Still waiting: Apology for a medical error

Jeni Dingman's plaint:

Today it will be 16 years ago that I lost my dear and wonderful mother due to multiple medical errors, miscommunications, and a flawed healthcare system that did not pay attention to the needs of patients and families. As there have been some changes in those years, years that I have freely given to a cause that I hope someday will save lives, 250,000 Americans still die every year due to medical error. The most important change has yet to come. It must concern communications, patient engagement, patient empowerment and partnering. This can ONLY occur if we are welcome and invited to participate by our providers. Most of all, patients and families must be listened to. I do not know what outcome might have occurred had clinicians listened to my mother and I so long ago, but do I know that my pain would not be as intense as it is every single day had we not been discounted, written off and ignored by those entrusted by our family to do the right thing. My mother was NOT anxious as the clinicians indicated, she was in trouble, and no one rescued her, no matter how hard I tried to get them to listen, they didn't, and they never ever apologized either, I am still waiting for that apology.

Thanks to Jeni for her source posting to Facebook.

Here in Massachusetts, many members of the Consumer Health Quality Council of Health Care for All have experienced errors in their families, but have not received apologies. We have filed a bill to encourage doctors and nurses to apologize for medical errors. We hope that any upcoming federal legislation about medical malpractice claims would strongly encourage, if not require, apologies.

Read a story about a hospital's apology.

Airline pilots and NASCAR teams have them: Hospital checklists

Dr. Peter Pronovost's story:

I was a young doctor doing specialty training in critical care, and I was exhausted. Partway through a 36-hour shift at my academic medical center, I was hungry and hadn’t slept for 24 hours, but I was facing an overflowing intensive care unit and somehow needed to discharge five patients to make room for more. Mr. Smith (not his real name), who'd had esophageal surgery [in the gullet], was a borderline call. But because of the pressure I was under, I decided to remove his breathing tube and transfer him to another unit.

That turned out to be a very bad decision. Before long, his breathing sped up as his oxygen levels dropped dangerously. I needed to reinsert his breathing tube. But what I didn't know was that he had severe swelling in his throat. When I looked into his mouth and tried to identify his vocal cords in order to insert the tube, all I saw was a swollen mass of dark pink tissue, like raw hamburger.

I took the instruments out and started to bag him, breathing for him, but he vomited, making that almost impossible. I finally go the tube in – but quickly realized it was in his esophagus, not his airway where it belonged. When you insert a breathing tube, you give the patient medication to stop his breathing. You have about four minutes before he suffers brain damage. It took me between three and five minutes to get the tube properly placed.

I waited anxiously for the medication to wear off, which usually takes about 15 minutes. But after an hour, he was still asleep. After six hours, I was panicked. Luckily, he regained consciousness shortly thereafter and recovered with no ill effects.

Before I pulled that tube, I should have had to complete a checklist that included input from the patient's senior physician and nurse. If anyone had disagreed, I wouldn't have been able to act. Many medical errors occur because hospitals lack standardized checklists for common procedures designed to minimize the chance of bad judgment. Airline pilots and NASCAR teams have them – why don't doctors?

A few years ago, I helped develop just such a list for doctors and nurses in more than 100 ICUs in Michigan. It focused on a common intensive care procedure: inserting a catheter into a vein just outside the heart for delivery of intravenous liquids. It ticked off five steps everyone had to follow, and in 18 months, it lowered the rate of catheter infection by 66% and saved 1,500 lives.

Such checklists are the subject of a bill just introduced to the Massachusetts legislature as Senate Docket #1766/House Docket #879.

Advice: Let your state legislator know you’d like such a law.

Read Paul Levy’s blog post about reducing central line infections through checklists, or read another story about checklists.

Thanks to Joe Kita and Dr. Pronovost for the source story in the October 2010 issue of Readers Digest.

I'm happy to give you a free blood test: A tetanus shot injection error

Ellen Kagan's story:
At the end of my visit with my new primary care doctor, he asked me if I wanted a tetanus shot. I acquiesced. He went to get the syringe and came back very quickly, shoving it into my arm. Pulling it out as if he had hit a live wire, he exclaimed, "My God! I forgot the serum!"

I stared at him blankly, totally losing my ability to breathe and to comprehend what he had just said to me. Then I started to understand and I became terrified, starting to shake uncontrollably, in my Johnny and my legs dangling over the side of the table. All I could think was, "Where did that needle come from? Did he just give me AIDS?" And, unbelievably, because my mind was completely frozen, I allowed him to come back and insert another needle into my arm, this time with serum.

Dazed, I quickly got dressed and met him in his office, where he told me that I was in great condition. "Sure," I thought, "if you didn't kill me just now!" I could hardly say a word to him – I think I responded in monosyllables – and then ran as fast as I could out of his building.

