Doctors' Deadly Mistakes

By MICHAEL D. LEMONICK

Vincent Gargano was lucky--or so he thought. The 42-year-old Chicago postal worker's prostate cancer was detected early, and he responded well to two five-day rounds of chemotherapy at the University of Chicago. On the third and final round, however, things went terribly wrong. Instead of getting 176 g per day of one drug and 39.4 g of another, as prescribed, he was mistakenly given 176 g of the second drug as well--a massive overdose. Within five days Gargano was deaf. Then his kidneys began to fail. Then his liver shut down. And just a few months after entering the hospital with a favorable prognosis, Gargano was dead, his body overwhelmed by infection.

Ben Kolb, 7, needed minor ear surgery, and his doctors at Martin Memorial Medical Center in Stuart, Fla., began by injecting him with lidocaine, a local anesthetic. Except that it wasn't lidocaine; it was adrenaline, a powerful stimulant. A minute later Ben's blood pressure soared, and his heart began to race. Nine minutes later his blood pressure plunged, his heart rate dropped, his lungs filled with fluid, and he went into cardiac arrest. Within hours, Ben Kolb was dead.

It's hardly news that medical professionals make mistakes--even dumb, deadly mistakes. What's shocking is how often it happens. Depending on which statistics you believe, the number of Americans killed by medical screw-ups is somewhere between 44,000 and 98,000 every year--the eighth leading cause of death even by the more conservative figure, ahead of car crashes, breast cancer and AIDS. More astonishing than the huge numbers themselves, though, is the fact that public health officials had known about the problem for years and hadn't made a concerted effort to do something about it.

Now they have. The Institute of Medicine, a branch of the National Academies, issued a report last week calling for a major overhaul of the nation's health-care system. Aptly titled "To Err Is Human," it explores the reasons doctors and nurses make mistakes, which can include drugs with names so similar that they're easy to confuse (see PERSONAL TIME: YOUR HEALTH) and duty shifts so excessively long that physicians and interns fall asleep on their feet (see accompanying story).

The report also proposes a series of solutions, including a new federal Center for Patient Safety that would set error-reduction standards for hospital procedures and medical equipment, as well as a mandatory reporting system that would require hospitals to fess up to what they like to call "adverse events."

Given the prevailing mood in Congress--which seems to be allergic to anything that expands the size and power of government--creating a new agency might be tough. But the Institute of Medicine has powerful logic on its side. Air travel in the U.S. is extraordinarily safe, thanks largely to the National Transportation Safety Board and the FAA. They try to pinpoint the cause of every crash and, when a problem is identified, they may order the airlines to redesign equipment or improve training or adjust pilot schedules to reduce the chance of more accidents. The Occupational Safety and Health Administration has driven down death and injury in the workplace. When not investigating actual incidents, these agencies study what sorts of systems and practices lead to accidents.

The patient-safety center would presumably do the same. Medical equipment, for example, often has lots of complicated controls. And because there is no single industry design standard, each manufacturer tends to have its own displays; nurses or doctors trained on one machine may well make a mistake when they switch to a different one. Another danger arises when patients have multiple disorders and doctors aren't aware of all their medications, leading to potentially lethal combinations of otherwise safe drugs. Uniform standards of record keeping and record sharing would certainly minimize such problems.

Indeed, this approach is already being tested on a smaller scale. In 1997 the American Medical Association and other groups created the National Patient Safety Foundation to come up with techniques to reduce mistakes. One straightforward example is the so-called sign-your-site procedure, in which both patient and surgeon literally sign their name in ink at the point where an incision is supposed to be made, or on a body part to be amputated, so there's no chance a doctor will, for example, lop off the wrong arm or leg.

Children entering emergency rooms present their own set of problems. When kids are involved, all sorts of medical procedures, from defibrillation shocks to drugs, have to be scaled down to take into account a child's smaller body weight. At the urging of the foundation, some hospitals now routinely weigh kids as they come in, slapping a colored band on their wrist. All the ER doctors and nurses have to do from then on is match the band to the appropriate color-coded labels that mark medicines and equipment settings.

Some hospitals, meanwhile, have come up with their own error-reduction systems. At Montefiore Medical Center in the Bronx, N.Y., doctors and nurses can call up patient records online from laptop and handheld wireless computers located throughout the center's two hospitals, 30 outpatient centers and doctors' homes and offices. If someone tries to prescribe a drug that will interfere with other medications, the monitor flashes a warning.

There are probably hundreds of other improvements that could reduce the chance of human error--but they can't be designed unless those errors come to light. And that won't happen unless doctors and nurses are willing to admit to their mistakes. That can be psychologically tough. Medical professionals, observes Dr. Nancy Dickey, former president of the A.M.A. and National Patient Safety Foundation, "have to have the audacity to make decisions that involve life or death. It's difficult to train those same people to be open about how they make mistakes."

It can also be expensive for them to do so. Doctors routinely pay $60,000 a year for malpractice insurance, and while some trial lawyers insist that lawsuits are what keep physicians and hospitals from making errors, it's hard to believe that fear of litigation is the most effective way to enforce medical standards.

Many hospitals are so concerned with cutting down on preventable errors, though, that they are ignoring the risk of malpractice claims and doggedly rooting out their mistakes. Even in the hours before Ben Kolb died, for example, Martin Memorial hospital's risk-management director Doni Haas had launched an investigation, sealing off the operating room and seizing the syringes, instruments and medications used in the procedure. She could do this without being obstructed, she says, because the hospital staff was focused on finding the cause of the problem and preventing such a thing from happening again.

It took Haas 3 1/2 weeks to discover what killed the boy, and at that point she went to see Ben's parents and the attorney they had retained. "I told them we had saved the syringes," she says, "and had them tested, and that we accepted full responsibility for the error, and we were very, very sorry." The case was settled that evening.

All these efforts are laudable, but unless they are universally adopted, patients will continue to die--not through gross negligence or incompetence but through plain human error. "This is a wake-up call," says Arthur Levin, director of the Center for Medical Consumers, based in New York City, and a member of the committee that wrote the new report. "The American health-care system has not put safety at the top of its agenda. Generally, they say this problem doesn't exist. But this is not an aberration. It's an all too common occurrence. And it is unconscionable to allow it to go on."

--Reported by Dick Thompson/Washington

With reporting by Dick Thompson/Washington