Medical mistakes happen when safeguards fail

By Tim Friend, USA TODAY

The attending physician led Paul Barach, then a third-year medical student, to a patient's bedside and ordered him to insert a central intravenous line into a major vein in the upper chest of a 75-year-old woman with emphysema.

		Dr. Paul Barach of the University of Chicago learned from his mistake and works to improve safety systems in hospitals.
		By Anne Ryan, USA TODAY

Central lines transfuse IV fluids faster than standard IVs and are used to deliver medicines to sicker patients, usually in the intensive care unit or operating room. The procedure involves making a shallow incision, locating the vein, threading the IV line into the vein, sewing the line and vein together, closing the skin and putting on a dressing. It normally takes about 15 minutes.

But the attending physician didn't ask Barach if he had done one before. (He hadn't.) As Barach made the incision, his mentor was summoned to treat a person suffering cardiac arrest. Alone and inexperienced, Barach pushed a needle through the vein into the chest wall, puncturing the air sac around the lung. The lung collapsed, and the patient had to be placed on life support. She developed complications and died as a result a few days later.

From pain comes a better way Activist Peter Provonost's efforts to improve patient safety came from being on the receiving end of errors. "I became interested in patient safety as a fourth-year medical student at Johns Hopkins when my father died of a medical mistake," Provonost says. A doctor failed to diagnose cancer, and it spread through his father's body. Then the doctor refused to provide adequate pain relief as his father was dying at home. "A scene stands out in my mind where we were carrying my father's 80-pound body, writhing in pain, up to his bed. We were told we just had to accept it. "I became convinced that we owed patients more, that we had to do better."

On Feb. 7, a medical team at Duke University Medical Center transplanted a heart and lungs of the wrong blood type into a teenage patient. The organs failed, and a second transplant was performed on Feb. 20. Jesica Santillan, 17, appears to have died from trauma associated with two consecutive transplant surgeries.

Sometimes, bad things happen to good people. That's what people sometimes say to comfort each other during a tragedy. But when bad things happen to good doctors, especially things that lead to a patient's death, the doctors typically are cast as villains, sometimes ridiculed and nearly always sued.

Most medical mistakes are not caused by the incompetence of a single doctor. They occur when hospitals, as stressful as battlefields and even more complex, have faulty systems to safeguard patients, experts say. Such systems are needed to help doctors and nurses do the right thing, Barach says. (Related item: Empower staff to make changes.)

"I was crushed by my experience," says Barach, a leader in the effort by physicians and nurses to improve safety, and an anesthesiologist at the University of Chicago where he also teaches. "The resident yelled at me and called me an idiot, and I wasn't allowed to talk to the patient's family to explain. I was angry that it happened with no supervision and angry at myself for not speaking up. I felt guilty for many years."

Sara Charles, professor of psychiatry emerita at the University of Chicago, says the impact of errors can be painful at best and sometimes devastating to the physicians involved. She has studied the effects of stress on physicians since the late 1970s, when she was sued for malpractice after a patient committed suicide. She was vindicated but not until five years later.

"For many of these catastrophic events that occur, and Duke is a catastrophic event, the people who are involved feel very deeply a personal responsibility and a failure of their responsibility," Charles says.

"One of the questions doctors ask themselves is, 'Did I kill this patient?' This is one of the most profound human experiences you can have, especially when you try to do good. For many of these people, it takes years to process this psychologically."

Some leave their professions after such traumatic experiences. Charles says the physicians involved in errors often do not seek counseling. But many develop depression and sometimes post-traumatic stress disorder.

In a report in the early 1990s, The Heart of Darkness: The Impact of Perceived Mistakes on Physicians, doctors described their emotions as angry, agonized, appalled, worried, guilty, fearful, embarrassed and humiliated. They have no place to turn, Barach says.

National media described the Duke error as a "botched" or "bungled" transplant and blamed surgeon James Jaggers. But the patient died because Duke bypassed a system for double-checking the blood type of donated organs with that of the patient, Barach says.

Barach says his mistake "galvanized" him to change conditions that lead to errors. He trains medical personnel, develops patient-safety courses for medical schools and researches errors at hospitals. "This is a problem that does not get enough visibility."

Peter Provonost, another leader in the patient-safety movement and an anesthesiologist at Johns Hopkins Hospital, says the hospital culture allows errors to occur. Barach describes the problem as "institutional arrogance and complacency."

Medical centers can be reluctant to acknowledge that errors occur and are unwilling to use them as a forum to help staff avoid future mistakes. Barach says his error more than a decade ago was covered up. "There was one story that was told to the patient's family, and the real story that was not told."

Jaggers reportedly informed Santillan's family when he learned a mistake had been made. But Duke did not publicly acknowledge the error for more than a week, and sources at Duke say hospital officials did not share information with staff. One source said it was handled as if the crisis would go away if it were ignored. Duke officials declined to be interviewed for this article.

Provonost says about 80% of mistakes are a result of miscommunication. Implementing programs to improve communication and the discussion of errors at Johns Hopkins has reduced hospital-acquired infections in the ICU, he says.

"In the Duke case, there were a lot of checks and balances that went wrong. In most cases, there is no one single great mistake that leads to the catastrophe. Rather it is a whole cascade of mistakes that occur," Provonost says.

Santillan's death was not the first time system errors have been linked to safety violations at Duke:

• In 1999, the government shut down 2,000 federally funded clinical research projects for five days. Duke was cited with 20 violations of safety procedures, including those designed to protect children.
• In 1995 and in 1997, the National Cancer Institute found violations of safety procedures designed to protect patients involved in studies of cancer treatment.

Barach says unless hospitals openly address errors and begin to change their cultures, medical mistakes will continue, no matter how skilled the staff. "We're only scratching the surface with our present safety reporting systems. The flawed process that led to the tragedy at Duke will likely happen at a different hospital."