I was so traumatized that I did not tell anyone what had happened to me. I just could not process it and felt sure that I was going to die. AIDS was a major topic at this time – 1993 – and everyone had heard horror stories of patients, as well as doctors and nurses, contracting it through contaminated needles.

Finally, three weeks later, unthinking, I blurted it out to my friend, Joe, who was stunned and cried, "My God, Ellen, that doctor could have killed you. That's how prisoners get rid of themselves in jail. They inject air into their veins!" Luckily for me, the tetanus shot goes into your muscle or I would have been dead instantaneously in the office of my doctor, a Harvard Medical School Professor of Medicine.

Later, to get my medical record, I made the trek back to his office, a place that I never wanted to see again. When I arrived, he was innocence itself when he greeted me and, instinctively, I understood that his attitude was a cover of his fear of what I would do about the tetanus shot. Focusing all his attention on me, he asked, "Why don't you want to come back to me, Ellen?"

I was certain that he already knew my answer, but that he was hoping that I had brushed off the terrifying incident. Moreover, by questioning me in front of his patients, I believed that he hoped that I would be too embarrassed to confront him. Clearly, he did not know me, and, undaunted, I said in as loud a voice as I could summon, "Well, Doctor, you almost gave me a heart attack when your tetanus shot had no serum. I was scared stiff – I still am – that you gave me AIDS. Where did your needle come from?"

Calmly and coolly, as if he were asked this question every day – and maybe he was – he said, "Oh, Ellen, that needle was perfectly fine. To prove it, I'm happy to give you a free blood test!" I looked at him in amazement. Did he really think that I would let him near me again and that I would trust his results? I declined his offer and was out of his office as soon as possible, grateful that I was still alive to tell the tale.

I have one regret about this incident: I did not report the doctor to the Mass. Board of Registration in Medicine. My beloved doctor Hank had protected me from the dark side of medicine, and I was a novice in Medicaland. As a result, I believed that the tetanus shot mistake was an aberration and that it would never happen again.

Today, though, I know that these horrors happen all the time. Therefore, I would be proactive and make public these terrible events. By not taking such a stance, I allowed an incompetent doctor to continue to practice very bad medicine and, perhaps, cause grievous harm to many more of his patients.

Read a story about a vastly different way that another culture prevents tetanus.

Thanks to Ellen Kagan for authorization to reprint this excerpt from her book, Ellen in Medicaland: True Stories of How I Fell Down Medicine's Black Hole and Still Lived After All.

If you would have come earlier: A cancer misdiagnosis

National patient safety expert Dr. Peter Pronovost describes what got him started on his crusade:

My father died at age 50 of cancer. He had lymphoma. But he was diagnosed with leukemia. When I was a first-year medical student, I took him to one of our experts for a second opinion. The specialist said, "If you would have come earlier, you would have been eligible for a bone marrow transplant, but the cancer is too advanced now." The word "error" was never spoken. But it was crystal clear. I was devastated. I was angry at the clinicians and myself. I kept thinking, "Medicine has to do better than this."

Advice: Get a second opinion promptly upon receiving a crucial diagnosis.

Read a very different story about the need for a second opinion. Thanks to Claudia Dreifus for the source interview in the New York Times of March 9.

But for the grace of God: Abigaile LeBron and caps on medical malpractice damages

After vaginal bleeding from unknown causes in the third semester of her pregnancy, Frances Lebron had a very difficult labor, and gave birth by C-section to Abigaile LeBron in an Illinois hospital in 2005.

It's hard to know exactly what went wrong. A jury agreed that Frances' Ob-Gyn doctor and nurse had not performed appropriate and timely tests on Frances, and/or didn't recognize, and appropriately intervene upon discovery of, a non-reassuring fetal heart tracing, and/or inappropriately continued labor-delaying ("tocolytic") medication, and/or failed to perform the C-section promptly enough.

The poor little girl suffered severe and lasting brain injury, and cerebral palsy, among other results, and will not be able to feed herself; she needs a gastronomy tube. She'll need substantial help for the activities of daily living, probably throughout her life. Of course, that will cost a lot of money – which the jury awarded.

The Illinois Supreme Court recently decided an appeal of that decision. The state Supreme Court ruled that a newly legislated cap on damages for medical malpractice is unconstitutional. The result is that the jury's award will indeed be able to help Frances care for Abigaile.

There, but for the grace of God, go I. Twenty years ago, doctors at a Harvard teaching hospital slowed my wife's premature labor with such a "tocolytic" drug (Turbutalene), and continued the drug too long, as with Frances – but my son was born healthy, and my wife had no ill effects. We were lucky.

I'm sorry for the anguish suffered by Frances and Abigaile, and by their doctor and nurse.

Advice for people who've suffered catastrophic medical errors: Ask potential lawyers if you'll be faced with a cap on damages in your state.

