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Medical Mistakes

Aired July 5, 2002 - 12:30:00   ET


ZAIN VERJEE, CNN ANCHOR: Going to hospitals to fix the problem, only sometimes the problems are made worse.


UNIDENTIFIED MALE: You must be careful about who you allow to touch you in a -- in a hospital environment.


VERJEE: Many simple medical procedures have been fatal.


UNIDENTIFIED FEMALE: Whether it's the death of a loved one or a very serious injury to yourself, you need to understand what's gone wrong.

UNIDENTIFIED FEMALE: They've got to take responsibility.

UNIDENTIFIED MALE: This is a problem with the health care system not incompetent and not careless individuals.

UNIDENTIFIED FEMALE: Tons and tons of thousands and hundreds of thousands of medical procedures and tests get performed every single day and perfectly well. They don't make the news.


VERJEE: But some do. Medical mistakes on Q&A right now.

Welcome to Q&A. Imagine going to the hospital for treatment or a surgery and discovering that the wrong limb has been amputated or the wrong artery has been bypassed. What about learning that a medical instrument has been left inside you or you were given the wrong medication and that's left you paralyzed? It's rare, but sometimes it happens.

Joining us to discuss this from New Orleans is Donald Palmisano. He's the president-elect of the American Medical Association, joining us, also, from Philadelphia, Michael Cohen. He's the founder of the Institute For Safe Medical Practices. And joining us from New York is Ilene Corina. She's the co-founder of PulseAmerica, which is an organization that's founded to support survivors of medical errors.

Ilene, to you first, a medical mistake has affected you personally. Your son died. Can you tell us what happened?

ILENE CORINA, CO-FOUNDER, PULSEAMERICA: My son had what was considered a routine tonsillectomy. He had his tonsils out. He had his adenoids out and he had tubes put in his ears. The surgery actually went very well until the -- we went home that night and a few days later, he started bleeding. And he was bleeding for a period of about seven days. And during that time, we went to numerous physicians and hospital emergency rooms and all these doctors said, "Don't worry. He looks fine." And on the eighth day after surgery, he actually bled to death.

VERJEE: So who do you blame for this? I mean what went wrong here.

CORINA: Well, I blame a system that went wrong. I don't -- I never said that the doctors were bad doctors. I think that he was a child that slipped through the system. And it was terrible -- it was a terrible mistake and a lot of people made a terrible mistake with this three-year- old child.

VERJEE: Ilene, you're in touch also with other survivors of medical mistakes and families of survivors of medical errors. What are some of the stories that they tell you? And what other kinds of experiences are people having?

CORINA: Well, everything that you said at the beginning of the show - - things go wrong all the time. A lot of the people don't know what went wrong and as part of the problem is that nobody is telling them what went wrong although you go in for one thing and something else happens, which is what's happening in hospitals and health care now.

VERJEE: Michael Cohen, how often does that happen?

MICHAEL COHEN, FOUNDER, INSTITUTE FOR SAFE MEDICAL PRACTICES: First of all, let me give my condolences to Ilene and her family. I'm sorry to hear about that situation.

These things do happen. I'm not sure that we really have a good handle on how frequently. We rely on a voluntary reporting program where practitioners actually tell us their story. They're doing that out of altruism. They wouldn't let us know the kinds of things that have gone wrong, but we can't really measure how frequently things like this happen.

I think steps are being taken now in various states here in the U.S. and other countries as well, to get a better handle on that through various types of reporting programs that are now starting up.

VERJEE: But let's pinpoint this, Michael. I mean you have an independent review of medication errors and so forth. You're in touch with what's going on. What is happening that is creating these problems and people dying...

COHEN: Well...

VERJEE: ... as a result of this.

COHEN: You know, really, there is no one thing. As you heard, it really is a system issue. For example, in my field, which is medication safety, it could be anything from the way that the pharmaceutical companies label products. Sometimes it's -- they're very confusing to the practitioners. They misread labels. Sometime we have sound-alike drug names, look-alike drug names. We have poor practice related issues in some of our hospitals who are now building in appropriate check systems into our processes.

So there's many different reasons for these. And that's the whole idea of reporting programs, to learn the underlining causes of these errors so that steps can actually be taken to prevent them through improvements in the system.

