All medical mistakes are problematic. A few are truly tragic. But every now and then, a medical error comes along that is downright hilarious. From AHRQ WebM&M, the case-based Web journal I edit for the federal government, here are two of the latter kind. They are a hoot.
We published the first about three years ago and called it “Allergy to Holter”:
A 52-year-old man was admitted for palpitations and chest pain. As part of the evaluation, on hospital day 4 the patient was sent to the cardiac clinic to start a continuous recording of his electrocardiogram via Holter monitor.
Since the patient was ambulatory and had gone for other tests on his own, he was told to go to the cardiology clinic for a check-up of his heart rhythm. He was handed a “Request for Consultation” form, on which there was only one word: “Holter.” The form did not state the patient’s name or the department.
The patient had been told the clinic was on the fifth floor of the ambulatory building, so he took the elevator to that floor. He presented himself to the reception desk of the first clinic he saw—the allergy clinic (which is on the same floor as the cardiology clinic)—where the nurse took his consultation form, and told him, “Mr. Holter, you are in the right place.” She then proceeded to conduct a complete pinprick skin sensitivity test on his back, which showed no evidence of allergies. Armed with a form that showed his “Holter” test was negative, the patient walked back to his ward.
Upon his return, the patient told his ward nurse, “I’ve just finished the Holter test.”
—”And where is the Holter device?” asked the nurse.
—”It is on my back and does not hurt at all!”
The nurse looked at the patient’s back and realized that he had had an allergy test. She then escorted him to the cardiac clinic to have an actual Holter monitor placed. There was no harm (fortunately) to the patient, other than an unnecessary test and a brief delay in the ECG recording.
Additional investigation revealed that the patient was able to read and there was no language barrier. The workload for the allergy clinic nurse was light. She had merely glanced at, but did not read, the consultation form. Since it was not the first time a patient had received an unnecessary allergy test, the hospital published the event in their incident report newsletter and changed the signs to clinics on that floor. The nurse retired from practice (as previously scheduled) the following month.
Years later, I still get a chuckle over “Mr. Holter.”
We published the second case a few months ago, and Medscape picked it up this month, where it quickly garnered a bemused following. We called the case, “Code Blue – Where To?”:
An 80-year-old man with a history of coronary artery disease, hypertension, and schizophrenia was admitted to an inpatient psychiatry service for hallucinations and anxiety. On hospital day 2, he had sudden onset of confusion, bradycardia, and hypotension. He lost consciousness, and a “code blue” was called.
The inpatient psychiatry facility is adjacent to a major academic medical center. Thus, the “code team” (comprised of a senior medical resident, medical intern, anesthesia resident, anesthesia attending, and critical care nurse) within the main hospital was activated. The message blared through the overhead speaker system, “Code blue, fourth floor psychiatry. Code blue, fourth floor psychiatry.”
The senior resident and intern had never been to the psychiatry facility. “How do we get to psych?” the senior resident asked a few other residents in a panic. “I don’t know how to get there except to go outside and through the front door,” a colleague answered. So the senior resident and intern ran down numerous flights of stairs, outside the front of the hospital, down the block, into the psychiatry facility, and up four flights of stairs (the two buildings are actually connected on the fourth floor).
Upon arrival minutes later, they found the patient apneic and pulseless. The nurses on the inpatient psychiatry ward had placed an oxygen mask on the patient, but the patient was not receiving ventilatory support or chest compressions. The resident and intern began basic life support (CPR with chest compressions) with the bag-valve-mask. When the critical care nurse and the rest of the code team arrived, they attempted to hook the patient up to their portable monitor. Unfortunately, the leads on the monitor were incompatible with the stickers on the patient, which were from the psychiatry floor (the stickers were more than 10 years old). The team did not have appropriate leads to connect the monitor and sent a nurse back to the main hospital to obtain compatible stickers. In the meantime, the patient remained pulseless with an uncertain rhythm. Moreover, despite ventilation with the bag-valve-mask, the patient’s saturations remained less than 80%. After minutes of trying to determine the cause, it was discovered that the mask had been attached to the oxygen nozzle on the wall, but the oxygen had not initially been turned on by the nursing staff. The oxygen was turned on, the patient’s saturations started to rise, and the anesthesiologist prepared to intubate the patient. Chest compressions continued.
