A Comedy of Medical Errors
(This item was posted on my previous blog in December 2005.)
Not long ago I took a five-hour headlong plunge into my 92-year-old Mom’s healthcare. She is staying in a nursing home in the Raleigh area, after having recently broken her hip and undergone replacement surgery. All things considered, she is doing quite well. Her walking is still not back to what it was before the surgery, she has increasing mild dementia, but she has kept her sense of humor and cheerful smile.
In describing these events, I have refrained from naming names or specific institutions, not just because I don’t want to create problems for them, but also because there’s no one person or group to blame. The problems I will describe seem to be (as a physician might say) systemic – as you will see.
First, a bit of background. For many years Mom has exhibited swelling of her ankles, but it recently became more severe, so I was asked by the nursing home to take her in for echocardiography to see if she had heart problems that might be responsible. She passed the test with flying colors, but last week the staff physician at the nursing home called me, expressing concern about her heart as it might relate to the swelling, saying he’d like to do some tests. My first clue that something might be amiss was when he asked me if she had ever had an echocardiogram. He seemed more than a little embarrassed when I reminded him that the nursing home had ordered one a few weeks before, and that I had accompanied her for the test. I also asked why he had called me, since my sister’s name was at the top of his list and she has better knowledge of Mom’s medical situation. He said he hadn’t been able to reach her at her office. (Later, I was to learn that the office number he had for her was two years out of date and was also incorrect by one digit.) He went on to say he was going to try some different medications and check her kidneys.
A few days later, the nursing home called my sister, telling her that they had done an x-ray and found a “foreign body” on the film – apparently a piece of a needle or catheter – and they’d like to send her to the hospital for surgery to remove it, since it might migrate to some other part of the body. Of course, she consented and scheduled the surgery for today, in spite of never being told about when and why Mom had been x-rayed. Since my sister was unavailable to accompany Mom, I agreed to meet the van from the nursing home at the Medical Office Building, adjacent to the hospital.
I arrived a little early and greeted Mom as the van arrived. The van driver unloaded her and we went to the desk. The cheerful receptionist had never heard of her. After a few confused phone calls, they were able to determine that she was supposed to be at the Same Day Surgery Unit in the main hospital building, so I wheeled her over there. A half hour had passed by the time I found out that they had never heard of her either. This turned out to be a matter of hospital policy; Mom has always gone by her middle name, but hospital policy requires admission under a patient’s given first name. The confusion resolved, Mom was assigned to bed #33. An orderly (obviously a new hire) couldn’t find the bed in the far corner of the unit, and had to ask for assistance. When we finally arrived at #33 by a circuitous route, two waiting nurses began to prep Mom for surgery. This included getting her weight and height (which, mercifully, they skipped since it was obvious she couldn’t stand on the scale), taking her blood pressure and heart rate, and putting her on IV saline. They got her on the gurney after almost pulling out the catheter and urine bag she was still using after the recent urinary tract infection – a fact that none of us had been advised about.
Blood work was required, too, but the first wisp of a technician couldn’t manage to get any blood from Mom’s tiny veins, so they sent for a bigger technician who was equally unsuccessful. Finally, the nurse got the necessary three samples (why 3?) and off they went to the lab – after quite a few loud complaints from Mom about the pain from the four or more holes she now had in her right arm. During this time, I was being asked questions about her medical history that I had answered countless times before and should have been easily accessible. Still, I recounted that she didn’t have diabetes, cancer, allergies or AIDS, and included details of her two caesarian deliveries (fifty-one and sixty-four years earlier), while the nurse dutifully recorded my answers in longhand. I guess you can’t be too careful or too computerized.
It seems Mom had been scheduled for surgery and not for an x-ray, but nobody was able to find any x-ray films or paperwork showing the location of the “foreign body”, so naturally they postponed her surgery until they could get an x-ray. Fortunately, a suitable room was available, so after a short wait we were introduced to the Radiologist. He seemed to be a nice guy, but was obviously frustrated because he had no information to indicate what part of her body to x-ray, so he elected to do a whole-body fluoroscopy. I was asked to retire to the waiting room during this procedure, to avoid the radiation risk. Presently, the Radiologist returned and announced that he couldn’t find any “foreign body” anywhere. Without being specific, he told me that someone had found the paperwork and that it appeared to belong to a different patient, that Mom didn’t have a “foreign body” and was OK. A nurse later asked me if Mom had gotten any x-rays done in Florida. I told her that Mom hadn’t been to Florida for at least thirty years.
