Recognizing and facing medical errors: the perspective of a physician who is also the patient

Itzhak Brook Department of Pediatrics, Georgetown University School of Medicine, USA KEY POINTS

• Medical and surgical errors are very common in the hospital and medical office setting.

• Errors are made by all members of the healthcare providers and include physicians, nurses, medical technicians, food handlers, secretaries, and speech and language pathologists.

• Medical errors generate medical malpractice law suits and increase the cost of medical care, patient stay in the hospital, and patient morbidity and mortality.

• Steps should be made to prevent medical errors that include improved training, awareness, and education of both the medical personnel and patients.

Medical and surgical errors are very common in the hospital and medical office setting. [1] Recent studies have shown that errors occur in up to 40% of individuals hospitalized for surgery and up to 18% of them experienced complications because of these mistakes. [2] These errors generate medical malpractice law suits and increase the cost of medical care, patient stay in the hospital, and patient morbidity and mortality. [3] The recent implementation of a mandatory bedside checklist is a simple, cost-effective method to prevent and reduce many of these mistakes. [4]

1 Dr Brook is the author of the book: My Voice A Physician's Personal Experience with Throat Cancer, (https://www.createspace.com/900004368) and "Preventing medical errors: a physician personal experience as a laryngeal cancer patient." Keynote lecture at the University Hospitals Quality and Patient Safety Fair, Case Medical Center, School of Medicine Case Western University: Cleveland, Ohio, March 5, 2014 (available at https://www.youtube.com/watch?v=ok3gOnmolHk).

Clinical Oncology and Error Reduction, First Edition. Edited by Antonella Surbone and Michael Rowe. ©2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.

As a physician and an infectious diseases specialist for over 40 years, I was not aware how of how frequently these errors occur until I became a patient myself. This became evident to me after being diagnosed with throat cancer (hypopharyngeal carcinoma), when I had to deal with these errors as a patient - not as a physician. [5, 6]

Initially, the small cancer was surgically removed and I received local radiation. However, after 20 months a local recurrence at a different location, a short distance away from the original one, was discovered. Unfortunately, my surgeons were unable to completely excise the cancer by laser after three attempts. At that point, I had to undergo complete pharyno-laryngectomy with free flap reconstruction at a different medical center with greater experience with this type of cancer. The tumor was completely removed and no local or systemic spread has been noted to date (after six years). [7]

Although the medical care I received at all the hospitals was overall very good, I realized that mistakes were being made at all levels of my care. They ranged from minimal to serious ones, and were made by all of the medical providers - physicians, nurses, medical technicians, and speech and language pathologists. Despite these adverse experiences I feel great gratitude to the physicians, nurses, and other healthcare providers that cared for me throughout my difficult and challenging surgeries and hospitalizations.

This chapter describes the medical and surgical errors I personally experienced in my care during my hospitalizations at three medical centers and how the medical staff responded to them. In each instance I will discuss the optimal approach of handling communication of these errors with the patient. What made it difficult for me to prevent and abort many of these errors was my frailty and inability to speak after I underwent laryngectomy. Fortunately, I was able to abort many of these mistakes, though not all of them.

Failure to diagnose the cancer recurrence My surgeons failed to detect the recurrence of my cancer in a timely manner although they examined me using an endoscope on a monthly basis after my initial operation. This is despite the fact that I had been complaining of sharp and persistent pain in the right side of my throat for over seven months. The otolaryngologists kept reassuring me that since they did not observe any cancer-like findings, the pain was most likely by the irritation of the irradiated airway mucosa by reflux of stomach acid. Even after they increased the acid-reducing medication I was taking, the pain did not go away.

The cancer recurrence was finally discovered by an astute surgical resident who was the first otolaryngologist who, while performing an endoscopic examination, asked me to do a Valsalva maneuver (closing the mouth while exhaling). This maneuver enables visualization of the pyriform sinus where the tumor was present. I was surprised that my experienced head and neck surgeons failed to perform such a basic procedure on my previous visits to the clinic. Should they have done it earlier, my tumor (that was already 4 x 2 cm in size) would have most likely been found and taken out at an earlier stage.

