Dr. Elaine Goodman had just finished her first year at Harvard Medical School when she became intimate with the consumer side of medical care. Her story, recounted on ProPublica.org, is a cautionary tale for everyone, professional or patient, and sheds yet more checkered light on patient safety in the hospital.
Goodman learned firsthand, while her mother was being treated for breast cancer, that plenty of errors and mishaps occur in the hospital, not so much from glaring medical malpractice, but from the "swiss cheese" holes everywhere in the system that too often lined up to hurt a patient.
When the daughter visited her mother one morning, she found her bloodied, hallucinating and disoriented. Mom had pulled out the staples from a recent procedure on her head. Another time, mom got a black eye from being banged in the face with a stethoscope. She fell frequently, experienced unnecessary side effects from drugs, almost had unnecessary brain surgery and was nearly given the wrong drug.
Remember, this is a person whose family member was part of the medical community. What in the world was going on?
“It was really eye opening for me to see the reality of how difficult it was to keep her safe in the hospital,” Goodman told ProPublica, the public interest investigative news outfit. “It’s not enough just to have caring, qualified people to keep the patient safe.”
Goodman’s mother died in 2008 after spending six months in the hospital. Her daughter believes the inpatient misfortune she suffered hastened her decline.
Goodman, now a second-year resident in internal medicine and primary care at Brigham and Women’s Hospital in Boston, participated in ProPublica’s coverage of patient safety by completing its Provider Questionnaire. ProPublica reporters confirmed the details of her mother’s story.
In her extended interview with ProPublica, Goodman addressed several issues about patient safety she hopes will contribute to the public good. Following are excerpts.
What did you your experience with your mom teach you about medicine?
“I hadn’t realized how hard it is to keep a complicated patient safe in the hospital. The harm is rarely caused by actual negligence. The vast majority of cases involve a lot of people doing fairly reasonable things, and somehow something just falls through the cracks.”
“One day my mom fell out of bed in the middle of the night. They had bed alarms to notify nurse if a patient starts to fall out of bed. But there’s also a chair alarm, and the nurses showed us that there were only enough electric outlets for one alarm at a time, and the alarms had identical cords – making it hard for the nurses to tell which alarm was plugged in. The day my mom fell, the wrong alarm was plugged in.”
Medication errors were frequent. My mom was on a seizure medication that needed the dose adjusted according to her nutritional status. The physicians probably knew this, but with all the handoffs, [see our recent blog about hospital shift changes] a new doctor would come in, see the drug level was low in her blood – and without carefully observing her nutrition – and then up the dose. She was being accidentally overdosed on the medication which caused her to sleep for days.”
“The biggest error related to her chemotherapy, which was administered by a device straight into the fluid of her brain. They’d give her the chemo about once a week, and it was supposed to last an entire week. One weekend … [a different] physician administered the chemo. About a week later her normal oncologist came to us in tears. …[H]er colleague had not administered the right chemotherapy drug, and the type she’d received had only lasted a day, not a week. My mom had effectively gone for a week without getting any treatment.”
How did the hospital doctors and officials respond?
“[The family] had a lot of conversations with the hospital administrators about what they were going to do about such a big medication error. We arranged to become members of the hospital’s patient safety committee. That got us involved in a way that made us feel they were addressing it.”
“... It turned out the drug that had been incorrectly administered had a name that was almost identical to the name of the correct drug, and the labels were almost identical. Plus, the hospital did not have a pharmacist who had specific expertise in chemotherapeutics. It was a case that illustrated what they call the “Swiss cheese model” for how errors occur. All the holes just line up and then the mistake is made. …”
“The hospital ended up hiring a new chemotherapy pharmacist, training the nurses and changing how the chemotherapy drugs were ordered and labeled.”
What do you see as the causes of ongoing patient safety problems?
“Complexity. There are exponentially more treatments, medications and technologies now compared to a few decades ago. We also have so many different ways patients are insured, different facilities they’re staying in and various aspects to their care. There are so many layers to manage.”
There’s also a huge problem with overbooking our physicians and medical staff. The patient volume is high, and they’re in and out of the hospital more quickly. … Physicians are constantly multitasking — being paged all the time, distracted, working long hours — with no time to sleep. …”
“And yet the emphasis is on the individual doctor taking care of all the issues. … Frankly there aren’t enough hours in the day to make sure you do all of that. You also don’t have the mental bandwidth to do it.”
How did your experience change the way you practice medicine?
“… When I was first in the hospital with my mom I tried not to ask too many questions. I didn’t want to be labeled ‘difficult,’ or as the daughter in med school who thinks she can dictate decisions. As a result, my mom’s care got worse. I realized that we family members had a lot to offer, especially in terms of handoffs between physicians. … In one case with my mom, a radiologist had picked a chemo drug he thought was best and later I saw a nurse begin to administer a different chemotherapy drug in response to his order. I questioned the nurse. The nurse was kind of annoyed, but she called the radiologist and then administered the correct drug.”
What did you learn about patient safety as a medical student?
“We had some lectures peppered throughout the curriculum. No patient safety course, but we had talks here and there. I went to med school because I was passionate about science and care, so the patient safety topics weren’t the most exciting. …”
“I would have been more attuned to this problem if the instruction had been tied to individual patients. When I came back to medical school [after caring for her mother], I did a patient safety elective – which was a new thing at the time – where students sit in on committees that are reviewing adverse events. Reviewing those cases made it easy for me to imagine myself as a physician who missed something important while caring for a patient.”
What’s one way medical providers can reduce the number of patients who suffer harm?
“Sometimes errors are not even tracked. When I returned to medical school after my mom’s death, I found that there was no way for medical students to report an error. There was an error reporting system, but the medical students did not have a login for it. …”
“And when errors are reported, the response is not always constructive. I filed an error report a few days ago about a medication event. Most people responded well, but a few emails I got showed some people were not happy being involved in an error report. … People are still prone to taking these things as personal failings instead of thinking about the system. …”
“We need to build a culture of patient safety. That means removing the stigma from patient safety and error reporting so we can collect data about errors and learn how we can fix things. That’s better than not knowing the scope of the problem because people are afraid to talk about it.”
To see the article Goodman wrote about patient safety for the American Medical Association, link here. To learn more about how to protect patients in the hospital, see my two-part newsletter on preventing common hospital errors, here and here.