The Anatomy of a Medical Mistake

Zeebrugge ferry victims remembered

On March 6 1987 the unthinkable happened. The roll-on roll-off passenger ferry The Herald of Free Enterprise left the Belgian port of Zeebrugge with it’s bow doors open, and capsized within moments, killing 193 passengers and crew:

The immediate cause of the sinking was found to be negligence by the assistant boatswain, asleep in his cabin when he should have closed the bow-door.

But the official inquiry placed more blame on his supervisors and a general culture of poor communication in the ferry company P&O European Ferries. The first officer was required to stay on deck to make sure the doors were closed, but apparently left the deck with the bow doors still open in the expectation that the assistant boatswain would arrive shortly. The boatswain, who is believed to have been the last person on the deck before the disaster was later asked why he did not close the doors given there was no one else there to do it.  He said it was “not his duty”.  Finally, the captain assumed that the doors had been closed when he set sail – he could not see them from the wheelhouse owing to the ship’s design and the fact that the shipping company had previously decided not to retrofit an indicator light in the wheelhouse.

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Serious medical errors often occur under similar circumstances, including flawed or violated safety protocols and failure of communication.

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For example, there were three instances of wrong side brain surgery at the Rhode Island Hospital in 2007. One time an experienced brain surgeon insisted to a nurse he knew what side of the head to operate on — but got it wrong.  Another time, a resident cut into the wrong side of a patient’s head after skipping a pre-op checklist.  In the third case, the chief resident started brain surgery in the wrong place, and the nurse didn’t stop him.

These errors happened despite required operating-room precautions adopted by the medical profession a few years ago to prevent such “wrong-site surgery” mistakes, including checklists, “time-outs” to double-check everything is correct, and indelible markers to show the surgeon where to cut.

These mistakes at Rhode Island Hospital suggest that such precautions can still be thwarted by the human element — ego and overconfidence on the part of surgeons, and timidity on the part of nurses too afraid to speak up when they see something about to go wrong.

Ongoing efforts to improve patient safety include: The use of information technology, such as hand-held bedside computers, to eliminate reliance on handwriting for ordering medications and other treatment needs. Avoiding similar-sounding and look-alike names and packages of medication. The standardization of treatment policies and protocols to avoid confusion and reliance on memory, which is known to be fallible and responsible for many errors.

However, the most important patient safety step is adopting a culture of patient safety at the hospital.

All staff must be encouraged to speak up if they identify a problem or mistake.

If the boatswain or first officer had simply flicked the switch to close the doors, or notified the captain they were still open, disaster could have been avoided on March 6, 1987.

Telemedicine on the ICU, Saves lives and $$s

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We have already bogged about the value of telemedicine for the evaluation of acute stroke patients in the emergency room.

Telemedicine can be valuable in any hospital department, including the Intensive Care Unit (ICU).  ICU telemedicine involves a combination of videoconferencing technology, telemetry, and electronic medical records in order to allow off-site intensivists and critical care nurses to assist in the treatment of critically ill patients.

A 2011 metanalysis of studies published from 1950 to 2010 had found that telemedicine in the ICU was associated with a significant reduction in ICU mortality and length of stay.

A more recent prospective study published in Chest last week showed that tele-ICU care improved adherence to ICU best practices, reduced the response times to alarms, leading to lower mortality and length of stay.

Keep in mind that the cost of 1 day in the ICU can be as high as $6,000-$10,000.

Atrial Fibrillation? Better ask your doctor about anticoagulation.

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Atrial fibrillation (AF) is a major risk factor for TIA and Stroke.

It is estimated that AF accounts for >20% of all strokes.

This risk can be lowered by as much as 60% by taking an anticoagulant such as warfarin (Coumadin).

Current guidelines recommend anticoagulation for all patients with AF, even paroxysmal (intermittent) AF:

1. If they have had a prior TIA or stroke, or

2. If they have two or more of the following risk factors: (1) age > 75 years, (2) history of hypertension, (3) diabetes mellitus, and (4) moderately or severely impaired left ventricular systolic function and/or heart failure.

