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"In healthcare, we make mistakes. Mistakes are made at every level, but you just try to keep them as infrequent and minimal as possible.
When I was a student rotating through OB/GYN, I wrote an order for a woman's post-partum continuation of magnesium sulfate as she was pre-eclamptic antepartum. I was careful because I knew what could happen with magnesium toxicity, and double-checked the order with the resident afterward.
The nurse, instead of hanging one bag of mag-sulfate and another bag of something else, she hung two bags of mag-sulfate, one of which she slammed into the patient over a minute, instead of slow-infusing over 12 hours.
The woman told the nurse she didn't feel right, and the nurse messed it up. I happened to be walking by and stopped in to see what was up. There they were, two bags hanging, both marked with a bright red warning label. We called for the fast response team.
They and my team got there in time and took over, but she still went into respiratory depression and ended up in the ICU.
I reamed the nurse when I overheard her laughing about the incident like she hadn't just almost killed someone. I don't know what she thought, getting told off by a rotating student, but I was upset at the time."
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"When I was an intern in the surgery department, I remember this guy (We'll call him John) in the late 50s came to the ER at 2 a.m. complaining about some vague abdominal pain. His medical history was free of any events except for absolute constipation for almost a week. My senior and I were thinking of intestinal obstruction and proceeded to do lab investigations for the patient and x-ray. The x-ray showed massive abdominal distention, so we decided to prepare him for abdominal exploration. After blood samples were withdrawn, and while we are waiting for the results, the patient asked if he could sleep a little on one of the beds in the ER. He was calm, and there was nothing that requires attention so we thought why not? One hour later, the lab technician called us. I remember the conversation we had:
'Hey, you have a patient named John?'
'Yes, he's in the ER.'
'What is he doing at the surgery ER? His blood glucose is 600 g/mol!!!'
I closed the phone and ran toward the patient. He was having a DKA (diabetic ketoacidosis), and we didn't know. When I reached his bed he wasn't asleep. He was dead. We tried to resuscitate him, called for help, but it was too late. He didn't mention anything about his blood sugar when we asked him. We failed to see that a patient with DKA could be presented by abdominal pain. I will never forget the look of his sons. He came to the hospital looking so good, walking on his feet and died within an hour because we failed to do a basic test that wouldn't take more than 30 seconds. I couldn't sleep for weeks."
"Pathologist here. The biggest mistake I ever made was cutting myself during an autopsy on an HIV patient. Lucky for me, I did not acquire the virus, so everything had a happy ending. For me, anyway. That guy was still dead."
"The first week of my intern year (year one outside of medical school, when you're on call overnight and all that, AKA 'Season One of Scrubs'), everyone 'signs out' their team's patients to the doctor on call overnight. So that doctor (intern, with an upper-level resident, also present overnight to supervise) is covering numerous patients they hardly know, maybe 60 or more. The situation was that a patient with dementia, unable to really communicate with people and clearly 'not there' but conscious, arrived from a nursing home with agitation as the original complaint.
Basic labs ordered in the ER showed the kidney function is worse than usual, which could be due to a number of things, but what really MUST be distinguished is between 'not enough blood pumped forward to the kidneys and rest of the body' (e.g. heart is failing and it's backing up into the lungs) VS 'not enough liquid in the blood TO flow' (e.g. due to vomiting a lot or something). This is critical to distinguish because for the first you give medicine to make them pee out the extra liquid, and in the second you give more fluid. Either treatment for the opposite problem is catastrophic. Fortunately it's usually easy to distinguish 'wet' from 'dry', based on: listening to heart and lungs, checking the chest x-ray (is there 'congestion' evidence?), checking blood pressure and heart rate (tend to drop BP and raise heart rate upon going from laying down to standing positions if you're too 'dry'), looking at neck veins while sitting up at an angle (they bulge if too 'wet'), and so on. This patient was unable to cooperate with the exam, answer questions, and the X-ray was sort of borderline (It was unchanged from the last x-ray maybe several weeks ago). My resident instructed me to sign out the patient with instructions to continue a 500mL saline inflow, then re-assess to see whether the patient looked more 'wet' or less 'dry'. I signed this out and forgot to make the order to stop the saline after 500mL, so it ended up running slowly in all night. The intern on call (also first week as a doctor) forgot to re-assess at all or shut off the saline if it had been noticed because they were so busy with new admissions. We'd also ordered three sets of 'heart enzymes' meant to diagnose a heart attack, which is one reason for a patient suddenly getting 'wet' (i.e. heart pump failure). Because the EKG was not interpretable (had a pacemaker which makes it impossible to tell). Lab messed up too because hospital policy was that if the first set of 'heart enzymes' was negative, apparently the second and third sets, each traditionally spaced six to eight hours later to catch a heart attack if it starts to evolve and become detectable by a blood test, were both canceled.