At this point, a staff nurse on the psychiatry floor came into the room, recognized the patient, and shouted, “Stop! Stop! He’s a no code!” Confusion ensued—some team members stopped while others continued the resuscitation. Although a review of the chart showed no documentation of a “Do Not Resuscitate” order, the resuscitation continued. The intern on the team called the patient’s son, who confirmed the patient’s desire to not be resuscitated. The efforts were stopped, and the patient died moments later.
The case generated a wonderful series of posts on one of Medscape’s physician forums. A few choice samples:
This made me laugh so hard… because this is EXACTLY the way a real hospital code goes down.
***
Well that’s just atrocious, if highly amusing. It is scandalous that there wasn’t even a damn AED on the ward… [see my prior post on this topic]
***
Sounds like a job for the Keystone Cops:
***
The term “Chinese fire drill” also comes to mind…
***
And, my favorite comment, referring to the erudite discussion of quality problems in off-site cardiac arrests by Dr. Bruce Adams, Chief of the Department of Clinical Investigation of the William Beaumont Army Medical Center, that accompanied the case on AHRQ WebM&M:
The juxtaposition of the stooge-worthy hijinx of the case followed by the dry academic deconstruction – that’s literature, my friends. Worthy of Ezra Pound or PD Wodehouse [sic]. Fabulous. You can’t make this up…
I couldn’t agree more. Sometimes, even when the subject is medical errors, you just gotta laugh.
True story from my early during internship. One of my classmates got called late one Friday night by a VA ward nurse to clarify an order for some drug to be delivered “AS, bid”. Having never heard of the drug and no idea what the hell “AS” means, Rick asked why the patient was in the hospital. “Well, he’s having a colonoscopy on Monday”, the nurse replied. Rick astutely deduced that ‘AS’ must mean ‘anal sphincter’, and ordered the drug to be delivered as such.
The ENT resident came by on Monday morning to find that the patient had been getting cortisporin otic up his ass twice a day for an entire weekend. AS means “left ear”.
Needless to say, this one made the annual trivia bowl.
Another CPOE hazard….from the Institute for Safe Medication Practices “Acute Care Edition”, May 31, 2007;12:1-3…found on the AHRQ website.
Remote CPOE error—a situation that’s more than remotely possible
Problem: ISMP received a report from a hospital where a medical resident had prescribed a NORCURON (vecuronium) infusion for the wrong patient via a computerized prescriber order entry (CPOE) system in a remote location. She meant to order the infusion for a ventilated patient in ICU but accidentally prescribed the drug for a patient on a medical unit. An inexperienced resident pharmacist processed the order and prepared the infusion, failing to recognize that a neuromuscular blocking agent should never be sent to a medical unit where patients are not intubated and on ventilators. The resident pharmacist affixed two labels to the bag: one noting that the infusion was a high-alert medication, and the other stating that the drug was a “paralyzing agent.” The pharmacy technician who delivered the infusion did not think to question why the medication had been prescribed for a patient on the medical unit.
An independent double-check was required for this medication before administration, so two nurses verified the drug, pump settings, and patient. The infusion was started, after which the patient began walking to the bathroom. He fell to the floor once paralysis began to set in, but fortunately, he was able to call out for help. The resident physician was called, along with the rapid response team. When the team arrived and asked what happened, one of the nurses questioned whether the “new drug” she had just hung could be responsible. Realizing the problem, the physician immediately stopped the infusion. The patient was treated and suffered no long-term effects, although he was frightened by the experience, as were the involved staff.
The prescribing error escaped the attention of at least five staff members–the physician, pharmacist, pharmacy technician, and two nurses. The error was also able to get through the system despite safeguards such as warning labels and double-checks. It is also likely that the nurses working on the medical unit, where the drug had never been used, had little knowledge of Norcuron, its indication, its paralytic effect, and the need for mechanical ventilation, despite the warning label.
As an intern on call, I was called about another intern’s patient having dyspnea and was now on a non-rebreather. I glanced at the check out card and saw the patient had been admitted for a pulmonary embolism. As I ran up the stairs to evaluate the patient, I checked the room number and went straight to the room. The patient was sitting comfortably in the bed without oxygen with family in the room. I asked a few questions, perplexed about why I was called to see this patient, and ordered a chest x-ray and an ABG. I ran out of the room to ask why the nurse had paged me about the dyspnea and the nurse stated he had paged about stopping the patient’s restraints.
