A Lean Guy Watches “CNN’s 25 Shocking Medical Mistakes”
Did anybody else see this show hosted to Elizabeth Cohen on CNN last weekend, titled “25 Shocking Medical Mistakes“? You can see a video preview or read the transcript online. I'm not sure if the whole show is available online for free or purchase (if you know where to find it, please post a comment).
I took some notes and will list all 25 items on their list, highlighting the things that are most clearly related to Lean, processes, and systems, even though it's almost always a system or process, as opposed to a bad person involved. They couldn't cover anything in much detail in a 60 minute program, but here's the list and discussion of the items and overall themes.
#25 Newborn babies stolen from the hospital – an alarm went off, but was not noticed… was this due to a system design problem where the alarm is too easily missed, or there's “alarm fatigue,” there's too much waste and confusion in the system for staff to respond promptly?
#24 Fake doctors – unclear how this ever happens. This seems pretty inexcusable.
#23 Treating the wrong patient – the hospital performed a CT on a pregnant woman, they had identified her only by her first name, clearly violating good guidelines to use at least full name and another identifier.
#22 Pharmacy mixup – wrong medication given to a patient with the same last name — it's disconcerted, but not unheard of, to hear the staff comments like “things get hectic,” due to phones ringing, the “onslaught” of really busy times. That's where the Lean concept of “muri,” or overburden, and the need to have systems that don't overburden people is so important.
#21 Botched plastic surgery – including a woman who, after a “butt implant,” had a piece of the implant (fat or silicone) break off and lodge in her lungs, causing a pulmonary embolism. The show recommends you only choose a surgeon certified by the American Board of Plastic Surgery… but does that really guarantee zero risk?
#20 Dosage errors – highlighting the case of the Quaid twins (much discussed here on the blog, including the systemic errors that caused this preventable mistake). CNN says, according to the Joint Commission, that medications are stocked WRONG in 4% of cases, a shockingly high error rate.
#19 Toxic transplants – a patient died after getting a kidney transplant… but the donor had rabies. Nobody suspected the donor had rabies… even though the donor had “all the symptoms of rabies” and they “should have never used the organs.” There are 100 victims of “toxic transplants” each year. They said it's tough to screen for rabies and all possible pathogens, so the best advice was to act quickly AFTER the transplant if the patient isn't getting better.
#18 Dumb discharge – a patient who just had brain surgery was sent home, alone, in a taxi. He was disoriented and didn't even know his own address. How do staff allow this to happen? CNN says “make sure you have a ride home” but I'd put more of the responsibility on hospitals to not let this happen.
#17 Ambulance errors – a 911 dispatcher sent an ambulance to Wells Street instead of Wales Drive (given the accents involved, it's somewhat understandable… but it would be a good practice for 911 to try to get a spelling if there's any uncertainty).
#16 Lost patients – Alzheimers patients gone missing from the nursing home… in this one case, the woman was found IN the nursing home, four days later, locked in a closet. They didn't do a good job of searching “every room,” as they had claimed, did they?
#15 Surgical souvenirs – that's a bit too flippant of a phrase for a serious problem, including the patient who had a footlong by foot-wide sponge left in his abdomen. An item gets left behind in 2 out of 10,000 surgeries. Famed patient safety expert Peter Pronovost commented on this and other cases in the show. “Nurses are supposed to keep track,” said CNN, but there can be errors on the inbound count or the outbound count. We can't just simply blame nurses, as there are many cultural factors in the O.R. that can pressure staff into cutting corners in these important steps (or errors in counting occur – it's human error we need to design around or find technology that addresses this).
#14 Baby switcheroos – a hospital worker gave the baby to a mother with the same last name… and she breast fed the wrong baby. Yet again, we need to check more than just the first name or last name. Yes, mothers should perhaps ask to match the ID bands, but that's the hospital's responsibility to do that properly.
#13 Air bubbles in blood – removing the patient's central line led to a sucking chest wound… nurses “failed to follow basic rules on removing a chest tube” (as in “standardized work” in the Lean parlance). The patient should have been laying down and they should have sealed the hole airtight with Vaseline. The mother (a medical student) begged for help, “but nobody called a doctor until it was too late.” CNN said (from Annals of Internal Medicine) that this type of error occurred 10 times in one hospital's ICU in one year.
Mid stream commentary — I know the theme of the show is “The Empowered Patient,” but I don't like all of the talk about putting some sort of burden on patients to ask if standard processes are being followed. As I've written about before, it's not fair to ask the patient to inspect our processes and work in hospitals. Are drivers asked to double check if the tire change place has properly tightened the lug nuts on all of your wheels? Are passengers supposed to double check that the airline pilot has properly followed their checklists?
#12 Misdiagnosed – a doctor refused to listen to the parents of a child who had been hit in the head with a baseball… he said she just had the flu. After finally relenting and doing a CT scan (which the parents had been begging for), they found (and fixed) a blood clot in her brain. “1 in 10 diagnoses may be wrong” (is that a process issue?)