VERJEE: Donald Palmisano, how do you explain all this?

DONALD PALMISANO, PRESIDENT-ELECT, AMERICAN MEDICAL ASSOCIATION: Well, we think that -- first, it is one error is one error too many. But we think that medicine in America is very safe and thousands of procedures are done every day with outstanding results. But we should try to fix the system.

I think the previous speakers have pointed out we need a system fix. We need a system where information is reported without shame or blame. Experts study that information and report back to the individuals and disseminate the information to everyone else so that no one else has to suffer the same fate. And we see that with the work that we're doing now, the National Patient Safety Foundation, with others. It was founded by the American Medical Association and our mission is to advance the art and science of medicine and the betterment of public health.

We are supporting a bill in Congress now; both in the House and the Senate, to encourage reporting and have experts analyze this. It doesn't do any good to gather data and not look at it. We need to have experts look at. But system problems need to be fixed.

VERJEE: System problems are certainly one thing that is being pointed out, but what about the issue of doctors. And some of them say, "Look, you know, we feel that if we report any medical errors here, we're the ones who are going to get sued and we're the ones who are going to have a major problem on our hands." So they sort of cover it up or don't report it.

PALMISANO: Well, the litigation system in America is certainly out of control, the tort system. We've identified that. And what we need is a confidential reporting system. We look to the successes of the anesthesia reporting system. We look to the successes of the aviation safety reporting system where information can be sent in -- if you have a near miss, you almost hurt someone, but you can report it and not be shamed or blamed. And that information can be analyzed quickly and we can figure out a way to prevent that. For instance, as a young surgeon, I was always concerned that the anesthesia tube would come out of the breathing tube, which is the trachea, and go into the esophagus. I don't worry about that anymore because now we have pulse oximeters, which measure the oxygen in the blood. We monitor the carbon dioxide that comes out of the breathing tube, so if it slips into the feeding tube, it goes to zero. So these are safety measures, additional system fixes. You can't connect an anesthetic line accidentally to the oxygen line, different connections. Those are the things that we're working on as well as the things...



VERJEE: Ilene, you know, we're talking about blaming the system. There are things wrong here with the system and obviously, as is being pointed out, there are. But the point, it seems to me also, is that people go into these hospitals. They trust their doctors. They think they're going to make everything OK. Is that even the right attitude to go into it? And should people go into hospitals and say, "You know, something may go wrong here and maybe I shouldn't trust my doctor really?"

PALMISANO: Well, you really need trust...

VERJEE: I want Ilene to take that.


CORINA: I think what we -- what we encourage as partnership in health care, we need to go into the doctor and in the hospital and say, "I want to know what's happening. I want to know what the procedure is and I've done some homework on this procedure." And if there's a question to what's happening, then doctors these days should be listening to the patient and let the patient take an active role in their health care. And we're not shifting the blame to the patient. We're not talking about blame. We're talking about -- errors happen. Things happen. And it's got to be a partnership. It's got to be where the patient speaks up. The patient has an advocate or is their own advocate and the doctor listens and includes the patient in their health care.

VERJEE: Michael Cohen, I'm thinking specifically of an incident that I was reading about where, you know, one doctor just made a blunder, a bad mistake and you know, for example, leaving instruments inside of the patient and stitching them back up. I mean is there no direct responsibility that's born there or do you just blame the lack of staffing and bad protocol or they got the names mixed up or that they amputated something wrong?

COHEN: Well, again, my focus is on medication errors and you know, perhaps Dr. Palmisano would speak better to that type of incident. But there are check systems that should be used as part of the system to make sure that that isn't done.

I actually think we've done a pretty good in recent years at identifying a lot of the problems. And we are beginning to see organizations, state regulatory authorities, federal regulatory authorities take action. We're actually letting people know what they're accountable for.

We have an oversight organization here in the states called the Joint Commission on Accreditation of Healthcare Organizations that has a Sentinel event-reporting program. And they're actually beginning to tell hospitals the kinds of things that they need to be doing specifically to prevent specific types of errors.

There will be six National Patient Safety Goals that are going to be established starting in January and they're fairly comprehensive. I think we're in for some real improvements now because we have been able to identify the problem and now, we're able to take action on them.