I was also examined by a radiation oncologist just three weeks earlier who had seen no abnormality when he performed an endoscopic examination of my upper airway. He also did not ask me to perform a Valsalva maneuver. This specialist confessed to me at a later date that he actually did not look down into the area where the new cancer was found because his instrument malfunctioned during the examination. Although I was disappointed and angry at his failure to perform the test appropriately, which delayed the diagnosis of the recurrence, his honesty and willingness to admit that his endoscopic examination was incomplete made it easier for me to forgive him. I also had deep appreciation for his kindness, compassion, and care and kept coming to him for my medical care. I did not appreciate until that time that radiation oncologists are less experienced in performing endoscopic examination of the airways than otolaryngologists.

Failure to remove the recurrent tumor using laser The first mistake that occurred during my initial hospitalization was when my surgeons, using laser, mistakenly removed scar tissue instead of the cancerous lesion. The cancerous lesion was farther down my airway. It took a week before the error was recognized by the pathological studies. This mistake could have been prevented if frozen sections of the suspicious lesion, not just of the margins, had been analyzed. This mistake meant that I had to undergo an additional laser surgical procedure ten days later in a second attempt to remove the cancer.

Initially, after the surgery, my otolaryngologists had informed me they were able to remove the tumor in its entirety by using the laser, and all the margins of the removed area were clear of cancer. This meant that I was spared from undergoing a more extensive surgery, which would have included total or partial laryngectomy and removal of tissues in my neck, requiring their replacement by tissues transplanted from my thighs or shoulder areas (free flap). I felt great relief when I heard the good news and felt very fortunate. Even though there was still much uncertainty about the final pathological results, the alternative was much worse.

The circumstances that lead to the physicians informing me about the mistake were very upsetting for me. The day of my discharge from the hospital finally arrived a week after my surgery and I was waiting to hear from my surgeons about the final pathological report before going home. The last day was dragging on and on, and my discharge papers were not in yet. Finally about 4.30 p.m., the chief otolaryngology resident, accompanied by a junior one, walked into my hospital room and asked me to follow them to the otolaryngology clinic. I was surprised because all I expected to receive from them were my discharge orders. They informed me that they wanted to reexamine my upper airway one more time before my discharge using endoscopy. This made sense and seemed reasonable to me because I assumed that they wanted to perform a final otolaryngological examination prior to my discharge. I expected this would take only a few minutes, and I would be allowed to finally leave the hospital.

In the clinic, the residents directed me to an examination room. I sat on the examination chair and the senior resident numbed my upper airway and inserted the endoscope through my nose. He seemed to concentrate on one region and asked the junior resident to also observe it as well. They mumbled something incoherent to each other and nodded their heads in agreement. When I asked them if everything was okay, they did not respond. After completing their examination, the residents left the examining room without uttering a word and closed the door. It felt strange to sit on the examination chair waiting for their return, but no one came back to the room for a long time.

After about 30 minutes, I left the examination room and searched the clinic to no avail, finding no one there. The long wait was very unnerving and did not make any sense to me. However, I had no suspicion that something was wrong.

After about 50 minutes, the two residents, accompanied by the two senior surgeons who performed my surgery, walked into the examining room and delivered to me the most distressing and upsetting news.

The head surgeon began: ”I would like to discuss with you the results of the pathological examinations. I have some good and some bad news. The good news is that there are no signs of cancer spreading into the lymph glands on the right side of the neck. The bad news is that the tumor is still in your hypopharynx. We have not yet removed it. The endoscopic examination done today confirmed that it is still where it was before."

Words cannot express the extent of my feelings when I heard the message. I was stunned. My first response was utter surprise and disbelief. Anger and loss of trust followed. Accepting the reality of my situation and making decisions for the best course of action came last.

