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.

medical-error-statistics-1
Serious medical errors often occur under similar circumstances, including flawed or violated safety protocols and failure of communication.

rhode

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.

Advertisements

Monmouth Epilepsy Program Receives NAEC Certification

Monmouth Medical Center’s Epilepsy Program was awarded prestigious level 3 certification today by the National Association of Epilepsy Centers!

Monmouth certificateThe National Association of Epilepsy Centers (NAEC) is a non-profit  association with the primary objective of connecting people with epilepsy to specialized epilepsy care and epilepsy centers.

Founded in 1987 by physician leaders committed to setting a national agenda for quality epilepsy care, the NAEC educates public and private policymakers and regulators about appropriate patient care standards, reimbursement and medical services policies.

NAEC works in conjunction with existing scientific and charitable epilepsy organizations.

A third-level center must provide all the medical, neuropsychological, and psychosocial services needed to treat patients with refractory epilepsy to achieve certification.

Click here to find out more about Monmouth’s Epilepsy Program.

Click here to find out more about seizures and epilepsy.

Abraham Lincoln’s Ventriculostomy

lincoln

xx

Ventriculostomy

ventriculostomy

During ventriculostomy, the catheter is inserted through the brain and dura into the ventricular system via through a hole drilled into the skull.

Ventriculostomy, or external ventricular drainage, is surgical procedure to alleviate raised intracranial pressure by inserting a tube through the skull into the ventricles to remove cerebrospinal fluid.

Ventriculostomy was first used by Claude-Nicolas Le Cat for treatment of a newborn boy with hydrocephalus in 1744.

ventriculostomy-hydrocephalus

Hydrocephalus before (A) and after (B) CSF drainage via ventriculostomy, showing significant reduction in ventricular size.

xx

Ventriculostomy for head trauma

Ventriculostomy is also used to measure (monitor) and treat raised intracranial pressure by draining CSF and blood to relieve increased pressure inside the skull from cerebral edema (brain swelling) after head trauma.

EVD trauma

Top row: CT scans after head trauma, showing bleeding and edema in the brain after head trauma, causing raised intracranial pressure.
Bottom row: Ventriculostomy (external ventricular drainage) used to monitor and treat raised intracranial pressure.

Untreated, raised intracranial pressure can result in “herniation” (downward compression of the brain stem), leading to dysfunction of vital centers that regulate breathing and heart function, and ultimately brain stem death.

herniation

xx

The Lincoln Assassination

Abraham-Lincoln-Shooting

Lincoln was shot in the head by Johns Wilkes Booth at Ford’s Theatre in Washington DC on April 14, 1865.

The mortally wounded Lincoln was carried out of the theatre, across the street to the Petersen House , where he was attended by three doctors from the theater’s audience including army surgeon Charles Leale, later joined by other doctors including Joseph Barnes (Surgeon General Of the US Army).

Lincoln was declared dead at 7.22am on April 15, 1865.

xx

The Abraham Lincoln Head Shot

peace lincoln shot

Illustrations depicting Abraham Lincoln’s head wound by David A. Peace MS from University of Florida’s Department of Neurosurgery. The track of the bullet passes through the lateral horn of the lateral ventricle.

xx

The Doctor’s Notes

Dr Leale, feeling around by hand, discovered the bullet hole in the back of Lincoln’s  head right next to his left ear.  Leale attempted to remove the bullet, but the bullet was too deep in his head,and instead Leale dislodged a clot of blood in the wound. Consequently, Lincoln’s breathing improved.  Leale learned that if he continued to release more blood clots at a specific time, Lincoln would still breathe.

Here are some exerts from Leale’s actual account of the event:

I quickly passed the separated fingers of both hands through his 
blood matted hair to examine his head, and I discovered his mortal 
wound. The President had been shot in the back part of the head, 
behind the left ear. I easily removed the obstructing clot of blood 
from the wound, and this relieved the pressure on the brain.

As the symptoms indicated renewed brain compression, I again 
cleared the opening of clotted blood and pushed forward the button of 
bone, which acted as a valve, permitted an oozing of blood and re- 
lieved pressure on the brain. I again saw good results from this action.

The Hospital Steward arrived with the Nelaton probe and an ex- 
amination was made by the Surgeon General and myself, who introduced 
the probe to a distance of about two and a half inches, where it came 
in contact with a foreign substance, which lay across the track of the 
ball ; this was easily passed and the probe was introduced several inches 
further where it again touched a hard substance at first supposed to 
be the ball, but as the white porcelain bulb of the probe on its with- 
drawal did not indicate the mark of lead it was generally thought to 
be another piece of loose bone. The probe was introduced the second 
time and the ball was supposed to be distinctly felt. After this second 
exploration nothing further was done with the wound except to keep 
the opening free from coagula, which, if allowed to form and remain 
for a short time, produced signs of increased compression, the breathing 
becoming profoundly stertorous and intermittent, the pulse more feeble 
and irregular. After I had resigned my charge all that was profes- 
sionally done for the President was to repeat occasionally my original 
expedient of relieving the brain pressure by freeing the opening to the 
wound and to count the pulse and respirations. The President's posi- 
tion on the bed remained exactly as I had first placed him with the 
assistance of Dr. Taft and Dr. King.

lincoln death bed

It is clear that the bullet track left an opening into the lateral ventricle, a ventriculostomy.

When this ventriculostomy track occluded with blood clot and tissue, the dying President developed raised intracranial pressure, with compression of the breathing center in the brain stem and more labored breathing.

When the clot was removed, and the ventriculostomy opened, the President would transiently improve.

Lincoln’s ventriculostomy.