors and hospital administrators in the States and the UK strongly resist adopting normal management techniques and the information technology needed for modern management. Which means that Wal-Mart is better managed than the average hospital. They will spout nonsense like “healthcare is not a business!” as if healthcare were a charity or a group of cooperating artisans, or as if “business” meant something cruel and heartless. Meanwhile, the technology is there to prevent almost all medication errors, at low cost, but it’s not being adopted.
— Charles, UK