Still getting inspiration from #hcldr tweet chat :)
The August 20, 2013 #HCLDR tweet chat blog post written by Lisa Fields (@PracticalWisdom) was entitled “Doctors Make Mistakes. Can We Talk About That?” This is the inspiration for this blog post.
How hazardous is healthcare? Apparently, it’s even more dangerous than bungee jumping! The 1999 Institute of Medicine report “To Err is Human: Building a Safer Health System” noted that at least in the US, between 44,000 to 98,000 people die each year due to preventable medical errors (http://en.wikipedia.org/wiki/To_Err_is_Human).Image credit: http://www2.fraserhealth.ca/media/how%20hazardous%20is%20healthcare%202.jpg
It may seem like an urban legend to those who hear of it now but I know the story is true. Not so long ago a doctor made a mistake in doing a thoracentesis at the emergency room.
Below is a typical chest X-ray showing a pleural effusion (fluid in the lung cavity) on the left side. You can clearly see the “L” marker on the upper corner.Image credit: http://intensivecare.hsnet.nsw.gov.au/five/images/pleural%20effusion%20CXR%202.jpg
When a patient has a pleural effusion, the doctor has to drain the fluid out. This procedure is called a thoracentesis. To do that, the doctor sticks a needle at the patient’s back in between the ribs. So to do that procedure, the patient has to sit with his back to the doctor.Image credit: http://www.hindawi.com/isrn/emergency.medicine/2012/676524.fig.0012.jpg
So this doctor had the patient seating in front of him. The x-ray was mounted on a negatoscope (a light box where x-rays can be viewed) in front of the patient up on the hospital wall. The doctor draped the patient exposing the same side as where the effusion can be seen on the x-ray directly on front of him – on the right side. WAS HE CORRECT?
The chest x-ray is taken PA view. The x-ray beam passes from posterior (back) to anterior (front). So when looking at this chest x-ray, it is as if you are looking at the patient FACING you. But when doing the thoracentesis, the patient is facing AWAY from the doctor! Thus, the doctor should have exposed the LEFT side of the patient’s back and not the right.
The story goes that the doctor had already punctured the RIGHT side of the patient and was not getting any fluid out (because there was no fluid on that side!) when another doctor happened to be walking by and pointed out the mistake to him with a quick whisper. Nonplussed, the doctor doing the procedure took out his needle and proceeded to puncture the patient’s LEFT back. He then told the patient, “It’s like puncturing a milk can, you need to make two holes!”
If you don’t understand why to make milk flow out from a milk can you need to make two holes opposite each other on top of the can, here’s the reason why.
It’s a good thing that no harm happened to the patient in this story. He did not get a pneumothorax – a complication from this procedure where air is introduced into the lung cavity, which can collapse the lung. The patient can then turn blue, unable to breathe!
There are many possible reasons for wrong site surgeries. Check Table 1 in this chapter entitled “Wrong-site Surgery: A Preventable Medical Error.” The chapter also details the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery: preoperative verification process, marking the operative site and “time out” immediately before starting the procedure.
As far as I know, the doctor did not admit his mistake to the patient. I wonder what would have happened if he did.
#HealthXPh is a platform where we can talk about stories like this. Join our Google Hangout every Saturday 10 am, Manila time. Be a member of #HealthXPh Google+ community.
We do commit mistakes. That is a given. What we do about it makes the difference. It’s never easy for both the patient and you. Be honest, direct, focused and empathize with an “extra mile”.
Great post! A HUGE source of preventable errors I see occur when physicians rely solely on radiologist’s reports (and don’t look at the raw data themselves). Should physicians base treatment on reports? A great topic for #HCLDR, I think!
Experience and knowledge are key factors in achieving expertise. To be considered an expert according to Malcolm Gladwell in his book Outliers one needs 10,000 hours.
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Wrong site surgery? WRONG SITE SURGERY??!?!?! I cannot even begin to wrap my brain around this kind of medical error, particularly when you have more than one health care professional in the room.
In your thoracentesis example, the letter L for LEFT is clearly visible on the chest x-ray. I’m assuming doctors can’t get through med school unless they can tell the difference between the patient’s left and right sides.