If you have AF, click here to calculate your CHADS2 score and stroke risk, and click here to calculate your risk of bleeding from anticoagulation.

Your risk of stroke is much higher than your bleeding risk, right?

Many AF patients don’t get anticoagulants because they are considered a fall risk. If you had AF and need anticoagulation, you would have to fall more than 300 times a year for the harm from the falls to outweigh the benefits of anticoagulation.

Despite these guidelines, recent studies have shown that:

1. Less than half of AF patients with a high stroke risk receive anticoagulants.

2. Even less patients with paroxysmal (intermittent) AF than those with permanent AF receive anticoagulants (31 vs 49%), even though the stroke risk is the same in both groups.

3. Too few patients with new onset AF are started on anticoagulants (only 52%).

We need to do better.


Click here to download a booklet about AF and stroke.

Click here to download a worksheet that you and your doctor can use to decide if anticoagulation is right for you.

Correct clinical diagnosis of dizziness in the ER could save $$ billions

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We have already blogged about the danger of escalating health costs in the USA.

The cost of emergency room visits for severe dizziness has grown exponentially in recent years, topping $3.9 billion in 2011 and projected to reach $4.4 billion by 2015.

Investigators from Johns Hopkins estimate that half a billion a year could be saved immediately if emergency room physicians stopped the routine and excessive use of head CT scans to search for stroke in dizzy patients, and instead used simple bedside physical exams to identify the small group of patients that truly needs imaging.

Click here to find out more about the Johns Hopkins study.

Click here to find out more about the hidden dangers of unnecessary CT scans.

Once they understand how inner ear disease can cause vertigo and nystagmus, any physician can use our simple clinical scheme to distinguish inner ear problems from more serious and rarer central causes like stroke in dizzy patients.  Click here to find out how.

Expensive Drugs Could Bankrupt Medicare!

Conceptual photo  illustrating expensive drugs and medicines

The United States spent about $98 billion on pharmaceuticals in 2006. This is despite 10% less drug use than other countries.  The problem is that our drugs, on the whole, cost about 50% more than other countries, 77% more for brand name medications.

Take the Lilly drug Cymbalta, for example – the average cost for a 1-month supply in the USA is $176, compared to $113 in Canada and $47 in France:

Think that’s expensive?  Sanofi will soon launch Lemtrada (alemtuzumab), an M.S. treatment that costs $60,000 per year. It will compete against Gilenya from Novartis, which is already on the market at $40,000 per year.

Why?  Some say that it’s because we’re wealthier and need to subsidize for the rest of the world. But even if we paid more based on our relative wealth, it would come to about a 30% premium, not the 77% we do pay. Some say that it’s because we in the US subsidize the massive research and development for drugs. But the entire bill for R&D for the pharmaceutical industry was less than $50 billion in 2006, far less than the “extra” we paid for drugs.  Some say it’s because we are subsidizing massive marketing in the US, which might be upwards of $40 billion in 2006. Again, far less than the “extra” amount.

Critics of pharmaceutical companies point out that only a small portion of the drug companies’ expenditures are used for research and development, with the majority of their money being spent in the areas of marketing and administration. The pharmaceutical industry has thousands of Washington lobbyists to protect their interests, and actually spent $855 million, more than any other industry, on lobbying activities from 1998 to 2006.

Prescription drug prices have become a real political issue in the United States.

Many third party payers can negotiate lower prices to control their low costs, but this causes pharmaceutical companies to raise their retail prices to offset costs.

Using a mail order pharmacy for a 3-month drug supply can save as much as a 29% in out-of-pocket costs and 18% in total prescription costs.

To save even more money, 10 million U.S. citizens bring in medications across land borders from Canada and Mexico each year.  Other patients shop on-line at lower cost overseas pharmacies, and an additional 2 million packages of medications arrive annually by international mail from Thailand, India, South Africa every year.