#11 Transfusion confusion – a surgery patient was given the wrong type blood for his transfusion. When the patient's blood was drawn, there was a LABELING error and they typing was done on the next patient over, in error. Keep in mind, this isn't a highly technical error… the lab was correct, but they did the work on the wrong specimen. Specimens are supposed to be labeled IMMEDIATELY after being drawn… and the patient died because this did not happen. CNN says “know your blood type, so you can double check the bag to see if it's a match” — but that only works if you're awake and coherent. That's an unfair burden, once again.
#10 Getting burned – a balloon was inserted into a patient's throat to stop the flow of gasses from his lungs. The doctor punctured that with a laser and “instead of stopping the surgery, the lasers started an explosion.” An expert says these types of errors occur due to multiple errors in setting up the operation. There are 650 surgical fires each year in the U.S.
#9 Look-alike tubes – a medical day care center made a mistake and pumped medicine (for her stomach) into her veins. The central line and feeding lines “look an awful lot alike” — so we need to design better solutions. “People get rushed… they cut corners” says an expert, Dr. Otis Brawley. So, how do we create situations where people aren't pressured for time? Can we use color-coded tubes or other error proofing methods? 16% of nurses and doctors say these mistakes happen in their hospitals… and, again, CNN says you, the patient, needs to double check!
#8 Biopsy blunder – they discussed the case of Darrie Eason, who I've written about before. These types of errors still occur… and it's something I'm going to blog about soon. We need to stop mislabeling specimens… getting a second opinion on a mislabeled specimen does no good.
CNN had some animation of how the error occurs… a person working with two specimens at once and they put the wrong one into the wrong cassette. CNN says 1 out of 1,000 lab specimens are mislabeled. That's completely preventable. I'm surprised CNN didn't recommend you follow your specimen into the lab!
#7 Having the wrong baby – mixup at a fertility lab… they had implanted another couple's embryos into the wrong patient — AGAIN, the same last name. When is healthcare going to learn?? Instead of saying “double check the petri dish,” CNN again recommends accreditation. I would assume the lab in Darrie Eason's case was accredited by CAP… did that help?
#6 Operating on the wrong body part – a surgeon cut into the wrong eye, “frankly, I lost sense of direction,” said the surgeon. The surgical site marking was covered up by the draping of the patient. There are 7 “body part mixups” everyday in the U.S…. and, yup, CNN says YOU should double check that the surgeon isn't going to mess up and “don't be shy about doing it.”
#5 Radical radiation – CT scan errors… patients' hair falls out. The scanners were programmed wrong and the patients got “monster doses of radiation” (8x the allowable dose). CNN says basically to “if possible, get ultrasound or MRI” instead of a CT scan. That's not getting to the root of the problem at all.
#4 Infection infestation – patients getting Hospital Acquired Infections, often viewed as preventable. Pronovost highlights the need for better hand hygiene amongst caregivers… “we're no different than a mosquito causing malaria,” says Pronovost. “Hospital infections kill 100,000 patients a year” (see sources and other data). CNN wants you to nag doctors and nurses to wash their hands. Sigh.
#3 Metal in the MRI room – a hospital worker walks into the MRI suite with an oxygen tank… of course, it goes flying to the magnet, hitting the boy in the head, killing him. “While the mistake is relatively unusual,” it does happen. Again, CNN suggest you make sure there's no metal on or around you. BUT I DON'T CONTROL WHO ENTERS THE ROOM. This advice needs to be given to the hospital staff and leaders, not the patient.
#2 The ER waiting game – after triage said the little girl just had a virus, she waits with her parents for FIVE hours and her fever climbs higher. She really had flesh-eating bacteria, not a basic virus. Cases like this show how important it is to improve E.D. patient flow. Check out the great book The Definitive Guide to Emergency Department Operational Improvement to learn more about how to do this. As they said in the show, you can't always tell who is sickest at triage… so I'd add that's why we need to improve flow for all. The average wait time in the U.S. is just over four hours. But, hospitals are often able to reduce this time by 40 to 50% through Lean process improvements. CNN suggests a workaround that fails to work if EVERYBODY does it – ask your doctor to call the E.D. while you are on your way because “doctors listen to other doctors.”
#1 Waking up during surgery – OK, this was just horrifying, the cases of patients who were paralyzed but feeling every “poke, prod, and cut” during the surgical procedure. Scary. Without adequate anesthesia, your brain stays aware… the reasons for underdosing could be “just a goof” like a vaporizer tank getting disconnected or being empty (“not defendable” said an anesthesiologist on the show). This happens in 1 out of 1,000 patients… “awake and aware” but not in any pain. CNN suggests asking for local numbing instead of general anesthesia… but that's just generally good advice, even if there wasn't any risk of error.
That show was exhausting, especially knowing how preventable most of these problems are. Thanks to CNN for the national “FMEA” exercise about what DOES go wrong… I hope their next special is about FIXING these problems. Which of these problems have you been able to address?
From the end of the show:
No good doctor ever means to hurt you. Doctors and nurses and everyone who takes care of us are just like us, human and make mistakes. Now you can help them get things right.
This is the job of hospital leaders and physicians… not patients. Yes, it's possible to get these things right. But, the healthcare industry needs to take responsibility and improve things…