Archives for category: life changing
Time line for Samule Adams' campaign for American independence. Horizontal axis = time, vertical axis the degree of campaign activity

Time line for Samuel  Adams’ campaign for American independence. Horizontal axis = time, Vertical axis the degree of campaign activity

The founding father most responsible for encouraging the colonist to seek independence from Great Britain is Samuel Adams. While he was in college at Harvard his father, a brewer and successful businessman, was driven to bankruptcy by a capricious ruling by the British Parliament. From that day on Samuel Adams dedicated his every hour to convincing his fellow colonists that our country needed to seek independence from the intrusive governance of the British.

As he began his efforts the Massachusetts Bay colonists were complacent. They were prospering and did no have to expend money for military protection. Their trade with the British was lucrative. All was well, why change? It took 17 years for Samuel to convince his fellow countrymen to act. How did he convert them from complacency to urgency?  He used 5 approaches:

  1. One-on-one meetings – He met individually with his countrymen to discuss British rule and to share his vision for an independent America. Using personal narrative and sharing the misfortune of his father he recruited those with a shared vision to join his campaign for American independence.
  2. Assembled a leadership group – Through his one-on-one meetings and through his membership in the Caucus club he identified young and influential members of the community to form a leadership team to create strategies and tactics for the campaign for independence. He also helped to create the “Sons of Liberty”.  Among his recruits were his younger cousin John Adams, and a highly successful merchant John Hancock.
  3. Editorials in the Boston Gazette and Public Advertiser.  These anonymous editorials warned of the danger of taxation without representation. When British soldiers shot 5 colonist for throwing snowballs, he labeled the event the “Boston Massacre” and had Paul Revere create an engraving and distributed the posters depicting the massacre throughout the Massachusetts Bay Colony
  4. Organized large gatherings beneath the Liberty Tree, Faneuil Hall and the Boston Harbor.  It was here that his fiery oratory aroused his audience and created an urgency to act.
  5. Created effective strategies and tactics that countered the British Government’s every move to manipulate the colonists. When the Stamp Act taxed colonists’ commercial activities Adams convinced his fellow countrymen to institute the “nonimportation” of British goods (100 years later this tactic received the name “boycott”). The refusal of American merchants to buy British products led British merchants to complain to their Parliament and encouraged the Parliament to rescind the tax.

The ultimate event and culmination of Samuel Adams campaign for independence came I773 when he organized the gathering of over 7,000 people (over half of the population of the Massachusetts Bay Colony) at the Boston Harbor to protest the unloading of tea by the British ship the Dartmouth. He had previously orchestrated a unanimous ruling by the colonial North End Caucus forbidding the unloading of British tea in Boston Harbor. This act was in response to a ruling by the British Parliament allowing the East India Tea Company to import their tea directly to the colonist, bypassing the American Merchants. The captain of the Dartmouth came to this large gathering and requested that he be allowed to unload his tea because the British Parliament had mandated that all cargo must be unloaded in American ports within 20 days and the 20th day had arrived. Samuel Adams instructed the Captain to go to the governor and request an exception to leave the port without unloading his tea. The captain beseeched the governor to make an exception, but he refused.

The captain returned to the huge gathering and informed Samuel Adams of the governor’s order. What should Samuel Adams do? Should he insight a riot, be labeled a traitor, and be immediately jailed? He implored the crowd “This meeting can do nothing more to save our country” and disbanded the crowd. As though on cue, 40 men dressed in Indian outfits yelled out “Boston Harbor a tea-pot tonight”, marched to the British ships unopposed, and with hatchets split open 342 chests of tea and dumped them into the harbor.

This act infuriated the British who blockaded the harbor, and sent 4 infantry regimens to Boston. These events precipitated the Battle of Lexington and Concord, the first Continental Congress, the Declaration of Independence, and the Revolutionary War.

Nothing is more American than organizing fellow countrymen to act. And those of us who have been injured by medical errors should follow the example of Samuel Adams to create a sense of urgency among our caregivers and our health systems. We should follow the example of this great founding father so that others will not suffer our fate, and to assure that those who have been injured by medical errors receive the care and compensation they so justly deserve.

For more about Samuel Adams read Chapter 6, “Culture is Nothing More than Group Habit” in Critically Ill, A 5-point plan to cure healthcare delivery.

John kissing his beloved daughter Kate

John kissing his beloved daughter Kate

Kate with Julia and John at her side. She is holding her first place trophy after winning her school's speech contest.

