Medical Mistakes that Led to a Greater Good

In his article “Ten Medical Mistakes That Changed the Standard of Care,” Dr. Barry Bialek offered a lemons-to-lemonade account on In reviewing these sad tales, Bialek demonstrates how medical errors — and the resolve to right a wrong — can advance science and the notion of best practice.

Bialek provides some historical perspective as well. Western standards of care, he notes, date to Hippocrates more than 2,400 years ago. The origins of our contemporary understanding of best practices date only to 1910, with publication of the Flexner Report, a seminal document in which Abraham Flexner surveyed the state of medical education in the U.S. and Canada. At that time, only 16 of the 155 medical schools required more than a high school education for admission.

“The practice of medicine across the U.S.,” Bialek writes, “is much more standardized, thanks in large part to changes made by medical schools in response to the Flexner Report.” Among those changes are rigorous medical school admissions and clinician licensing. In addition, standards of care are (mostly) based on science.

Here are Bialek’s 10 tales of teachable mistakes.

1. In 1976, Dr. Jim Styner, an orthopedic surgeon, crashed his small plane into a Nebraska cornfield. His wife was killed and he sustained serious injuries, as did three of their children. The local hospital’s care was inadequate, even by the standards in those days. Later, Styner stated, “When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system, and the system has to be changed.”

Their tragic adventure spawned Advanced Trauma Life Support (ATLS) and changed the standard of care in the first hour after trauma.

2. Judy, 39, underwent a supposedly routine hysterectomy. But she died on the operating table, and an autopsy revealed that the anesthesiologist had placed a breathing tube not in her trachea, but in her esophagus.

Such a grave, simple anatomical mistake today is avoided because an anesthesiologist measures the patient’s carbon dioxide levels, which are much higher from the trachea than from the esophagus, with a CO2 monitor.

3. Sally’s labor for her first child was long, so her obstetrician administered Pitocin, a synthetic version of the hormone oxytocin, to speed things up. Unfortunately for the baby, the Pitocin prompted fetal distress that went unrecognized, and she suffered severe brain injury and cerebral palsy.

Today, fetal monitoring to test both uterine contractions and fetal heart rate is the standard. If fetal distress registers, it takes only 30 minutes for the baby to be delivered.

4. Bill was driving when he suffered a seizure and crashed his car into a tree, crushing both legs. Arteriography, an X-ray mapping of the arteries depicting the progress of an injected fluid, revealed that his right leg was salvageable, but his left leg was not. But the X-ray technician mislabeled the films and the orthopedic surgeon amputated Bill’s right leg.

Today, the surgical site is marked and multiple health-care providers interview each patient before he or she undergoes surgery.

5. Tom was 12 when his appendix burst. Three days after his appendectomy at a local pediatric hospital, his fever spiked anew. After one week, the surgeon performed a second procedure and found the cause-a surgical sponge had been left inside the wound.

Today, post-operative sponge and instrument counts are routine. In addition, threads visible on X-ray are woven into surgical sponges, so that such tools are readily apparent in post-operative X-rays.

6. As a young child, Betty had been given penicillin, turned blue and was rushed to the hospital. At 15, she contracted Strep throat, was given penicillin and died. No one had asked her about medication allergies.

Today, medical questionnaires always include a high-profile space for allergies.

7. Linda was in her first trimester of pregnancy, and not doing well. Nausea and vomiting had left her severely dehydrated and low on potassium. She was seen in a busy emergency department where the nurse made a simple mistake in arithmetic and added too much potassium to her IV. Within an hour, Linda was dead.

Today, clinical personnel don’t compound this medicine on the fly-potassium is added to IVs by the manufacturer and labeled.

8. Frank, 72, broke his right leg in a car accident. He recovered for a few weeks in a rehab facility in which the nurses didn’t know they were supposed to move him periodically, and he developed deep pressure wounds. They became infected, and Frank’s leg had to be amputated.

Today, caregivers know that pressure wounds are mostly preventable by regularly repositioning at-risk patients every two hours to enable blood flow to the skin.

9. Lillian was 68 and weighed 250 pounds when she underwent surgery to remove her gall bladder. The second day after surgery, she needed help walking to the bathroom. Her nurse, Millie, couldn’t bear the load, and they both fell, breaking Millie’s right arm and Lillian’s left leg.

Today, clinical personnel are taught proper lifting techniques, and they practice them.

10. Christy was 42 when her doctor discovered a large lump in her left breast. It would have been evident during Christy’s two previous annual exams, had those physical exams been complete. By the time it was diagnosed, the cancer had progressed beyond cure.

Today, breast self-exams are taught widely, and are routine in physical examinations. Mammograms are also standard care.

Bialek concludes his malpractice roundup by noting that the federal government and medical schools, acknowledging that all of the mistakes he recounted could have been prevented, have developed guidelines for prevention and treatment of many diseases. Chief among them is the Agency for Healthcare Research and Quality (AHRQ) from the Department of Health and Human Services. The website offers guidance to medical consumers as well as practitioners, including how to locate good quality medical care and reduce medical errors; how to compare medical treatments; how to navigate the health-care system; and how to assess insurance coverage.

We’ve discussed several of these topics in our monthly newsletters. If you think you or a loved one might have been the victim of medical malpractice, link to our Medical Malpractice A-Z page for guidance how to proceed.

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