The surgeon proceeded and explained that the tissue they removed with the endoscope was not the cancer, but rather scar tissue that seemed to him to be abnormal. That abnormal area was only half an inch away from the cancer, but was higher up in my airway, so that when he inserted the endoscope, he observed it first. Because that area looked very suspicious, he assumed that this was the cancerous lesion. He removed it and sent it to the pathological laboratory without confirming that what was taken out was indeed cancerous. He then proceeded to obtain biopsies around the resected area. These biopsies were immediately frozen and inspected in the operating room by a pathologist who found them to be cancer-free. When the pathology laboratory studied the resected tissue suspected to be cancerous several days later, to the surprise of everyone, there were no cancer cells to be observed and it contained only scar cells. To my question of why they did not do perform biopsies of frozen sections of the tissue suspected to be cancerous right at the operating room, the surgeon responded: "We were convinced that what he had removed was the cancer."

It was clear that the surgeons erroneously assumed that they had taken out the cancer. However, if they had requested that the pathologist who was present in the operating room confirm this by looking at the frozen sections of the suspected cancerous lesion, the mistake would have been discovered right away and they would have proceeded to search and ultimately remove the tumor, which was so close by.

The surgeons discovered their error only a week later when the pathological report came back and showed only scar tissue in the specimen. What they had to do at that moment was to go back and try to remove the actual cancer. The surgeons told me that they were planning to do that in a couple of days.

I was puzzled and upset by the surgeons' incompetence. I had so many disturbing questions to ask them: "Why is this not the standard of care to immediately study by frozen section the removed tumor right in the operating room?" This could have prevented me from needing another surgical procedure. Furthermore, this failure delayed the removal of the cancer for nine additional days. "How could you have missed finding the cancer tissues you observed during an endoscopic examination several times before?"

What was even more upsetting was that a few days before the surgery, my surgeon had reassured me that he was going to take biopsies of the suspected cancer tissues before removing it and confirm the presence of cancer at the site. His email just prior to my surgery read: "We will take multiple mapping biopsies, from both your new primary site and old site."

Later, I learned from the otolaryngologists that an additional adverse consequence of the failure to remove the cancer on the first surgery was that any immediate subsequent surgery is more difficult. This is because the initial surgery induces extensive local swelling and inflammation, rendering an immediate new surgery in the affected area harder. This was especially significant in my case because my cancer was located at a very narrow, and difficult to access and visualize, site. In other words, the best chance for successfully removing the growth by laser had been in the first operation. Following the initial surgery, the narrow passage where the tumor was located had become inflamed, irritated, and swollen, and its diameter was therefore narrower. This made any immediate future interventions more difficult because insertion of an endoscope and visualization of the area were more difficult. This is indeed what happened in my case, as the two follow-up attempts to remove the cancer in its entirety were not successful.

It was very hard for me to contain my feelings of extreme anger and my loss of trust in my surgeons; but I knew it was inappropriate for me to express these emotions freely and in a non-inhibited way as I wished I could have done. I was very vulnerable and depended on these surgeons who were still caring for me. I also had close professional relationships with many of them for over 28 years and liked them very much as individuals. I wished I could tell them how angry I was and walk away to get treatment elsewhere. I regretted not having the laser surgery done by surgeons who had more experience with this procedure.

I realized at that time that personal experience is very important in this kind of surgery, and since throat cancer frequency is diminishing in this country, there are fewer patients with this type of cancer and surgeons consequently have less experience removing it. With fewer patients, it is not surprising that expertise in the removal and care of this kind of cancer is concentrated in fewer places.

When I asked him, two days prior to my surgery, about his previous experience in laser surgery for my kind of cancer, he told me that he had done it only once. Obviously, my surgeons had very little experience of using laser to remove my type of cancer. However, he reassured me that if he felt that he could not remove my cancer with laser, he would tell me so. I sympathized with his honest self-confidence because, even though I am not a surgeon, I had probably manifested similar self-assurance whenever I talked with patients and their family members. However, as I became older and more experienced, I often admitted my shortcomings and deferred decisions to physicians who were more experienced in areas I was not.