VERJEE: What kind of action, Donald Palmisano, is going to improve the safety record in the United States for patients?

PALMISANO: Well, the important thing that my colleagues here have mentioned -- the identification, the partnership and the feedback. For instance, concentrated potassium chloride should not be at the nursing station. We've identified that. The JCAHO has done a good job at the Sentinel event reporting that and we've removed that and keep that in the pharmacy.

As far as the -- an instrument being left in or a lap square, a sponge, being left in, it is rare to find a circumstance where the lap or the instrument is left in and the count is incorrect, but one would stop the operation if the count was incorrect. It's when the count is correct that it's left in. So we have an imperfection in the system that we need to address.

Some people address it by taking an abdominal film or a chest film on the area open, the abdomen or the chest on every case. One man did that for over 30 years. And at the end of 30 years, he found he had left a sponge in. And his question is -- was it worth it for all the people to get that radiation.

We need to find a better system, a system that prevents that from happening. But I think it's happening. Both at JCAHO, the National Patient Safety Organization, Michael's group, all of these groups and the consumers that you're hearing from right now, we need to be partners and we need to speak up, which is the JCAHO program, National Patient Safety Foundation, stand up for patient safety. And don't be afraid to ask your doctor, "What is that medication?"

My mom is 88. She had an operation the other day. It was done on the spinal. My younger brother was in the room when the nurse came in to give some medication. I was in the room too. And he said, "Excuse me, what's the medication you're giving my mother right now?" And they didn't get upset by that question and that's the way to do it.

My wife had a knee operation. We wrote an arrow and it said, "Bob" -- that was the doctor's name -- "This knee, Bob." And she -- we put on the other leg, "wrong knee, Bob." And when she came back from surgery, there was a note from Bob. He said, "thanks" with an exclamation point. So...

VERJEE: All right. Donald Palmisano...

PALMISANO: Thank you.

VERJEE: ... thank you so much. Michael Cohen, Ilene Corina, appreciate you being on Q&A with your thoughts, thanks.

Medical mistakes more common than you may think and certainly, not a problem confined to the United States. So what can be done? We're actually going to talk to Britain's chief medical officer about what they're doing when Q&A returns. Stay with us.


VERJEE: Welcome back. We're talking about medical mistakes. What happens when people check out of hospitals with more problems than when they checked in? A recent pilot study in Britain indicated that some 10 percent of patients of Britain are victims of medical errors. Joining us now to talk a little bit about this is Sir Liam Donaldson. He's Britain's chief medical officer.

Sir Liam, there was dispute or so over the numbers in that pilot study by the British government Can you pin down exactly how many medical blunders there are in Britain?

SIR LIAM DONALDSON, BRITAIN'S CHIEF MEDICAL OFFICER: Well, we've been majoring on patient safety for the last year and one of the things that we've done is to set up a National Patient Safety Agency, which will received reports on all adverse events, all medical errors and all near misses in the whole of the National Health Service. And over the last six months, we've been there running a pilot study in 30 hospitals to see how it will work.

The very good news was that the staff were willing to report. We'd been told in advance that because of a fear of blame and retribution, they wouldn't make reports. But we also learned a lot about the problems of collecting complicated data of this sort. And so, when we move to the roll out of this program, to the whole country, we'll be doing it slightly differently.

VERJEE: But there's a case to be made though that numbers necessarily won't tell the whole story when you're looking at hospitals. I mean you need to look also at people in doctors' offices, in nursing homes and...


VERJEE: ... retail pharmacies and all that. I mean the numbers will then not really even be accurate to show the extent of it in Britain.

DONALDSON: Well, most of the research that's been done worldwide -- and there have been three major studies in the U.S., in Britain and in Australia -- have come to very similar conclusions. But they've all been based on hospitals and we need to move out into the community and extend the data gathering to -- as you say, to doctors' offices and into community health centers. That's what we're doing in our pilot study.

But most of the data, as you would expect, comes from the hospital area because that's where the high technology work is and that's where the opportunity for error of a more serious nature is more common.

VERJEE: You said before that many of the blunders have been caused by system errors, faulty equipment, lack of protocol and so forth and emphasize that these are preventable. So why is it that it's happening and it hasn't been prevented now?