Read another story on a C-section error. Thanks to Illinois attorney Martin Dolan and Lauren Bishop for discussing and forwarding this story.

What we have known all along: ACGME's review of guidelines for residents' work hours

I still remember the helpless fear I felt on a bus in 1978 as we twisted our way along the narrow hilly road leading to Jerusalem, steered by a sleepy bus driver. Each time he nodded off, his head then snapped right up again. Thank God, we arrived safely.

But God didn't prevent an accident from exhaustion when my son was born, 12 years later. Going into premature labor eight weeks early, my wife was admitted to a Harvard teaching hospital, where doctors delayed her childbirth for a week. Then when hearing one evening that she was experiencing abdominal pain, the sleep-deprived residents confidently attributed them to gas pains! Finally the next morning, a pelvic exam revealed her cervix was nearly fully dilated, ready for delivery. Exhaustion had ruined their judgment, so my wife had to suffer the pain of childbirth for 12 hours without any pain medication.

Now the Accreditation Council on Graduate Medical Education (ACGME) may start facing what we have known all along: exhaustion creates errors. Even for very intelligent and dedicated doctors. At ACGME's Board meeting on Feb. 7 they'll consider whether to restrict the hours that hospital residents can work.

Supporters of the status quo say that shorter work hours require more dangerous hand-offs from one doctor to another. This is seductive but misleading. Yes, sometimes an alert and well-rested resident hands off the responsibility for a patient's care to another alert and well-rested resident, and communicates clearly and comprehensively. But much more often, an exhausted resident hands off to a chronically sleep-deprived resident. We know that exhaustion fogs memory, and clouds judgment and complex thinking, like the ability to prioritize and summarize. So it's hard to imagine that hand-offs as they are now performed consistently provide a clear and thorough briefing for a patient's care.

The best solution is both to reduce the use of exhausted residents, and thoughtfully improve the hand-off process. Error-proof it by minimizing the reliance on memory. For example, how about a "Hand-off" command in the electronic medical record system that could automatically summarize the patient's diagnosis and recent key lab results and vital signs for a doctor coming on shift? Or the audio recording of the hand-off communication as it occurs, for prompt automatic transcription into the electronic medical record?

A bereaved mother and national patient safety leader – Helen Haskell – organized a press conference today on these topics. She is leading an effort to reduce residents' work hours – which could have saved the life of her 15-year-old son, Lewis Blackman. See the new website on shortening residents' work hours, and share your story there.

Would you want my Israeli bus driver as your child's doctor in the hospital?

Read a fatal fatigue error story.

Overmedicated and misunderstood: Appropriate care for the elderly

Candy Schulman's story:

July 2, 2009
To the Editor:
My 96-year-old mother, who died two weeks ago, had difficulty finding physicians trained in geriatric medicine, even though she lived in Florida.

She was overmedicated and misunderstood. Early symptoms – and potential treatments – were missed. A robust woman who drove and played golf until she was 90, she felt infuriated whenever presenting a symptom, only to hear many doctors respond, "What do you expect…at your age?"

Once a year I took her for a checkup with the head of geriatrics at a leading New York teaching hospital, a gifted physician who reduced her medications. But the geriatrics department was eliminated. My mother never found another geriatric physician with the same insight and sensitivity until she was in hospice care. She received better medical care when she was dying than when she was living.

We desperately need to fill this huge gap in medical care between middle-age patients and the elderly at the final stage in their lives.

Advice: There are many electronic databases now that assist in the choice of a doctor. If you have trouble finding them, get the help of a professional patient advocate.

Read a story about drug interactions in the elderly.

Thanks to Candy for her letter, reprinted from the July 8 issue of the New York Times.

The Impact of Medical Error on Family Members: A study

Sherry Worsham, a graduate student at Harvard, is conducting a study on the impact of medical error on family members. She is looking for adults with a family member who experienced an injurious medical error between Jan. 1, 1999 and Jan. 1, 2009 to answer a 30-minute online survey. You can learn more about it here; type in CAT as the password.

Advice to injured patients and their family members: Look for opportunities to tell your story.

Thanks to Helen Haskell of Mothers Against Medical Errors for passing this on.

40th Birthday in the Kingdom: A fatal misdiagnosis by an EMT

Gina's story [the names are changed]:
My older sister was 39, almost 40, and lived in Beaufort, South Carolina, on St. Helena's Island. My kids called her Aunt Mell. One day, we had to call for emergency help for her. The firemen came first, then two EMTs (emergency medical technicians).

The emergency medical technicians (EMTs) tried to help her up, but couldn't. At that time, at 5:34 am, her pulse was 126, which was regular; she just needed oxygen. They decided not to treat her until she got up herself. One guy thought she was faking it. With a lack of oxygen, you act a little funny…But they said, If you don't get up, I'm going to call the policeman! They wouldn't let me intervene.