Since I liked my surgeons very much, I ignored consideration of their competence in this procedure when I made my decision to let them operate on me. What facilitated my decision was the response of one of the surgeons to my inquiries about the importance of previous experiences that in surgery: "You see one, you do one, and you teach one." I know now that his response should have been: "You see one or two hundred, you do one hundred, and you teach one."

Although the error made by my surgeons was very regrettable their honesty in admitting and accepting responsibility for what happened made it easier for me to endure it. Even though the surgeons suggested that I could seek care at another center, I decided to give them a second chance to remove the cancer. Unfortunately they were unable to remove the entire tumor using endoscopy on two subsequent attempts.

Failure of nurses to respond to breathing difficulties in the Surgical Intensive Care Unit I experienced several hazardous situations because of nursing errors. On one occasion, one day following my laryngectomy while I was still in the Surgical Intensive Care Unit (SICU), I experienced a sudden obstruction of my airway and reached for the call button. It was not to be found as it had fallen to the floor. I tried to no avail to call the attention of the staff first by disconnecting my oxygen monitoring probe, and then the electrocardiogram electrodes. Even though I was only a few feet away from the nursing station I was ignored until my wife happened to arrive about 10 minutes later. I was helpless in asking for aid without a voice and was desperately in need of air while medical personal passed me by.

When my wife went to the nurses' station to complain about what had happened, she was rudely rebuffed by the SICU attending physician, who told her not to interfere with the medical rounds. I insisted that the incident be reported to the nurse supervisor, but when she showed up a few hours later she was not apologetic and did not seem to be concerned. She explained that my nurse was busy caring for other patients. I was too sick to pursue the matter with her any further. Having a single nurse care for more than one patient in SICU exposes the patients to unacceptable risks and is probably caused by budget cuts and attempts to cut costs.

When I brought this incident to the attention of my surgeon, he just shrugged his shoulders and told me that he had minimal influence on what transpired in the SICU; but he assured me that things would be much better for me when I was moved to the otolaryngology floor which he was in control of. He told me that the staff on the otolaryngology floor were more familiar with patients with my kind of operation, so the care there would be much better and more customized to my medical needs.

The unwillingness of my surgeon to act upon my complaint was very disappointing and upsetting for me. Instead of dealing with the problem in the SICU where care for his critically ill patients was given, he comforted me by promising better care at a point when I would be less in need of such care.

Failure to respond to breathing difficulties in the otolaryngology ward A similar incident occurred in the otolaryngology floor a week after my laryngectomy when the nurse did not respond to my call to suction my airway through my trachea. I felt a sudden difficulty in breathing, as mucus which had built up in my trachea was obstructing my airway. I could not get out of bed as I was connected to intravenous and arterial lines and a catheter. I pressed the call button that was attached to my bed, but no one came to my assistance. I was able to get the attention of a nurse assistant who told me that my nurse was on a break. Since the nurse assistant was not trained in suctioning airways she promised to look for a nurse who could assist me. The nurse finally came to suction my airway only 15 minutes later. I learned that she was the only nurse on the floor at that time as the other nurse was on a coffee break, and that she was on the phone ordering supplies during all that time.

This was a very distressing event as I was agitated and struggling to breathe in the middle of the otolaryngology floor. There were two residents and several nurse assistants on the floor, yet no one helped me for what felt like a very long time. It is obvious that even on a ward dedicated to people with breathing difficulties and ventilation issues, there were many distractions that prevented physicians and nurses from paying attention to their patient's urgent needs.

Even though I brought the incident to the attention of the nurse supervisor and the head surgeon I never received any feedback from them about what was to be done to prevent such incidents in the future. The lack of response by these medical supervisors was inappropriate and contributed to my frustration and anxiety. I felt that I could not rely and trust the medical team to come to my help in an emergency.