I came in and first thing in the morning checked on this patient, who was screaming things nobody could understand and the nurses had chalked up to dementia and agitation. I checked the labs and saw the second and third heart enzymes hadn't been done. I went to the bedside and saw the IV fluids still running. I immediately ran to the overnight intern, who said things had been so busy and nobody had called to notify that things were wrong. We stopped the fluids, immediately got a heart enzyme test, learned this patient was by now having a massive heart attack made much worse by the addition of IV fluids all night to this frail failing pump. I can't get the screams out of my head, and cried a lot and was pretty depressed for a few weeks at least after this. The patient died because the status ended up being decided as not to resuscitate based on what the nursing home had on file, although no family members were known at all. This patient was totally alone and spent the last night of their life in physician-induced agony. But I acknowledge the failure of two interns, the nurses, and the lab. Ultimately the blame fell on the lab and I think someone was fired, but I made clear to everyone that I felt to blame and wanted quality improvements made to prevent future errors, or at least catch them early if they happen. That's I think the best you can do when you make a mistake.
There's a Scrubs episode where I recall at the end there's a brief scene where the ghosts of dead patients representing medical errors follow around the physicians like little trains. It's very poignant."
"Intern (1st year resident) in Internal Medicine here. My third week out of med school, and I was in the ICU on night-shift. I had around 30 extremely sick and complicated patients for me and my senior resident to handle, and a few more coming in from the ER. My senior told me to manage the current patients while he did the new admissions. I was 'signed out,' meaning given information from the day team, about all the patients and what I needed to watch out for and follow-up on at night.
One patient, in particular, Mr. X, was an elderly man in his 70s with altered mental status (he was acting loopy and nobody knew why) and nobody could get any information out of him. He was in arm restraints because he was pulling out his IV lines and acting aggressively towards the staff. He was also developing what appeared to be signs of sepsis. He needed a CT scan of his abdomen that night to look for a possible source of infection, and it was part of my job to follow-up on those results and start any necessary antibiotics/consult surgeons/etc if needed. No problem. About 30 minutes into my shift, I get paged that the patient is supposed to go down to radiology, but he's too agitated to sit still for the scan.
So I decided to give him a medication called Ativan to calm him down enough for the CT to be done.
About 10 minutes after I gave the phone order, I hear the alarms go off and the overhead announcement of 'Code Blue - CT scan. Code Blue - CT scan.' My heart skipped about five beats.
I run down to radiology and call my senior to meet me there. As I arrive, the patient is laying on the scanner, unresponsive and not breathing. His nurse said his breathing became shallow then abruptly stopped. His adult daughter was standing beside him glaring at us.
But we were capable and ready to revive him without a problem - he just needed some respiratory support (a little help breathing). I got the bag/mask and meds ready. That was until his daughter said, 'Don't touch him!' I had forgotten Mr. X was on file as DNR (do not resuscitate) by his family's wishes. I knew I could save him, but my hands were tied.
In those last minutes, I had to watch my patient die. I anguished over my decision to give him the sedative. Did I give him too much? Should I have not given him the sedative and just canceled the CT scan outright? What would have happened if we never found the source of his infection? Mr. X's daughter wasn't surprised that her father died that night. She was upset, but not at me. She was a better person than I would have been in her shoes.
The next morning my attending physicians (supervising doctors) told me Mr. X was on the edge of death, to begin with, that he probably would have died of his infection in the next few days, that I didn't really make a mistake. I didn't and still don't see it that way though; I knew they were just trying to be supportive. They all answered that if they had been in the situation they would have used an antipsychotic like Haldol instead of a benzo like Ativan. I still wonder how that night would have gone differently if I had known that medical fact just one day earlier.
