Medical Mistakes—They Will Happen

I wrote this post back in October 2006, and I'm featuring it at the top of my blog because it remains one of my most popular posts--readers are concerned about avoiding mistakes in their cancer care. As they should be.

Last Thursday, I picked up a refill prescription for Xanax, which I take for anxiety, at my cancer center in Seattle.

The next morning, as I lined up the six or seven bottles of prescription drugs I take each day, I thought I had been given the wrong drug.

The label said, “alprazolam, Take one or two tablets every six hours as needed for pain.” Well, as I mentioned, I take Xanax, and it’s for anxiety, not pain. I had to go online to double-check that I had indeed been given the correct drug. The bottle should have been labeled with both the generic (alprazolam) and brand name (Xanax), and the appropriate indication—anxiety—should have been listed.

This is not the first time my pharmacy has made a mistake. Another time, one of my prescriptions was mislabeled. The generic name was correct, but the brand name was wrong. I took the bottle back after I discovered the mistake (while trying to figure out how much I was supposed to take before an MRI), and the pharmacy staff took the bottle back and relabeled it.

But then—and this is the part that rankles, even more than a year later—a pharmacist came over and said to me in a flip tone of voice, “Sorry about that.”

Sorry about that? Not good enough.

If you have a chronic medical condition—which includes many, if not most, cancer patients—get used to the possibility that what happened to me could happen to you. No matter how carefully you choose your doctor and your cancer center or hospital, mistakes happen. Doctors, nurses, and other medical personnel are human (and often over-worked or sleep-deprived), and they sometimes make errors.

Odds are you will be the victim of medical mistakes, large and small, and that your hospital or cancer center will deny the mistakes ever happened or make light of them.

“Fixing America’s Hospitals” an article in the Newsweek issue dated today, October 16, says the most important hurdle for U.S. hospitals is improving patient safety. This year, according to Newsweek, medical errors harm at least 1.5 million people and cost some $3.5 billion a year. A sidebar by Dr. Lucian Leape, of the Harvard School of Public Health, suggests that doctors and hospitals need to “disclose, apologize, and explain.”

I couldn’t agree more.

What I Do
This is how I protect myself from medical errors:
* I double-check everything.
* I keep notes and lists.
* I ask questions.
* I read the information sheets my doctors, nurses, and pharmacists give me.

This is not paranoia. Nor does it imply a lack of trust or confidence in the people who are treating me. Rather, it is a pragmatic attitude that acknowledges that medical mistakes do happen, and that I want to do what I can to make sure they don’t happen to me.

Other Mistakes
Last Thursday was a bad day for errors at my cancer center. In addition to the mislabeled prescription drug, the woman who drew my blood at the lab did not follow the proper procedure for identifying me. All patients have a green card embossed with their name, date of birth, and patient ID number. When I check in for a blood draw, I turn over this card to a staff member.

Then when the technician calls me back, he or she is supposed to ask me to give my name, spell it, and give my date of birth. Only after checking what I say against the card should the tech poke me and draw my blood.

This woman, however, already had the needle in my arm and the blood flowing into the first test tube before she said, hurriedly, “Oh, your birthday is eleven, seventeen, fifty-four, right?” And that was it.

She had the right patient, so no harm done, but this is not the way it’s supposed to go.

One other time, a lab tech drew my blood using the wrong type of test tube, so I had to return to the lab and have it redrawn. Again, a small mistake, and one that did me no harm, other than an extra needle stick. But it illustrates a carelessness that makes me less than comfortable.

In the Chemo Room
It’s hard to ignore newspaper headlines about cancer patients dying after receiving the wrong chemo drug, or the wrong dose of the “right” drug, so I am especially vigilant about mistakes in the Infusion Room, where I get my chemotherapy treatments.

When I check in for chemo, my green card is used to print an armband with my full name, date of birth, and patient ID number. I wear this until it is time to go home.

Once I’m settled in my chair and the chemotherapy drugs have arrived from the pharmacy, two nurses check each drug against my chart and against my armband—a check intended to prevent mistakes.

Just a few weeks ago, the chemo nurse, who was not the nurse I usually see, forgot to do the safety check. She was hooking up the drug when I said, "Did I miss it? Did you do the double-check?" She quickly apologized and called in another nurse to do the check.

In my experience, mistakes are more likely to happen when you are not treated by the caregiver you usually see.

Another time, also when my regular nurse was not available, the nurse assigned to me had not ordered one of the drugs I was supposed to get.

The orders apparently were not in my chart. If I had not been paying attention, or had not known what drugs I was supposed to receive (I keep a list in my daytimer), and had not spoken up, the nurse would have had no reason to double-check and I would not have gotten the drug.

Would this have harmed me? Probably not. But it was a mistake, one that I caught by knowing which drugs I am supposed to receive and on what schedule.

