Archives for category: medical mistakes

I haven’t posted in quite awhile. Why? Because for the last 6 months I have devoted over 125 hours to creating a course that will provide you with the tools to fix our healthcare delivery system. Every system is designed to produce the results it achieves, and unfortunately at this time our healthcare systems are inadvertently designed to harm patients.  You will learn how to apply the principles that high performing manufacturing systems to continually improve quality, you will learn how to apply the lessons you learned in team sports to becoming an integral member of your healthcare team. When patients become part of the healthcare team they are far more likely to receive higher quality, safer and more efficient care. You will learn how to recognize impending errors and dangerous conditions so that you can avoid harm. One of the most important lessons I will be teaching is how you can become an adaptive leader, a leader who can bring about change, and goodness knows our health systems need to undergo dramatic changes. And finally I will teach you how to organize others to achieve the goal of continually improving healthcare delivery. The course is free and it is offered through the University of Florida and Coursera. The Institute of Healthcare Improvement with the help of Michael Briddon has generously offered a number of teaching modules that have been incorporated into our course. Upon completing the course you can become part of the solutions. If everyone makes one or two small improvements every week or month our systems of healthcare delivery will steadily improve. WE ALL CAN MAKE A DIFFERENCE.

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?

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

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.


Carla was 50 years old at the time. She had difficulty with her left knee and consulted an orthopedic surgeon who recommended a total knee replacement. She failed to seek a second opinion. She subsequently learned that a total knee was unnecessary. Unbeknownst to her, the surgeon placed a non-FDA approved prosthesis, and according to a second orthopedist who she subsequently consulted he misaligned the prosthesis.

Carla's Xrays
Xrays of Carla’s knee: Left her first repair, Right the second repair

Following the placement of her total knee she experienced continual severe pain requiring strong narcotic pain medications, oxycodone and oxycontin. These medicines precipitated a severe depression and a suicidal attempt. She was unable to work and suffered financial hardship.

6 months after placement of the first prosthesis she had to undergo a second major operation to replace the prosthesis. Her pain continued and she sought legal recourse, however given her fragile mental state she was unable to tolerate the emotional stress of litigation and withdrew her claim.

After a 1 1/2 years she discontinued her pain medications and thanks to her deep abiding faith she was able to overcome her disability and pain. She transformed herself from a victim to a survivor, and now is a successful realtor.

As her father had warned her as a child “Life is not always fair.”

But shouldn’t Carla have received financial assistance during this difficult period of pain and mental anguish?  Her injury was not her fault, and I suspect the surgeon installed this new prosthesis expecting a superior result. Unfortunately his lack of familiarity with the prosthesis led to misalignment and Carla’s poor outcome. What would have happened if he had acknowledged his mistake, sincerely apologized, explained his plans to prevent this outcome from happening to other patients and contacted his insurance company to fairly compensate Carla during the period she was unable to work? Carla would have felt validated and in all likelihood would have recovered more quickly. She and her physician could have maintained a positive relationship, and Carla’s distrust of the healthcare system would have been alleviated.

Oregon now is considering a legislative act entitled: RESOLUTION OF ADVERSE HEALTH CARE INCIDENTS that will encourage this much more effective approach to patient injury. Our legal system has failed in making injured patients whole, <25% of those with preventable medical injuries receive a legal settlement and when they do 2/3rds of the award goes to their lawyers. Litigation creates an adversarial relationship between caregivers and patients and prevents both groups from communicating. This lack of communication makes emotional closure nearly impossible and stokes the fire of destructive anger. Patients need to devote their emotional energy to recovery rather than toward blame and anger. Bills like the one in Oregon have the potential to help transform victims of medical errors into survivors.


Meet Tanya. Her 17 year old daughter Jess died as consequence of medical errors. She had fainting spells for 4 years and neurologists claimed they were seizures. The family found out about the prolonged QT syndrome, but the doctors refused to listen to them. Finally Jess was seen by a cardiologist who claimed she did not have prolonged QT syndrome. Five of her tests were misread. After Jess died the cardiologist reviewed the Holter monitor, and it revealed she had the syndrome. Genetic analysis revealed her father carried the gene.

Jess died because her doctors refused to LISTEN and failed to properly review her tests. Patients and families can serve as an effective resource by researching possible causes of the patient’s illness, as Tanya and her family did. Physicians and families have the same goal to heal the patient. In the ideal world they should form a true interdependent team. In effective teams all members are respected and their opinions valued. Imagine if the physicians who cared for Jess had been open to the family’s suggestion that she had prolonged QT syndrome, and allied with the family to explore this possibility. Jess would be alive today. I have found so often that effective healthcare is not about aptitude, but about attitude.

Tanya has dedicated the last 6 years to driving changes in the Canadian health system and she will never stop. Every day she thinks about her beautiful daughter Jess. And she will continue her quest until our systems of healthcare delivery are healed. View her website to understand how she is trying to improve patient care

Watch her video. I agree with every recommendation!  And I will never forget Jess. After you watch this video you also will carry her story in your heart.

We all must work together to end stories like Jess’s.

Rowing on Lake Santa Fe before my injury

Rowing on Lake Santa Fe before my injury

All through high school and college I played three sports. My senior year at college I earned letters in Football, Wrestling and Lacrosse. You may think, “Was this guy crazy? How did he have time to study?” I was born with a great deal of energy and when I wasn’t working out, I felt as though something was missing. Throughout medical school I continued vigorous exercise, playing rugby and then settled on rowing as my lifetime sport.

I began my rowing career the year of my medical internship at Boston City Hospital, and rowed that year in the Head of the Charles. I will never forget getting ready for the race. I was so nervous I leaned out to place my oar and fell into the water. Needless to say I was a little embarrassed. I rowed the race in wet cloths. Fortunately it was a warm day.

For the past 20 years prior to my injury, I rowed nearly every morning. I drove to Lake Santa Fe at 6 AM to enjoy the glassy waters, the herons, egrets, and osprey. The rhythmic rowing on this idyllic lake created a meditative state and served as a spiritual beginning to every day.

Now my day begins by grabbing my walker and hopping to the living room where I place a sleeve over my residual leg. I measure the diameters of the leg each day to document the degree of swelling and decide how many socks I will need to add to be sure the socket fits properly. I then lubricate the seal of the sleeve and slip into my prosthesis. Will it fit properly today? Will it be painful when I bare weight? I never know. There are good days and there are bad days. I practice walking. I try to stop from dragging my left hip backwards, and try to keep my hips even as I walk with my crutches. On good days I can use a cane. I always feel a little anxious about falling.

Two months ago I returned  to the lake for the first time since my injury. As my brother, Steve, and I arrived near the shore, all the memories of rowing on the lake came rushing back. With tears in my eyes I walked toward the water. The toe of my prosthesis caught in the grass, and I suddenly tumbled. I pulled my lower back muscles trying to catch my fall. I never made it to the water. My back pain forced me to turn back. My brother had to carry me under my arms to the car, and we headed home. I had back spasms for two days, and I haven’t gone back to the lake since that sad day.

How has your life changed since your medical or surgical injury?

(For the description of Dr. Fred’s preventable hospital injury hit “About Dr. Fred”)