Kate with Julia and John at her side. She is holding her first place trophy after winning her school’s speech contest.

John and Julia Hallisy’s daughter Kate was first diagnosed with retinoblastoma of both eyes at the age of 5 months. She required 2 years of aggressive chemotherapy and radiation, as well as removal of her right eye. She appeared to be cancer free until age 8 when she developed severe pain in her right upper thigh. She quickly underwent a biopsy that confirmed the worst, she had a second tumor, osteosarcoma, a bone tumor that can on occasion accompany retinoblastoma.

Her surgeon planned to resect the tumor and leave sufficient bone to allow her to have a functioning leg. However, a preventable postoperative infection got in the way. Within 48 hours of her biopsy, Kate became hypotensive due to Staphyloccocus aureus sepsis resulting in respiratory and kidney failure. She underwent an incision and drainage of the infected biopsy site, received prolonged intravenous antibiotics, required ventilator support, and remained in the intensive care unit for 7 weeks.  Painful bedsores also complicated her hospitalization.

The delay in treatment of her osteosarcoma resulted in continued growth of the tumor. As a consequence her leg had to be amputated above the knee two weeks after her discharge from the ICU. Kate’s parents were devastated, but John insisted, “We’re not going to mourn for her while she is still alive. We’ll have the rest of our lives for that. Our job is to make the most of every minute we do have.”

Kate’s last 19 months of life were extremely hard. Kate suffered from severe phantom limb pain, a well-known complication of amputation. The damage to her lungs during her septic episode reduced her ventilatory function to 70% of normal leaving her breathless when she tried to walk with her heavy prosthesis. She experienced severe post-traumatic stress from her intensive care experience frequently awaking after a nightmare or after wetting her bed. Through all her suffering Kate maintained a positive spirit and tried to look at the bright side of her predicament. After the loss of her leg she told her parents “You know, I will be able to walk again with a prosthetic leg. Some people lose both legs or a leg and an arm. I have it easier than they do.”

Julia and John will never forget their courageous and beautiful daughter. Following her daughter’s death Julia has been working as a patient advocate keeping Kate’s memory alive. Through her advocacy organization The Empowered Patient Coalition http://www.empoweredpatientcoalition.org she has reached out to other patients harmed by medical errors, and has documented over 500 hundred stories of pain and suffering.

Problem: Kate suffered a preventable Staphylococcus aureus infection following a “routine” biopsy that resulted in septic shock, respiratory and renal failure. The delays required to treat this infection prevented limb sparing surgery and necessitated an above the knee amputation.

Solution: It is likely that the skin overlying Kate’s biopsy site was not properly washed to remove surface Staphylococcus aureus. Prior to any invasive procedure the operative area should be thoroughly cleaned with Chlorhexidine. It is also possible that the biopsy instrument was contaminated with S. aureus and reliable procedures must be in place to assure that all surgical instruments are thoroughly heat sterilized.

We have a supermarket chain in Florida called Publix. George Jenkins founded this remarkable company in 1930 at Winter Park, Florida. The success of his company has always been based on customer service. As he told his employees at the end of each orientation, “If there is ever a customer you can’t handle, give them my phone number, because I will.”

Publix has a guarantee posted in every store that reads:

“Publix guarantees that we will never knowingly disappoint you. If for any reason your purchase does not give you complete satisfaction, the full purchase price will be cheerfully refunded immediately upon request. We have always believed that no sale is complete until the meal is eaten and enjoyed.”

Publix has been rated by Fortune Magazine as one of the top ten best companies to work for (2005–2008) and is one of Forbes Magazine’s top ten largest private companies (2009). Publix consistently scores higher than any other supermarket for customer satisfaction based on the national American Customer Satisfaction Index survey (1995–2010). (See Critically Ill: A 5-point plan to cure health care delivery)

Publix attributes its success to a continual focus on its customers. The key question arises, if Publix supermarkets can guarantee their food after it leaves the store shouldn’t our health care systems be willing to guarantee the care they provide to their patients after they leave the hospital or clinic? Stories like those of Jess, Carla, Marty, Veronica, and Georjean, would never have to be told. Imagine if each time a medical error occurred, the caregiver and health system immediately informed the patient, deeply and sincerely apologized, explained how the health system was taking steps to prevent the same error from harming others, and then fairly compensated the patient.  Patients injured by medical errors would no longer feel as though they were being ostracized. They would no longer lose their trust in our medical system. They would no longer be suffering the financial hardship brought on by their injuries. After all, these injuries were not the fault of the patient. Why have the very institutions whose charge is to help those in need turned their backs on the patients who morally and ethically most deserve their help? When our health systems and caregivers make mistakes, shouldn’t they do everything in their power to help those they have injured?