DONALDSON: Well, when we talk about this subject in public in Britain and use a term like "system error," which we, as professionals, use a lot, people don't really understand what we mean by that. And I think it's important that we don't forget that we expect from our doctors and our nurses high standards of practice, high skill and conscientious practice.

By having said that, we have to believe that human error in any field is inevitable. And we have to accept that it's inevitable. We can't remove it entirely. But what we can do is reduce its impact so that when an error is made, it doesn't cause any harm. And that's been done very, very successfully in the airline industry. And it's been achieved largely through learning from what goes on and implementing the learning to lower risks.

And so, what we've seen in the airline industry is a major increase in reports, but a major reduction in the severity of those reports. And that's what we would like to see in the health service as well. And as a patient, I would not want to be treated in a hospital that didn't make reports because if that were such a hospital, I would conclude that they weren't taking safety seriously.

VERJEE: So if I'm a patient and I'm going into one of the hospitals, should I just have low expectations of the doctors and the nurses and say, "Look, you know, they're fallible people and you know how they get things wrong sometimes." And I shouldn't think that this is someone who is capable enough to protect me and to care for me.

DONALDSON: No, you should take the view that serious medical error is very, very rare even though many people come into hospitals with serious health problems and are treated with very highly complex techniques. Even in those circumstances, error is rare.

But what you should be confident about is after 50 years in which nobody recognized the concept of medical error or patient safety in America, in Britain, and in some other western countries, this is now being taken very, very seriously. So that 10 years ago, health care safety wouldn't have -- or patient safety wouldn't have even been mentioned in professional meetings of doctors and nurses. Now, it's at the very top of the agenda.

So what I think we're going to see is a generally, highly conscientious style of practice made even safer because the organizations providing health care -- the hospitals, the clinics -- that after surgery, will be building safer systems around those highly skilled practitioners so that when the inevitable errors do occur, they won't have the impact to cause serious harm to patients.

VERJEE: One of the issues though that we also discussed earlier in the show is the issue of trusting doctors and this is perhaps an extreme example, but you know, one thinks of Dr. Harold Schiffman (ph) and a gross and a heinous preach of trust between doctor and patient.

DONALDSON: Well, those incidents, extraordinarily rare. An individual like Schiffman (ph), although malicious intent coming along, is an extraordinarily rare event worldwide, a serial killer.

But even in that particular case, we can learn lessons and we can identify that when you look at that case, the opportunities to have noticed that something was going wrong at a much, much earlier stage were all there. It's being looked at, at the moment, in a public inquiry. But I think we'll find that even in the case like that, if the systems were tight, if the data were coming in, if people were looking at the data intelligently, they would spot problems and they would spot trends. And that's the position we're trying to get to.

VERJEE: Do patients or victims of medical negligence get compensated?

DONALDSON: Well, I think they should be compensated. And in Britain, we're looking at a range of options to try and take some of the legal part of medical negligence away so that we're looking at options for no-fault compensation. We're not quite sure what we're going to do now. But generally, in an environment where you have a climate of blame and retribution and people being pursued by lawyers, then we're not going to get people who are willing to make reports from which we can learn because they'll be too fearful to make those reports.

And really, the ideal situation is when the unfortunate experience of one patient is used to help the next patient to come along. That's the position we want to get to.

VERJEE: Tell us, in the few moments that we have -- if you can just nail down to us what the most common cause of errors in Britain is. And I'm thinking of specific things like confusing names or writing the wrong prescription. What are the examples that you can give us?

DONALDSON: Well, 25 percent of medical error worldwide falls into one single category and that's medication error. And within that category, it's confusion over labeling, confusion over the calculation of dosages, confusion in interpreting handwriting. And there are system's ways to correct those things. We can look at computerized prescribing. We can look at bar coding. We can look at clearer labeling. We can look at distinguishing similar drugs much more easily. So there are all sorts of things we can do.

But if we wanted to make some early successes...


DONALDSON: ... and safe more lives, then it's in the field of medication safety that we can make the most gains.

VERJEE: Liam Donaldson, Britain's chief medical officer, speaking to us from London. Thank you Sir Liam, appreciate it.

That's Q&A for now. Make sure you have a good weekend. The news is next here on CNN.





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