Getting ready to go back to the nursing home, Mom said she was hungry. Since she had been expected to have surgery, she had no breakfast, and meals hadn’t been prepared for her. But she could have orange juice. She promptly guzzled two large glasses and insisted, “Let’s go home.” In the interim, the hospital had lost the wheelchair in which Mom had arrived. Fortunately, it was found after a brief search – someone had dutifully put it in storage. The nurse said she had called the van driver and they’d be there within a half hour. After forty-five minutes had passed, I took it upon myself to call the transportation service on my cell phone, wondering if they had been delayed. (I’m not sure whether using the cell in the hospital was prohibited, but I used it anyway.) I was told they were waiting at the main entrance – nobody had told them to come to the bed #33 alcove. They arrived moments later, and Mom was safely loaded back into the van and on her way to a very late, much deserved, hot lunch. She was hungry, tired, rubbing her punctured black-and-blue arms, but otherwise unscathed.
An aside: During my visits in various areas of the hospital, I happened to overhear fragments of a few possibly telling conversations. For example, I heard one nurse ask another if she had intentionally left an IV tube clamped. The answer was “no”, she went to un-clamp it, and commented that she had wondered why the liquid in the IV bag hadn’t dropped in the past two hours. In another exchange, I heard one nurse ask another where a patient was – she couldn’t find him in the computer. The other remarked that it happens all the time recently, computer problems are common. A few minutes after that, another pair of nurses were trying to figure out whether a particular patient was a man or a woman.
Later, I was able to observe the Radiologist’s report since I briefly had it in my custody before giving it to the driver from the nursing home. I suppose reading a physician’s handwriting is an acquired skill, but to my untrained eyes it was totally illegible except for an occasional “and” and “the” and the words fluoroscope and Florida. I even found it difficult to read the doctor’s name on the line labeled “print name here”.
Mom is on Medicare, Medicaid and a State Employees’ Health Plan which, collectively (mostly at taxpayers’ expense), covered most of the costs of this episode. At this writing, I have no idea what the total hospital, radiology, lab and transportation costs might be, but I’d speculate they will total $1,000 or more. Of course, this doesn’t include the intangible but very real costs of my losing a day’s work, the loss of medical resources that could have been used by someone who really needed them, or the pain of multiple needle-sticks and a long and exhausting adventure for a sweet little 92-year old lady, who really had no idea why she was being put through it all. I also am concerned that somewhere out there is a patient with a “foreign body” floating around, and nobody knows about it anymore – the point of a needle or catheter that could lodge in a vital spot and cause death or serious injury.
I read recently that 172,000 Americans die every year from medical mistakes, more than from heart disease or cancer. I recall being skeptical of that number, but having experienced today’s comedy of errors, I am inclined to fear that it’s true. In this day of medical miracles, marvelous computers and the Internet, it’s hard to believe that communications within the medical community are as inadequate, difficult and jumbled as my observations seem to indicate. Simple errors, omissions and blatant failures to move information from person to person seemed to haunt my Mom at every turn.
These events aren’t the first to raise doubts in my mind about the healthcare system in general. I won’t bore you with the details of my Mom’s earlier $2200 case of indigestion or my son’s $1,800 ingrown toenail, nor will I take the time to describe the pitfalls faced by a dear friend who claims that he’d be dead three times over at the hands of the American Healthcare System if he hadn’t been a physician himself.
Doctors and the medical establishment will dismiss my stories as anecdotal, not supported by properly compiled statistics. I challenge them (and the U.S. Government) to show me scientific justification for why America has the highest healthcare costs in the world and an appalling number of deadly medical mistakes. In the meantime, I thank God that Mom hasn’t yet been seriously victimized by any of the errors and miscommunications related to this ongoing series of frightening episodes. I hope my family and myself can remain healthy enough to avoid putting our lives in the hands of a healthcare system that seems to accept a level of performance that wouldn’t be tolerated in my mechanic’s garage. Perhaps it’s because (unlike the auto repair shop) you have to pay the hospital whether they’re successful doing their job or not.