Georjeanfinal
A recent picture of Georjean

In December of 2008 Georjean had robotic assisted laparascopic surgery to remove her kidney that contained a large tumor. The good news was that the tumor proved be noninvasive papillary transitional carcinoma and had not spread to her lymph nodes or to any other adjacent tissues. She was cured. The bad news was that immediately following the surgery she began experiencing severe abdominal pain. The physicians and nurses minimized her complaints. However, on the second day after her surgery Georjean became hypotensive (her blood pressure dropped). She looked into her husbands eyes and told him she was going to die. He called for help and the surgeons rushed her to operating room where they discovered her bowel had been nicked during her prior surgery and over a billion bacteria had leaked out of her bowel into her peritoneum and into her blood stream. Her severe abdominal pain and septic shock had been caused by what is called secondary peritonitis, a very dangerous and potentially fatal infection. The large collections of pus and bacteria were washed out, and drainage tubes were placed throughout her abdomen,

Her infection was complicated by respiratory failure requiring that she be intubated (a tube placed in her airway), supported by a mechanical respirator, and moved to the intensive care unit where she remained for 20 days. Soon after being moved to a regular floor she was discharged to her home with multiple drains, only to return 6 days later because of additional undrained abdominal abscesses. A total of 8 abscesses required drainage, and one was infected with a fungus in addition to bacteria requiring strong anti-fungal therapy in addition to intravenous antibiotics. After multiple procedures and prolonged antibiotic treatment requiring over 2 months in the hospital, she was again discharged to her home in mid-March. Here she required a special vacuum dressing and continued dressing changes for open wounds that finally healed 6 ½ months after her original surgery.  As she became more active she developed large hernias in both inguinal areas (lower abdominal areas) as well as a large midline hernia.

Her surgeon elected to delay repair because of all her recent suffering. Unfortunately because of her illness she had lost her job, and soon lost her health insurance coverage. Now she could not longer afford to visit her surgeon and could not personally pay to have her hernias repaired, and by the time she was able to get Medicare coverage her surgeon was fearful of operating. He warned that surgery on her extensively scarred bowel could cause further bowel damage. Because of her poor bowel function Georjean eats a very limited diet and has to wear a special binder to reduce her hernias. Many physicians have discharged her from their care because “You ask too many questions.” Now she asks no questions and agrees with whatever the doctor says, but she wishes they would help her to fully regain her health.

Problem – Georjean underwent resection of her kidney using a laparascope. Laparascopes minimize the size of the incision and usually allow the patient to recover more quickly.  However laparoscopy is technically more challenging and makes visualization during surgery more difficult. As a consequence the surgeon accidentally cut into her bowel causing severe peritonitis and septic shock.

Possible solution – Physicians who have not undergone extensive simulation training in laparoscopic surgery should utilize open abominal exploration to reduce the risk of a complication.

Problem – The nurses and physicians minimized Georjean’s complaints about abdominal pain. They thought she was a troublemaker,

Solution – Doctors and nurses should carefully listen to their patients’ complaints and order the appropriate tests to exclude a serious cause. In Georjean’s case she should have undergone surgical exploration and drainage within the first 24 hours. This would have reduced the severity of her infection, and probably preventing her from developing respiratory failure, as well as reduced the number and severity of her abdominal abscesses.

Problem – Georjean lost her job and her health insurance as a consequence of a surgical error.

Solution – Shouldn’t the health system and physician who made this mistake have assisted Georjean both medically and financially, rather than dropping her from their care? Is this how you would want to be treated? Anyone in her shoes would agree that hospitals and caregivers need a new approach to caring for patients who are injured by a medical  or surgical error. Potential solutions will be discussed in my next post.

Vera and her daughter, Veronica, celebrating Christmas

Vera and her daughter, Veronica, celebrating Christmas

Vera’s illness began with a soft tissue infection called cellulitis probably brought on by a whirlpool bath treatment. She was hospitalized and treated with Intravenous antibiotics. She was discharged to home and told to stay off her foot, and while at bed rest developed pneumonia. She required readmission to the hospital. While being fed dinner she choked on her food and the food ended up in her lung. She required placement of a breathing tube, respirator support, and transfer to the ICU. Despite several attempts to take her off the respirator her thick secretions repeatedly led to worsening respiratory failure requiring replacement of the breathing tube. Because prolonged respiratory support was anticipated she underwent an elective tracheostomy.