That was in July. It scared the heck out of me and haunted me for months afterward, but it made me a more vigilant doctor."
"As a young doctor in training, I misdiagnosed a woman with epilepsy. Some years prior she had sustained a shot wound to the frontal area, damaging the underside of one of her frontal lobes and severing an optic nerve to one of her eyes, as well as some of the muscles that rotated that eyeball. Surgery saved her life but the frontal lobe was scarred, and the eye was blinded and always pointed down and at an angle away from her nose.
A few years after that she began having spells of a bizarre sensation, altered awareness, a pounding in the chest, and she had to sit down, stop what she was doing, and couldn't speak. These were odd spells, and I assumed she had developed frontal lobe epilepsy from the scar on her brain. Increasing doses of anti-seizure prescription seemed to work initially, but then the spells came back.
A couple of years after my diagnosis, her endocrinologist, who treated her for diabetes mellitus, checked a thyroid. It was high. The spells were manifestations of hyperthyroidism. She drank the radioactive iodine drink which ablated her thyroid, got on thyroid replacement therapy, and felt well thereafter. No permanent harm was done, and she was able to come off the anti-epilepsy prescription.
She was obese - not the typical skinny hyperthyroid patient - and if she developed thyroid eye disease, I couldn't tell because her one eye was already so messed up. I see how I messed it up. However, in retrospect, I have never been sure what I could have done differently, except test her thyroid at the outset of treatment. Hence, a lot of patients - thousands - have had their thyroid checked by me since then. Every so often I pick up an abnormality and it gets treated.
The lady was an employee of the hospital where I trained, and I ran into her one day; she gave me a hug and let me know how this had all gone down. She made a point of wanting me to know she didn't blame me 'because I always seemed to care about her and what happened to her.'
I think about her, and how I messed up her diagnosis and set back her care, almost every day. I am a much better diagnostician now, but I always remember this case, and it reminds me not to get cocky or be too sure that my working diagnosis is correct."
"I missed a bullet wound once. A guy was dumped off at the ER covered in blood after a rap concert. We were all focused on a wound with an arterial bleed that was distracting. The nurse placed the blood pressure cuff over the shot wound on the arm. We all missed it because the blood pressure cuff slowed the bleeding.
I was doing the secondary assessment when we rolled the patient, and I still missed it.
We didn't find it until the chest x-ray. The bullet came to rest in the posterior portion of the thoracic wall without significant trauma to major organs.
The patient lived, but I still feel like I messed up big time."
"I tried to protect the kidneys of a gentleman who had to get just a TON of contrast. Ended up giving him too much fluid and pushed him into pulmonary edema. Spent about an hour on bi-pap, but he did OK after.
Did a FAST ultrasound on a trauma patient. Thought it was negative, but in retrospect had a small pericardial effusion. He coded about 30 minutes later after said effusion expanded. He had so much head trauma everyone told me he wouldn't have lived anyway, but I still feel awful about it.
EVERY resident and doctor makes mistakes and the ER is basically a perfect storm of the factors that contribute to errors (multiple patients, constant interruptions, fast-paced environment, lack of familiarity with patients, ETOH/prescription, incomplete histories, and multiple providers). You just hope that when they happen your mistakes are small.
Our hospitals and programs try hard to have a blame-free work environment as when you review common medical errors they are usually caused by a culmination of circumstances rather than one person just not doing their job right. Residents routinely present M&Ms (morbidity and mortality conferences) that go through the scenarios that led to the mistake and analyze the reasons and fixes that can be made. It's universally thought of as our best conference because you can often see how very easily one could have made the same mistake in the other person's shoes.
As has been said, we try our best to do right by patients and to get the right answer. I work with incredibly smart people every day who are driven, committed, and who have excelled their whole life in order to be incredible doctors. Unfortunately, errors are part of the job. We just need to do your best to recognize them, learn from them, and most importantly prevent them from occurring more than once."