So they didn't treat her for some time – for 18 minutes. I was praying for everything to be all right. I was in shock. She was my big sister, and she depended on me to come through for her. That morning, when she really needed me, I felt so helpless. I tried to help her by letting them help her.

He had his boots on her arm to help her stay down, or whatever.

She went into cardiac arrest. The one EMT guy just flipped out, called her by name, and then he knew she was gone. The EMT guy tried to work on her. "We have no time to waste," he said. They tried to revive her for 15-20 minutes, but I knew she was gone already. So instead of having her 40th birthday party with us, she had it in the Kingdom [of God].

I wanted an autopsy. The nurse said, "We have to do an autopsy; who do you want to take the body? I have to talk to a family member." But they acted like there was a mix-up, like one of my other siblings had told them something different. They went ahead and had a funeral service director pick her up, so there was no autopsy.

But their mistake was in the record anyway, so we were able to find out the truth. Most people thought she had died from an asthma attack, but I saw, and I knew better. I never thought I'd witness a medical team that didn't give help. It was such a nightmare – I thought I was dreaming.

I went through all of this in a deposition with a lawyer. The EMT guy was really mean; he had anger management issues. My attorney picked up on that, and said, He's a very angry man! But nothing happened to that man.

My mom was devastated by this. She spoke at the deposition, and poured her heart out. That brought her peace. She knew the truth, but was in too much pain to talk about it. The stress from all that shortened her life.

I haven't told anyone about this for ten years, until now.

Gina's Advice: If the EMTs don't seem to be helping your family member in an emergency, call 911 again, or call the police. Act right away!

Read another story of a 911 call gone awry.

Thanks to Gina for telling her story over the phone. A fuller account can be found in the October 2004 issue of the Journal of Emergency Medical Services, in Volume 29.

Motivated to advocate for quality improvement: “Quality Care Saves Lives” Event at the Massachusetts State House

This is a transcript of my introduction this morning’s event at the Massachusetts State House:

My name is Ken Farbstein and I serve as President of the Consumer Health Quality Council.

The Consumer Health Quality Council consists of a diverse group of people who have suffered, or whose family members have suffered, health care errors. So we are strongly motivated to advocate for quality improvement and patient safety. The group has been active since 2006.

Today four Council members will be sharing their stories: John McCormick from Pembroke, Jen Tosca from Kingston, Robena Reid from Acton, and Lucilia Prates, our founder and former president, from Arlington. Their video stories serve as powerful examples of those who are taking an active role in improving health care quality in Massachusetts. I would also like to acknowledge all of the Consumer Council members who are here today. Please stand up. Thank you.

The Council Members have been working with students at Boston University School for Public Health to make these video stories. We want to thank Dan Dao, Daniel Lau, Elizabeth Romero, and Nandini Ravishankar for their work.

If you are interested in learning more about the Council, please feel free to pick up information at the table or speak with me or any other member of the Consumer Council or Kuong Ly of Health Care For All.

You will hear some individual stories today, just a few of the many – too many -- stories across Massachusetts that make clear why we need to improve health care quality.

The short videos appear here.


John McCormick's Advice: You can insist on having a more senior doctor see the patient if you are unsatisfied with the resident's care.

See another video from Health Care for All.

He'd sailed through heart surgery: Failure to rescue

Six-year-old Christian Padilla of Fort Wayne, Indiana had sailed through a successful heart surgery to correct a birth defect in 2005, only to die days later from the preventable complications that characterize a failure to rescue case.

"The nurse didn't recognize his symptoms as something of concern," said the boy's father, Jim Padilla, 38, an assistant professor at a local university. "She described him in her medical notes as 'acting fidgety.'"

In reality, Christian was unconscious and suffering seizures as a result of the brain swelling that killed him, said his father, who received a $1.25 million combined settlement from the Indiana Patient's Compensation Fund and the hospital, according to the Indiana Department of Insurance.

It's not clear whether a drug reaction or another problem caused the swelling, said Padilla, who was at his son's side, frantic, throughout the ordeal.

"We got to the point where I had asked multiple times: 'Should he be sleeping so long?'" he said. "Over and over, I was told this was normal.'"

Such a failure to make a diagnosis in time, or to provide treatment in time, is called "failure to rescue."

The nurse's failure to notice Christian's subtle but increasing symptoms of distress is a key element of this measure of how well hospitals respond to unexpected complications — or don't, said Dr. Samantha Collier, chief medical officer for HealthGrades. "As an example, somebody comes in for an elective surgery like a knee replacement and turns up with vague symptoms, like shortness of breath, and the next thing you know, somebody dies," explained Dr. Collier. "It's obvious that if you go in for a knee surgery, you shouldn't die."