At 90 years old Vera remained alert and very intellectually engaged. While in the ICU she listened to classical music and danced with her arms. After about 2 weeks, she had improved sufficiently to warrant transfer to a less acute facility where weaning her from the respirator could be completed. Soon she was managing up to 40 hours breathing on her own. On her 6th day in her new facility the nurses experienced some difficulty suctioning her thick mucous secretions and decided to take out her tracheostomy tube and replace it with a smaller one.  This procedure was conducted without the supervision of an experienced physician. A little after midnight, without a physician’s order, her tracheostomy tube was again changed to an even smaller size.

Worried, her daughter Veronica called every two hours throughout the night, and each time was told her mother was stable. However the following morning while in church her daughter received bad news. Veronica was told her mother suffered an “event”. While being rolled over in bed her small tracheostomy tube came out, and Vera remained without significant oxygen for a prolonged period. As a consequence she suffered irreversible anoxic brain damage resulting in waxing and waning coma, and a loss of the ability to speak. Over the next 6 months Vera continued to require hospitalization. Her downhill course was complicated by a large and painful pressure ulcer (13cm, Stage Four ulcer that developed within 3 weeks of her brain injury), followed by C. difficile diarrhea, sepsis, renal failure and death.

Vera, an intelligent, talented and deeply loved mother was taken from her daughter by mismanagement of a tracheostomy tube. Veronica quit her job to take care of Vera. She lost her mother twice. First, after anoxic brain damage, and second after the many complications led to her death. Veronica remains a second victim suffering from depression and post traumatic stress syndrome. I hope that sharing her mother’s story will help Veronica to heal and to transform her into a survivor.

Lessons learned from Vera and Veronica’s experience:
Tracheostomy tube accidents are all too common. The number of injuries and deaths due to tracheostomy mismanagement is unknown. There were three major problems associated with the management of Vera’s tracheostomy:

Problem – The tracheostomy tube was replaced without the supervision of an experienced physician.
Solution – Guidelines from experts in the field recommend that an Ear, Nose and Throat (ENT) surgeon be present the first time a tracheostomy tube is changed. Tube exchange after a new tracheostomy (incision below the Adams apple that creates an air passage below the vocal cords) can result in the accidental closing off of the tracheostomy site and this complication may require emergent surgical intervention.
The Guidelines state, “An initial tracheostomy tube change should normally be performed by an experienced physician with the assistance of nursing staff, a respiratory therapist, medical assistant, or assistance of another physician.”

Problem – The tracheostomy tube came out and Vera could not be properly ventilated for a prolonged period. The tube was not properly tied down, and it is likely that the diameter of the tracheostomy tube was too small. These two conditions allowed the tube to be easily dislodged.
Solution – Tracheostomy tubes should always be anchored with a tie-down ribbon around the neck to prevent the tube from becoming dislodged. Guidelines specifically state “Tracheostomy tube ties should be used unless the patient recently underwent local or free flap reconstructive surgery or other major neck surgery.” Second, an ENT surgeon should have decided on the diameter of the tracheostomy tube.  A number of factors need to be considered when deciding on the diameter and type of tracheostomy tube.
Guidelines state:
1. “When determining the appropriate diameter tracheostomy tube, lung mechanics, upper airway resistance, and airway clearance should be considered.”
2. “When determining the appropriate diameter tracheostomy tube, indications for the procedure, trachea size, and shape should be considered.”
3. “When determining the appropriate diameter tracheostomy tube, clearance for ventilation and communication/speech needs should be considered”

Problem: The exact events that resulted in Vera’s anoxic brain damage remain to be fully clarified; however based on the outcome it is clear that the emergency response was inadequate, and in all likelihood the caregivers were not properly trained in tracheostomy care.
Solutions: All caregivers and family members should be properly trained in how to manage tracheostomies, including emergency care.
Guidelines state:
1. “Utilization of a defined tracheostomy care protocol for patient and caregiver education prior to discharge will improve patient outcomes and decrease complications related to their tracheostomy tube.”
2. “Patients and their caregivers should receive a checklist of emergency supplies prior to discharge that should remain with the patient at all times”
3. “Patients and their caregivers should be informed of what to do in an emergency situation prior to discharge.”

Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. Jan 2013;148(1):6-20

Byron Dyce, my fitness trainer, brought me back.