During Surgery
As you can imagine, it is harder to be vigilant about medical mistakes during surgery, because you are sedated. (But there are some steps you can take to protect yourself; see the links below.)

Several years ago, two errors occurred during a day surgery to place a port under the skin on my chest so that I could receive chemotherapy with a drug called Navelbine (generic: vinorelbine), which can damage tissues if given directly into a vein.

The doctor placed the port on the right side of my chest—the same side as my mastectomy and later radiation therapy. When I got home after the surgery, I read the little booklet provided by the port’s manufacturer and found that it is not supposed to be placed in tissue that has been radiated.

I asked my medical oncologist (not the doctor who placed the port) about this at my next visit, and he said he thought it was OK. To this day I’m not sure if he said that because the port was already in place, or because he really thought it was OK to put it on the side that had been radiated, despite the manufacturer’s clear instructions.

Regardless, I had a string of five or six frightening infections with the port, each one requiring at least one course of antibiotics.

The other thing that happened with the port was even weirder. I have a note in my chart that says I am allergic to latex. Well, the team that placed my port did not notice this note until after my surgery (nor did they ask me about any allergies before the surgery).

Later on, while I was still at the cancer center, a staff person came looking for me to make sure that I was OK and had not gone into shock. I was woozy still from the anesthetic when he found me, but I do remember him saying that my chart mentioned a latex allergy and they had just implanted in my body a port made partly of latex.

This could also be a reason for the string of infections I had with the port—the latex in the device kept irritating the tissue around it. Even though I tried to follow up on this mistake, I never got a clear answer and I still don’t know how the error occurred.

There is no neat, quick wrap-up to this story, and no happy ending.

I have been living with cancer for eight years. All of the mistakes described above—which are all the ones I know about in my care—happened during the past three. It kind of makes me wonder what happened during the first five years without my knowing it.

The good news is I am still alive, and still enjoying life. To help keep things that way, I maintain my vigilance in every medical situation.

Read more:

Cancer: Guarding Against Medical Mistakes

Chemotherapy Errors

Mistakes During Surgery

Radiation Therapy Mistakes

Alternative Therapy Errors

Prescription Drug Errors

Keeping Medical Records

Medical Mistakes--Overwhelmed?

@ Jeanne Sather 2006

Comments

[Joy Price]

Jeanne... This is good... good writing, good advice that I could add to, like receiving the wrong medication from a local pharmacy a few years ago. I took it back and he said "sorry."

[Rachel]

I really do think your message is very important. I've heard so many women complain about things that could be remedied by being more assertive, like their ob/gyn exam experiences. I always encourage them to speak up, and that it's perfectly appropriate to call an end to the exam and leave (and find a new doc) if their needs are ignored (such as in a needlessly painful exam). A bit of context from my own experience:

-A clinician recently tried to give me a penicillin shot for strep throat. I'm very allergic, which I had to tell them, despite the fact that it's in my medical record and on every form I've ever filled out, every time I've ever been there.

-I had a broken kneecap for 6 weeks because the ER docs thought it was just a dislocation that would heal on it's own. It wasn't, and I ended up having surgery after getting a second opinion.

-It took me nearly two years to have my thyroid condition diagnosed. I was told everything from "You're just too stressed" (when I was so tired I went to get checked for mono) to "All my nurses are tired, too." Grrr.

-My mom had to have a hysterectomy because of undetected cervical cancer and months of ignored complaints.

I can definitely relate. Thanks for doing the work you're doing on your blog.

[Ada]

This is a great post for anyone who is undergoing any form of treatment or medical procedure. As a doctor I encourage my patients to ask questions about anything I need to do for them. Healthcare givers should not feel intimidated by inquisitive patients. Questions help to sharpen our communication skills and keep us on our toes.
If you're on the recieving end of any treatment or therapy you need to be an active participant in what is being done to your body. At the end of the day, you'll have to live with it.

[Jeanne]

Thank you, all of you. I am especially grateful to hear from a doctor who likes my approach and who encourages her patients to ask questions.

Things are starting to change in the medical world, one good doctor at a time.

[RubyShooZ]

Bravo to you Jeanne. I've just discovered your writing here and I sure look forward to reading more - there's alot of excellent information here and I like your style of writing as well.

My own medical mistake that almost took place was years ago when I'd gone in for laproscopic surgery for adhesions in my abdomen area and was in the pre-op waiting room with my husband when a nurse came in and said, Hello Norma, So, you're here for your cataract surgery eh? (My name is Nora!) I almost ran at that point... but it taught me a very good lesson that I need to be very clear and watch out for my own health, my own health care, and everything that goes along with it.

Thank you for your blog. You have some very important information here and it's much appreciated.