Premature oral feeding after laryngectomy The most serious error in my hospital care was feeding me by mouth with soft food a week too early. Early feeding by mouth after laryngectomy with free flap reconstruction can lead to failure of the flap to integrate and cause its failure. The feeding continued for more than 16 hours. I remembered that my surgeon had informed me that I would not be able to get oral feeding for at least two weeks after my surgery. Only my persistent questioning brought this issue to the attention of a senior surgeon who discontinued the premature feeding. I wondered what would have happened if I had not continued to question the feeding and when (or if) the mistake would have been eventually discovered.

Even though I repeatedly requested an explanation from my physician about how this error occurred they avoided responding to my inquiries. I learned later by looking in my medical records that this mistake occurred because the order to start oral feeding was intended for another patient and was erroneously transcribed into my chart because of miscommunication of verbal orders.

This incident demonstrates the risk involved in transcribing medical orders and the need to listen to a patient's inquiries and questioning. It also illustrates the importance of informing patients about their future treatment plans so that they can challenge and question any deviation from them. It was another example of the complete lack of communication by the physician with me to explain and apologize for the mistake that had occurred. Accepting responsibility for the error and explaining what steps would be taken to prevent such mistakes in the future would have been the appropriate way of handling the situation. Ironically, trays of food were brought to me for a couple of days even after the oral feeding was discontinued.

Nursing mistakes Some of the errors made by nurses and other staff members included the following (Table 2.1): not cleaning or washing their hands and not using gloves when indicated; taking oral temperature without placing the thermometer in a plastic cover; using an inappropriately sized blood pressure cuff (thus getting incorrect and sometimes alarming blood pressure readings); attempting to give medications Physician errors Failure to detect cancer recurrence Premature oral feeding Removal of scar tissue instead of the tumor Forgetting to write down orders Nurse errors Not responding to emergency calls Forgetting to connect the call button, when bedridden and unable to speak Not cleaning or washing hands or using gloves when indicated Taking oral temperature without placing the thermometer in a plastic sheath Using an inappropriately sized blood pressure cuff (thus getting wrong readings)

Attempting to administer medications orally intended for nasogastric tube Delivering an incorrect dose of a medication Administering medications through the nasogastric tube that were dissolved in hot water (thus causing esophageal burning)

Connecting a suction machine directly to the wall without a bottle of water Forgetting to rinse the hydrogen peroxide after cleaning the tracheal breathing tube (thus causing severe irritation)

by mouth that were intended to be administered by tube to the stomach; dissolving pills in hot water and feeding them through the feeding tube (which caused burning in the esophagus and potentially inactivated the medications); delivering an incorrect dose of medications; connecting a suction machine directly to the suction port in the wall without a bottle of water (thus exposing my airway to harmful bacteria); forgetting to rinse away the hydrogen peroxide used for cleaning the tracheal breathing tube (thus causing me severe tracheal irritation); forgetting to connect the call button when I was bedridden and unable to speak; and forgetting to write down physicians' verbal orders.

Even though I always notified the nurse supervisor and in many cases the resident and or attending physicians about the errors, I was never informed what action was taken to prevent similar mistakes in the future.

Conclusions All of the mistakes in my care made me wonder what happens to patients without a medical background who cannot recognize and prevent such errors. Fortunately, despite these mishaps, I did not suffer any long-term consequences. How-

• Implementation of better and uniform medical training.

• Adherence to well established standards of care.

• Performing regular record reviews to detect and correct medical errors.

• Employing only well educated and trained medical staff.

• Counseling, reprimanding, and educating staff members who make mistakes. Dismissing those who continue to make them.

• Developing and meticulously following algorithms, set procedures, and bedside checklists for all interventions and procedures.

• Increasing supervision and communication between healthcare providers.

• Investigating all errors and taking action to prevent them.

• Educating and informing the patient and his/her caregivers about the patient's condition and treatment plans.