Byron Dyce, my fitness trainer, brought me back.

I will never forget the kind expression and deep concern of my vascular surgeon as he explained that I would require an above the knee amputation. He had reviewed every alternative and had considered radical surgical approaches; however the angiography of leg revealed no blood flow below the knee. An above the knee amputation was the only solution.

In preparation for my surgery the anesthesiologist and pain specialist explained the advantages of placing local catheters along my sciatic and femoral nerves and infusing a numbing agent. He was excited and enthusiastic about reducing my postoperative pain, and I agreed to have a local block. Immediately following surgery I was able to control my pain by changing the infusion rate of the local anesthetic. Because I was able to control my pain locally, I required no systemic narcotics which are notoriously addictive, and often cause nausea, sleepiness, and severe constipation not to mention respiratory arrest at high doses.  The pain team came by each day to make sure my pump was working properly. I was and am impressed by their dedication to preventing pain, and their very caring approach. To me they rank up there with the saints. Thanks to their home infusion program I was able to be discharged 24 hours after my amputation.

Because my pain was so well controlled within 12 hours of my  amputation, two physical therapist were able to teach me how to walk using a walker. I was able to ambulate over 200 feet on my first try. They also quickly trained me how to transfer from bed to chair, and balance on one leg. Their encouragement and positive attitude showered me with hope that I would be able lead a normal life without my leg.

During my three hospital stays my nurses fulfilled my every request and continually expressed their concern for my well being. I will never forget one of my nurse’s description of her fight to defend one of her patients from abuse at a chronic nursing care facility. She lost her job trying to do her best for her patient. I knew I was in great hands.  My nurses were like air; they were always around, always hovering. I deeply admire their dedication to the well-being of all patients.

Upon leaving the hospital I was transferred to the care of an outpatient physical therapy team. They massaged my swollen residual limb, taught me strength exercises to build by gluteus muscles and to stretch my contracted ileopsoas muscle. As my strength improved I was finally able to wear a prosthetic limb. They coached me on how to walk. I felt like an infant, as I awkwardly took my first few steps. With each session my gait has improved. I am learning how to keep my hips parallel and drive off my toe by contracting my gluteus muscles. The closest analogy to walking with a prosthesis is cross-country skiing. My goal is to become an expert at my new sport (walking), and I have the best coaches an athlete could ever hope for. Their enthusiasm and positive attitudes are infectious, and their dedication to improving my life inspiring.

I have learned from other amputees that the most critical person in their lives is their prosthetist. If the prosthetic limb does not fit properly walking is a painful ordeal and life becomes very limited. The ideal prosthetist is patient and understanding, and continually adjusts the limb socket to assure the amputee is comfortable, and that is exactly what my prosthetists have done. Whenever I call with a problem, they  respond immediately. They placed padding at sore spots, raised the height of my prosthesis, adjusted the resistance setting of my electronic knee, and continually offered sympathy and encouragement. What an important role they have played in my life and in the lives of others who have lost a limb. My lost limb now plays a very central role in my life. If I am unable to walk or have pain in my residual limb my whole day is ruined. A black cloud hovers over me, but through their careful adjustments, my prosthetists are able to quickly lift that cloud and create a sunny day.

After four surgeries and my prolonged illness I lost over 14 pounds. I was mere shell of my former self.  I decided I needed strength training. However, when I tried to lift weights in the gym, I was unable to pick up the dumbbells and position myself on a bench using my walker. I needed a trainer. And fortunately I found the ideal trainer. Young, powerful and very athletic, this former University of Florida football player took on the challenge of bringing me back. The first few sessions I was fragile and demonstrated minimal endurance. During our third session I fainted. My limb pain combined with my tendency to hold my breath while lifting caused me to black out. Patiently he lay me down and gave me fluids. I quickly recovered. Twice a week at 6 AM I work with my trainer who has created a rigorous one hour program designed to improve my flexibility and strength: shoulder stretches, prone back extensions, forward planks, reverse planks, rope pulls, dumbbells, weight machines, push ups, pull ups, and dips. Each week I grow stronger, and I have regained my weight thanks to the patient and concerted efforts of my trainer.

When friends and colleagues greet me today they frequent say “Fred, you look so healthy. I can’t believe how well you look.” And I realize my recovery was only possible because of the dedicated efforts of my incredible healthcare team at UF&Shands, Hanger Clinic, and Gainesville Health and Fitness. I will always be grateful. When I add up all my teammates I count over 50 caregivers*. It takes a team to pick up the pieces. Putting me back together after my preventable injury has represented a herculean effort.