The term "failure to rescue" refers to cases where caregivers fail to notice or respond when a patient is dying of preventable complications in a hospital. Between 2004 and 2006, failure to rescue claimed more than 188,000 lives, amounting to about 128 deaths for every 1,000 patients at risk of complications, according to a report from HealthGrades, a health care ratings organization. That's more than any other measure found in the 2008 report, and indeed in five consecutive annual reports by Health Grade.

Advice to family members of a hospitalized relative: Insist that a Rapid Response Team help your relative if you see them declining rapidly in the hospital.

Thanks to JoNel Aleccia for the source story in MSNBC, and thanks to Helen Haskell.

When she had a second check: Kylie Minogue's breast cancer misdiagnosis

The Australian pop star Kylie Minogue appeared as a guest a few months ago on comedienne Ellen DeGeneres' TV talk show. She had just heard Ellen and her earlier guest, Senator Hillary Clinton, discuss the importance of the early detection of breast cancer. Ellen asked Kylie about her bout with breast cancer two years before.

"Listen, this is an opportunity for me to say something that I have not said before," Kylie said.
"I was misdiagnosed initially. So my message to all of you and everyone at home is, because someone is in a white coat and using big medical instruments doesn't necessarily mean they are right."

The misdiagnosis had happened before she embarked on her Showgirl concert tour. Later, when she had a second check, it was discovered she had breast cancer. She is now in remission.
Ellen DeGeneres also told the audience she had a mammogram and was given the all clear, but then "a couple of weeks later" she found a lump in her breast and had it removed.

Kylie Minogue's advice to women tested for breast cancer: "If you have any doubt, go back again."

Read a story of delayed detection of breast cancer.

The source article appeared in the Sydney Morning Herald of April 8, 2008.

They walk the talk all the way to Japan: The healthiest response to a fatal medical error

I was privileged to hear a talk today by Dr. Gary Kaplan, the CEO of Virginia Mason Medical Center in Seattle. He described their long quality journey in using the Toyota system of lean production.

He spoke of a preventable death of a patient in 2004, and what the medical center has done to systematically prevent medical errors.

Mary L. McClinton had moved from Alaska to the Seattle area in 1996. She had dedicated her life to helping others, her family said. She was even adopted by the Tlingit tribe for her work as a vocational coordinator. She worked at the Greater Trinity Missionary Baptist Church in Everett, Washington, helping to find jobs for people with physical and mental disabilities.

Mary went to the hospital in 2004 for an eye procedure, and as she was sitting in a waiting room, a large picture, about 6 feet square, fell onto her head, and "knocked her silly," her son Gerald said. In the days afterward she felt dizzy, so he took her to an Everett hospital where a brain scan revealed a swelling in a blood vessel in her brain - an aneurysm.

Later, she came to Virginia Mason Medical Center for treatment for the aneurysm. The hospital had recently switched from a brown iodine-based liquid to a clear antiseptic for cleansing a patient's skin before and after procedures. During the procedure to treat the aneurysm, hospital staff would inject a clear marker dye into the patient's blood vessels to make them visible on X-rays. "At some time during the procedure, the clear antiseptic solution was placed in an unlabelled cup identical to that used to hold the marker dye," according to a hospital memo tracing the root causes of the error. The antiseptic, rather than the dye, was then mistakenly injected into a main artery that carried blood to Mary's leg.

The antiseptic solution was highly toxic when injected into a blood vessel: it blocked the flow of blood to her muscles, causing the leg to swell; her blood pressure dropped, her kidneys failed, and she suffered a stroke. She died soon afterward, in November 2004.

The hospital promptly took the unusual step of publicly explaining, and apologizing for, the error. The only way to improve patient safety, Dr. Kaplan said at the time, is to be "open and honest about our errors. ... You can't understand something you hide."

Since the error, the liquid antiseptic has been removed from the hospital and replaced with a swab on a stick. It's now impossible to mistake the clear liquid dye for the swab. This is an example of pokayoke – a safeguard that makes an error impossible.

Most of us try to suppress the memory of a big error. It's to the credit of Dr. Kaplan and his management team that they instead tried to use this awful error to stimulate their continued improvement. Indeed, the hospital has developed the Mary L. McClintock Award, and has made awards annually since 2006, to teams that have significantly improved safety in the Critical Care unit, the IV [Intravenous] Unit, and the Stroke Center, in the last three years.

Dr. Kaplan mentioned Mary in his talk this morning, but, appropriately, did not make her the centerpiece of his talk. The hospital's quality journey started before the error that killed Mary, and is far more system-wide than even the clinical functions that ripple around her care. Board members are now expected to join the CEO on trips to Japan to continue learning how to improve quality, using Toyota’s methods. Each Board meeting begins with a story by a patient or family member about an error. Staff on various teams have now participated in 500 intensive five-day sessions to redesign specific elements of the hospital's care.