"My first day as a camp nurse for people with intellectual disabilities, I gave nine prescription drops to the wrong guest. I didn't know who I was looking for and asked my friend to send out the guest. His hypochondriac roommate walks out, tells me he is the person I'm looking for, I asked my friend for confirmation who THOUGHT the correct person had come to me and confirmed from afar that it was, and I administered the meds. He had a LOT of medication allergies. Stomach dropped when the actual person I was looking for came out 12 seconds later.
Luckily, we called poison control and most of the pills were vitamins and the ones that weren't vitamins were either similar to ones the guy was already taking, or in therapeutic low-dose form. He was fine and still continued to ask for everyone else's prescription at all times.
Worked there two summers, and thankfully had no other disasters like this one."
"I messed up when I was fresh out of training to be an ICU nurse. I admitted a crash-and-burn patient. They were young, but in bad shape. Extreme hyperkalemia indicating kidney failure, just waiting to code. The nephrology doctor was called in to place a dialysis catheter so they could start dialysis because the elevated potassium level (hyperkalemia) would inevitably cause a heart arrhythmia (weird heartbeats that require shocks and emergency meds). Their respiratory status declined precipitously, and the blood gas I got (indicating how well they were breathing) was terrible, but I didn't call it in fast enough to the attending. We tried Bipap (a machine that forces air into your lungs via face mask) but what we should have done was intubate (insert a tube into the lungs to force air via a machine in a more invasive but more effective manner). Granted, I was being supervised and constantly consulted both my charge, a seasoned ICU nurse and the respiratory therapist, also experienced and trusted. That patient died. I don't hesitate as much to call the attending if I need to. The patient was pretty much on death's door when they arrived, but the marginal chance of saving them was lost in moments of hesitation and indecision.
Another mistake I have made was not checking the IV medications that were going to a patient I had been taking care of for five months straight. I knew their medications and doses back-to-front, so I neglected to do the safety checks required at the beginning of the shift to ensure that the right medication was going at the right dose. Turns out that two of the medications were switched, so they were getting a higher dose of one and a lower dose of the other. The medications (dobutamine and nesiritide) are not forgiving, but fortunately, the different rates were almost negligible. At that point, that patient had become a friend and I was their advocate. I messed up and told them straight up that I did. Even though I wasn't the one that set those meds up incorrectly, I didn't check because I thought I knew better. The patient forgave me, for which I am grateful, and my ICU director also appreciated the fact that I took full responsibility for my mistake, but I can tell you that I still feel bad and will forever check my drips upon assuming care of a patient."
"My brother had a mic-key put in his stomach so that he can be fed through a g-tube due to aspiration risks secondary to cerebral palsy. During the surgery, the surgeon accidentally perforated his bowel, and it went unnoticed. This is probably due to my brother's unusual anatomy as he has severe scoliosis and kyphosis. My mom started to notice my brother appeared to be in pain. He, however, had no way of telling her what was wrong (non-verbal and no control of muscle movements). She then noticed the smell of feces coming out of his incision site. His medical team assured her he was alright and she was overreacting.
It was soon discovered that he was going septic as his digested food was going back into his stomach and poisoning him. By this time, he was in life-threatening condition and had to be airlifted to a city a four-hour drive away. The perforated bowel was repaired, and my brother made a full recovery. His surgeon now does that procedure differently to prevent the same complication, and I've been told it's been effective. I believe he does an endoscopy before closing up, and that adds 5-10 minutes to the surgery. My parents had no interest in suing and are glad my brother is healthy, and his situation helped advance medicine/possibly save others."
"I had a 9-year-old girl brought in one night with her parents complaining of fever and respiratory distress, presented with coughing and wheezing. The kid was out of it, and the parents were upset. I thought it was Bronchitis, but I admitted her and ordered treatment for her fever and cough as well as throat cultures.
I was with another patient when the kid started hallucinating, sobbing, and spewing everywhere. I figured it had to do with the fever, so I packed her with ice, but she died maybe a half hour after that. This wasn't my first death, but it was one of the worst. I couldn't tell she had a stiff neck since the kid was out of it. She also couldn't tell me anything else that would point to simple or complex seizures.
She died of Neisseria meningitis. Completely wrong diagnosis. To make matters worse, we called in all her schoolmates and anyone else we could wake up just in time to see three other kids go. The rest got antibiotics quickly enough.
Probably my worst day in medicine."
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