THANK YOU!

*My Team
1      me**
4      vascular surgeons
6      resident physicians
2      urologists
6      anesthesiologists
15     nurses
4      in hospital physical therapists
6     outpatient physical therapists
2     dieticians
4     blood drawers
3     house maintenance people
2     prosthetists
1     fitness trainer
56   Total team members
**It is critical that each patient become an active member of his/her team

Marty and Gwen  Survivors

Marty and Gwen Survivors

Meet Marty and Gwen

Marty is a master carpenter who for years molded wood into the most magnificent heirloom furniture imaginable. He had a thriving architectural woodworking business and was always in demand. Gwen worked as a fund raiser and health policy advocate for a university health system.

In 2001, as Marty was turning 50, he was examined because he had some blood in his stool.  During his colonoscopy a polyp was found near the rectum and was removed.  In retrospect the polyp base had not been completely removed. He was told the polyp had cancer cells, but he was never scheduled for a follow-up colonoscopy. In the following seven years no one in whose care he was under ever recommended that he be seen every year.

In September 2005 Marty complained to his primary care physician that he had noticed blood in the rectal area. He was examined and told this was due to a hemorrhoid. Again in 2006 he noted blood on the toilet paper, and again he was told it was caused by a hemorrhoid. He trusted his physician, after all it was “not his place to question or quibble”. In mid-2007 he called the physician’s office complaining of globs of blood from the rectum and again was told it was just his hemorrhoid.

In July 2008 he was diagnosed with a malignant neoplasm of the rectum, stage IV cancer, meaning the cancer had spread to his lymph nodes. Marty was devastated. He had trusted his physicians. But he soon learned that he had not received the standard of care he deserved. Rectal bleeding should have been taken more seriously. An entire academic health center had failed him.

He was told by the first surgeon he saw that he had the worst colon cancer she had ever seen, and that he would be required to wear a colostomy bag for the remainder of his life. She demonstrated no empathy for his situation. Discouraged Marty thought about giving up, but Gwen would have not part of surrender. Through her connections they identified an outstanding surgeon, oncologist and radiation therapist. After extensive surgery,  high dose chemotherapy that resulted in the loss of sensation in Marty’s hands and feet, as well as extensive radiation that resulted in delayed wound healing requiring 14 months of dressing changes, Marty recovered. He is now cancer free.

Marty could have sat at home angry and depressed over what had happened to him. However, having grown up in the 60’s he remembered the words of Bob Dylan’s song The Times They Are-A Changing:  “Shake your windows. And rattle your walls”. And that is exactly what Marty has done. He met the the Chancellor of the Medical Center that had failed him in the hopes of preventing similar events from happening to others. He has spoken to healthcare providers (strike on this link to watch his eloquent presentation) describing in vivid detail both the worst and the best that our health systems have to offer.

Marty wants to be a force for change, and I hope that you will join Marty and me in our quest to reduce errors in our health care systems. The sharing of our stories can and will make a difference.

Lessons learned from Marty’s and Gwen’s experience:

  1. Problem – Marty was not provided with proper follow up instructions after his 2001 colonoscopy.
    Solution – All colonoscopy reports should include recommendations for follow up. In Marty’s case a colonoscopy should have been recommended within 3 years or earlier if he experienced rectal area pain, bleeding or anemia.
  2. Problem – His primary care physician ignored his complaints about rectal bleeding. She attributed blood on his toilet paper to a hemorrhoid, which she misdiagnosed. She made a common reasoning mistake. Her diagnosis became anchored and she was unwilling to change her diagnosis despite additional input from Marty. She failed to listen to the concerns of her patient.
    Solution – All physicians  must be aware and guard against anchoring their diagnoses. An expert diagnostician keeps an open mind, takes in new information, and changes his or her leading diagnosis accordingly. All clinicians should also consider the worst case scenario, and exclude the most dangerous diseases that could harm their patients.
  3. Problem – When Marty presented his complaints to the Chancellor of the Medical Center, the administration and physicians circled the wagons. They never apologized and claimed Marty’s illness was a complication that could not have been prevented. This forced Marty to take legal action increasing the settlement costs to the medical center and causing great emotional stress to Marty and Gwen.
    Solution – When an error occurs the caregiver and medical center administration should immediately acknowledge their error and sincerely apologize, describe the ways they will prevent similar errors from hurting patients in the future, and offer a fair monetary settlement for the harm they have caused.