Virginia Mason used several of the same elements that CareGroup (then a six-hospital system in eastern Massachusetts) did in its multi-year quality attempt to become the safest hospital to get medication in the world: The CEO very publicly led a high-profile multi-year broad project. Clinicians regularly discussed errors to learn from them. And well-grounded, proven change concepts provided the basis of the transformation.

Advice to people needing hospital treatment: Find a hospital that learns from its errors rather than hiding from them.

Read about another look-alike error.

Thanks to Nick Perry and Carol Ostrom for the source story in the Seattle Times of Nov. 25, 2004.

We can still do some good: Public learning from a fatal misdiagnosed aortic dissection

This story was the subject of a particularly popular seminar at the conference today of the American Society for Healthcare Risk Management in Boston. It was so popular that the room was filled to capacity, leaving many others outside – like me. So this story comes from Michael O’Connor of the Omaha World-Herald, rather than from the presentation by lawyer Sara Juster, Vice President of the hospital:

Watch a new video produced by Methodist Hospital and you'll see Tyler Kahle looking just like he did the weeks before he died: chiseled face, short brown hair and a big smile.

The death of the 19-year-old Omahan five years ago resulted in a lawsuit against Methodist and an out-of-court settlement that included creation of the video.

Parts of the 20-minute video are a tribute to the young man. It shows him graduating from high school, skateboarding, wave-boarding and doing the high-energy activities he loved.

Other parts carry messages that legal experts say are surprising and uncommon.

In the video, initiated by Methodist, the hospital's doctors acknowledge the mistakes that Methodist made in diagnosing the medical problem that caused his death. Legal experts say it's rare for doctors and hospitals to publicly acknowledge mistakes after a settlement.

"It's more common that they don't parade around [saying] that we made a mistake," said Craig Dallon, a professor at the Creighton University School of Law.

What's also unusual, he said, is that Methodist has posted the video, made in cooperation with Tyler's family, on its Web site and plans to distribute it as a DVD nationally to educate other hospitals and doctors about the aortic dissection that led to Tyler's death.

"It was a way to memorialize Tyler, and we hope to prevent this from happening again," said Sara Juster, a vice president for Nebraska Methodist Health System, whose duties include overseeing the hospital's legal cases.

During negotiations for the settlement with the man's family, Methodist raised the idea of the video and the family backed it, said Juster and Deb McMillan, Tyler's mother.

Deb said the video provided the justice she wanted for her son. She wanted Methodist to publicly admit its mistakes. She also wanted the hospital to help educate other health care providers and prevent deaths.

"If I can't have my son back, we [can still do] some good," she said.

During an eight-day span in fall 2002, Tyler went twice with chest pains to the Methodist emergency room and once to his family doctor at Methodist Physicians Clinic.

All three times, Methodist physicians diagnosed and treated Tyler for upper respiratory problems.

Deb repeatedly told Methodist doctors about her son's family history of aortic dissection, but he was never given a scan for the ailment. He died four days after his last trip to the Methodist emergency room.

Aortic dissection — deadly if not diagnosed quickly — is a tear in the lining of the main artery for blood leaving the heart. It can be spotted with medical imaging equipment and can be treated. The ailment, which killed actor John Ritter, runs in families, including Tyler's.

In the video, Methodist doctors say Methodist did not take into account Tyler's family history of aortic dissection and did not consider the fact that it can occur in young people.

Dr. Anton Piskac, Methodist vice president for quality improvement, said in the video: "We had multiple opportunities to do the right thing and repeatedly neglected to do so."

Dallon, the law professor, said the video may reflect the frustration some doctors and hospitals have with defense attorneys who typically advise not to acknowledge any mistakes. The "I'm sorry" laws in Nebraska and more than 25 other states are another sign, he said.

Nebraska's law, approved in the last session, makes a health care provider's expression of apology, sympathy or compassion inadmissible as evidence of liability in a lawsuit.

Juster said Methodist wanted to share its experience because hospitals across the country have lacked an understanding that young patients with a family history of aortic dissection can suffer from it.

She said Methodist did not offer to produce the video as a way to reduce the financial payment to Tyler's family that was part of the settlement. Both sides declined to reveal the amount.

Omaha attorney Jeffrey Welch, who represented Tyler's family, said money wasn't the family's priority. They wanted to keep the young man's memory alive and prevent other deaths.

Advice to parents: If you disbelieve a doctor's diagnosis, ask what else it could be. If you know an inheritable condition may be involved, ask if that can be ruled out as a diagnosis, and why.

See a short video by a survivor about an instructive medical error.