• Having a family member and or friend serve as a patient advocate to ensure the appropriateness of the management.

• Responding to patient and family complaints. Admitting responsibility when appropriate, and discussing them with the family and staff and taking action to prevent them.

ever, I had to be constantly on guard and stay alert and vigilant, which was very exhausting, especially during the difficult recovery period.

My post surgical weakness and the powerful pain medications I received made it difficult for me to communicate my questions and challenges when I noticed a deviation from the correct treatment. My inability to speak created another barrier as all my communications were made by writing messages on a small erase board or a notebook. I also hesitated to challenge the medical staff because I did not want to upset them and be branded as a "complainer" or "trouble maker." However, as the errors kept accumulating I realized that it was up to me to prevent them even at the price of antagonizing my medical caregivers.

I also found out that the help of a dedicated patient advocate, such as a family member or a friend, is very much needed for all hospitalized patients (Table 2.2). Although my family members are not in the medical profession they were instrumental in preventing many mistakes, especially when I was unable to prevent them.

My experiences taught me that it is very important that medical staff members openly discuss with their patients the mistakes that were made in their care. The occurrence of errors weakens patients' trust in the medical team. Admission and acceptance of responsibility by the medical care providers can bridge the gap between them and reestablish the lost confidence and trust. When such a dialog is established, more details about the circumstances leading to the error can be learned, which can assist in preventing similar mistakes in the future. Open discussion can assure the patients and their family members that their medical caregivers are taking the matter seriously and that steps are being taken to make their hospital stay safer.

Obviously medical mistakes should be prevented as much as humanly possible. [8] Ignoring them can only lead to their repetition. Not discussing the errors with the patient and their family members increases their stress, anxiety, frustration, and anger, which can interfere with the patient's recovery. Furthermore, such anger may also lead to malpractice law suits.

Medical practice can be improved by strengthening disclosure policies and supporting healthcare professionals in disclosing adverse events. [9, 10] Increased openness and honesty following adverse events can improve provider-patient relationships. There are important preventive steps that can be implemented by each institution and medical office (Table 2.2).

Educating the patient and their medical caregivers about the patient's condition and planned treatment is of utmost importance. These individuals can safeguard and prevent mistakes when they see deviations from the planned therapy.

I am sharing my personal experiences as a patient who sustained medical errors in his care in the hope that they will encourage better medical training, contribute to greater diligence in medical care, and increase supervision and communication between healthcare providers. It is my hope that sharing my experiences will contribute to the reduction of such errors and lead to a safer environment in the hospital setting. It is also my hope that medical care providers will openly discuss these mistakes with their patients.

References

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2 Griffen FD, Turnage RH. Reviews of liability claims against surgeons: what have they revealed? AdvSurg 2009; 43: 199-209.

3 Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical malpractice litigation. NEnglJMed 2006 11; 354: 2024-2033.

4 Byrnes MC, Schuerer DJ, Schallom ME, et al. Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-basedintensive care unit practices. CritCareMed 2009; 37: 2775-2781.

5 Brook I. A physician's personal experiences as a cancer of the neck patient: errors in my care. Am JMed Qual 2011; 26: 73-74.

6 Brook I. Neck cancer - a physicians' personal experience. Arch Otolaryngol Head Neck Surg 2009; 135: 118.

7 Brook I. My Voice: A Physician's Personal Experience with Throat Cancer. CreateSpace Publication, Charlston SC, 2009. (http://www.createspace.com/900004368)

8 Hilfiker D. Facing our mistakes. N Engl JMed 1984; 310: 318-322.

9 O'Connor E, Coates HM, Yardley IE, Wu AW. Disclosure of patient safety incidents: a comprehensive review. IntJ Qual Health Care 2010; 22: 371-379.

10 Mazor KM, Simon SR, Gurwitz JH. Communicating with patients about medical errors: a review of the literature. Arch Intern Med 2004; 164: 1690-1697.

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