An hour after being discharged from the Emergency Room: A family physician's conflict of interest

Question for the Ethicist:
I am a family physician. A patient I'd not seen in months passed away about an hour after being discharged from an emergency room. Her mother, also my patient, asked me to review the records and autopsy to see if she should bring a malpractice suit against the E.R. physician and the hospital. I am friends with the physician and on the hospital's board. Ought I to comply with this request?
-J.R., Connecticut

Answer:
You should not. Indeed, you cannot – not properly, not without risking charges of bias. Your attachment to your friend and your position on the hospital’s board create – or may seem to create – divided loyalties. You should recuse yourself from this task, explain to the patient's mother why you are doing so and refer her to a disinterested physician with the expertise to review the records and advise her how best to proceed.

Update:
J.R. met with the family but did not offer a medical opinion, explaining that the records offered insufficient information for him to do so. He said he believed that they would not be satisfied unless the matter were investigated further and so suggested they speak to a lawyer who would have a neutral expert review the case.

Read about another ethical issue.

Thanks to Randy Cohen for the source story in the Ethicist column in the New York Times Magazine of May 25.

I should be an indignant patient-plaintiff: Apology for drug interactions and other medical errors

Amy Silverstein’s story:
For the many errors that I have witnessed as a heart transplant patient at a well-regarded New York City hospital over the last 20 years, there has been only one doctor with the courage and character to say "I'm sorry."

I should be one of the "indignant" patient-plaintiffs who send legal costs and insurance rates soaring, but I am not. Money cannot heal the ways that I – and many other patients – have been damaged.

It does not take the surgical removal of the wrong kidney or arm – the stuff of lawsuits – to bring about the kind of injury worthy of a hospital's attention. A patient fills a prescription written by her doctor, only to be warned by the package insert that the drug interacts dangerously with another medication prescribed by this same doctor, and there is error, destruction of trust and near loss of life. And no one pays attention.

Even without the threat of lawsuit, a wronged patient deserves some long, hard thought among doctors and hospital administrators.

The writer is the author of "Sick Girl," a memoir.

Advice: Read the package insert after you pick up your prescription.

Read a celebrity’s fatal drug interaction story.

Thanks to Amy for her source letter to the editor, printed in the May 26 issue of the New York Times.

Twice he was given last rites: Staph infection from a knee replacement

Robert Besse's painful journey began when he checked into a Cincinnati hospital a year ago to get his right knee replaced. The 60-year-old retired pharmacist had worn down the joint skiing and hiking and working on his feet for years.

Ten days after leaving the hospital, his knee was still oozing bits of fluid. "The pain was off the scale," he said. One of his surgeons took a look and immediately had him admitted to a different hospital, where he declined rapidly. Twice during the first night he was given last rites. But he survived until the morning when the surgeon opened up his knee again and found a raging staph infection that took two rounds of surgery to clean up. He spent the next several months on infused antibiotics and pain medication. He was barely able to celebrate his 60th birthday with his family in Breckenridge, Colorado.

He might have fared better at a specialty hospital – one of 200 centers in the U.S. that focuses on the care of a particular body part like the heart, spine, or joints, or a specific disease such as cancer. A study by the University of Iowa on thousands of Medicare patients found that rates of bleeding, infections, or death ("complications") are 40% lower for hip and knee surgeries at specialty hospitals than at big community hospitals. A study funded by Medicare in 2006 found that mortality rates for orthopedic surgery, e.g., knee replacements, are 75% lower for orthopedic patients in specialty hospitals than for other hospitals.

Advice to patients about to have surgery: Consider having the surgery at a specialty hospital.

Read another knee replacement story.

Thanks to David Whelan for the source article in the March 10 issue of Forbes magazine.

Medical negligence acknowledged in detainee's cancer death: A lawsuit

The federal government has acknowledged it was negligent in the death of an immigrant whose cancer went undiagnosed for nearly a year while he was in custody at the San Diego Correctional Facility.

The government last week acknowledged medical negligence, an allegation contained in a lawsuit filed by the family of Francisco Castaneda, 36.

"Was there medical negligence and we're saying yes," U.S. attorney's spokesman Thom Mrozek said yesterday. The claim carries maximum damages of $250,000, he said.

Francisco, an illegal immigrant from El Salvador, was placed in immigration custody after serving an eight-month state prison sentence on a 2005 drug conviction. While at the San Diego facility, he notified immigration officials that he had a large, painful, growing lesion.
Despite recommendations from several doctors, the cancer was never biopsied and Francisco received no treatment except for pain pills during his 11 months in detention, government records indicated.

Francisco was released last year, went to a hospital and was diagnosed with metastatic squamous cell carcinoma. He died in February.

Advice to families of detainees: Advocate vigorously for your relative's health while they are in custody.

Read another detainee’s story.

Thanks to the Associated Press for the source story, printed today in SignOnSanDiego.com. Staff writers Jose Luis Jiménez, Pauline Repard, Mike Lee and Sandra Dibble contributed to this report.

I killed her: My first malpractice suit

I stared down at my name neatly typed next to the word "Defendant." And just below the heading: "Complaint: Wrongful Death Based on Medical Negligence."

Oh my God. Deceased. It was me. I killed her. That's how I heard about my first malpractice suit.

I was the new doctor in the group. I had joined fresh out of residency two years before. I was the first woman doctor in the clinic, and one of only a handful of women physicians in semi-rural Clackamas County.

My last note in Helen Simmons' chart [not her real name] was from last August, a visit for chest pain. I had first met her in my first year in the practice, in December of the year before she died. She had gone to the Emergency Room of the local community hospital with chest pain, and had been admitted overnight for observation by one of my senior partners. Covering for him, I met Helen the next day.

Her chest pain had not been a heart attack, according to blood tests overnight. Her pain was gone. But she was a time bomb, I realized. She had heart disease up and down her family tree, she smoked, and her blood pressure was high.

I told her I was glad she hadn't had a heart attack, but that I was worried she was going to, sooner or later. She could save her own life, I said, by quitting smoking and taking care of herself. She wasn't worried about all that. She wanted to go home and have Christmas with her family.

Her EKG (electrocardiogram) showed she may well have had a prior heart attack, not previously discovered, but that she had not had one just now. Heartburn was the more likely diagnosis, so I sent her home with a prescription for medicine to block stomach acid.

She had scheduled her two-week post-hospital visit with my partner, who had admitted her to the hospital. She told him her pain was better, and the way she described it fit the heartburn pattern. A special X-ray called a barium swallow confirmed acid irritation of the stomach, so my partner gave her another acid blocker prescription.

Two weeks later her time bomb went off. In mid-January she came to clinic with bad chest pain, and I sent her right up to the hospital. It was her first official heart attack. She had quit smoking a few days before. Trying to change her lifestyle, she had tried to exercise.

A few days later, the cardiologists reopened a cholesterol-plugged artery in her heart. After that she could exercise without chest pain and joined a health club. She lost some weight and stayed off tobacco. I saw her every month or two through the winter, spring and summer, congratulating her at every visit for her progress. She was 44.

She came in for a final visit in August, complaining of chest pain. It fit the pattern of stomach pain rather than heart pain. I ran an EKG on her at that last visit, and it was normal – normal for her, that is; it showed nothing new, and even some improvement. I switched her to an even stronger acid blocker. And I never saw her again.

Ten days after that last appointment with me, Helen had died in her sleep. What probably killed Helen was her heart suddenly jumping into a bad rhythm, that didn’t pump blood forward – sudden cardiac death. We don't have any good way of predicting whose damaged hearts are more likely to do that, or when. I couldn't have diagnosed, predicted, or prevented it.

At the trial, there were some surprises. Helen had quit smoking. But her family and friends hadn't, exposing her to secondhand smoke that can increase the risk of abnormal heart rhythms. And in her last visit with me Helen had said she had been able to work out in the gym for hours without chest pain. But her daughter and a friend testified that Helen could only stay on those exercise machines a few minutes before she had to stop and rest until the chest pain went away.

She lied to me. She was playing a role, the role of a good patient. She was telling me what she thought I wanted to hear. Maybe she wanted to hear me congratulate her again on how well she was doing.

I didn't see through Helen's performance. That was the mistake I made. That was my negligence.

I "won" the case and went back to work. I say it was my first malpractice suit. There hasn't been a second – yet – but I don’t want to get overconfident.

Advice: Always tell the truth to doctors.

Browse for related stories in the index at the very bottom of this page, or read a patient-doctor miscommunication story.

Thanks to Dr. Merilee Karr for the source article in Creative Nonfiction, issue #33, 2007.

How easy it is to be silent: Apology for a surgical error

What does not weigh on Dr. John Riley's conscience is silence. [Names have been changed.] As tempting as it was to tell Thelma Jones and her son that a biopsy was planned of her right lung and that the pneumothorax was the unfortunate outcome of a necessary procedure, John Reilly chose to tell the truth. I admire him for that. I know just how easy it is to be silent.

Many years ago, I witnessed an Ob-Gyn make a terrible mistake during a routine hysterectomy. I stood in the Operating Room retracting a patient's belly while he carelessly hacked out her ovary. I stood next to her hospital bed as he lied to her about his mistake.

"We had to take the right ovary, Gina."

"Why? What happened?"

"Jesus Christ, Gina. It was a mess in there."

"I'm sorry."

She apologized. As if it was her fault that he had butchered her ovary.

He offered no other explanation. Yet I did not speak up when this incident occurred. I was a medical student with my career in front of me; he was an attending surgeon. I participated in the complicity of silence.

Advice: Ask for a clear explanation if a medical procedure has not gone as expected.

Browse for related stories in the index at the very bottom of this page, or read a patient-doctor miscommunication story.

Thanks to Dr. Helena Studer for the source article in issue 33 of Creative Nonfiction.