It has now dawned on me that I have mistaken the bed number for the last digit of the room number. I then run into the right patient’s room and notice he needed to go back to the ICU. Once I helped get him stabilized, the first nurse asked me to come back and see the patient as he was quite distressed. I look at the patient’s card and see that he is being worked up for Creutzfeldt-Jakob Disease. I go back in to explain to the patient and family my mistake and then apologize.
The next morning, I relate the story to the patient’s intern and he chuckled. Later that day, he pages me and relates the patient’s side of the story. The patient had been convinced that his doctors were trying to kill him and the wife had spent all day convincing him otherwise and he had finally believed his wife when all of a sudden, some doctor comes running in the room, yelling out orders, asking some questions and then darts out. The patient then starts yelling that the doctors are trying to kill him and the poor wife was up all night trying convince him otherwise.
Bob,
Considering your blog of December 7, “Can a Medical Center Be Too Rich”, and the current topic, the enclosed report from CBS News of Pittsburgh affiliate KDKA that appeared on the internet may be of interest to your readers:
CT Scan Finds Device Inside Patient After Surgery
Reporting
Marty Griffin
PITTSBURGH (KDKA) _ The KDKA Investigators have uncovered a medical mistake even doctors call bizarre.
A 10-inch metal surgical device was left inside a patient for a month and when he pointed out the problem to doctors, he was told he may need a psychiatrist.
The device is called a retractor. In layman’s terms, it’s a 10-inch pair of tweezers used to pull back skin or hold something in place. The surgeon is supposed to hold onto it the entire time it’s in use. Lawyers representing the patient in this case say he didn’t. In fact, he left it inside a man and it stayed there for a month.
A CT scan taken of 57-year-old Daryoush Mazarei a month after his surgery showed the device in his lower abdomen. His daughter Farnoosh was the first to spot it without an X-ray.
“It was sticking out from this side,” she said.
Farnoosh says the pointed end of the device was poking from under her father’s ribs.
“He said that he feels like something is poking him from the inside,” she said.
Turns out it was. Mazarei went in for surgery two years ago at UPMC Presbyterian. He was to have a device installed called a shunt to allow fluid to drain from his brain. The surgery went well, but Mazareai’s attorney says the surgeon left the 10-inch metal retractor in Mazarei’s abdominal cavity.
“This is an interesting case that the question comes up can you count to one,” Jon Perry, Mazarei’s attorney, said. “There was actually no policy in this hospital to count things this large because even they didn’t think that anyone could lose something that large into a surgical field.”
“I’ve been doing this a long time and if you told me this was possible I would have argued with you,” Perry added.
According to a lawsuit filed against UPMC, the doctor and Presbyterian Hospital, Mazarei asked on several occasions about the pain. He was told to seek psychiatric treatment.
“An excruciatingly painful physical experience and then when you lay on top of that the fact that his doctors essentially told him he was nuts and sent him to a psychiatrist, it had an emotional overlay to it that was equally disturbing,” Perry said. “And by the time he was nearing the end he was, he was having a very difficult time both physically and emotionally because he knew he had pain but the doctors were telling him that he needed to treat with a psychiatrist.”
Medical mistakes of this nature are actually very rare. According to a recent study in the New England Journal of Medicine, of more than 30 million inpatient operations per year, there are more than 1,500 cases of a retained foreign body that occur in the United States. A foreign body would be described as a sponge, a scalpel, retractors left in a patient after a surgery. Still, in this case, one was too many.
“We told them that he has pain. They told us that he’s lying and they told us about the story of the crying wolf,” Farnoosh Mazarei, the victim’s daughter, said.
Griffin: “They actually told him, in a nice way, they told your dad he was crazy?”
Mazarei: “Yes exactly. Yes they did.”
Turns out he was not crazy. After a month of pain with the device still left inside him, it was removed in an extensive surgery. To this point, the hospital, the doctor, will not, cannot explain how the mistake occurred.
“Given the size of the object I just cannot even hazard a guess as to how a physician with assistants and scrub nurses could leave that object in a patient,” Perry said.
The family is currently in litigation regarding the incident. In fact, there has been one attempt at mediation between both sides and there apparently will be another.
Meanwhile, Perry says the hospital has apologized. We have been in touch with UPMC regarding this case for several days. UPMC at this hour has not provided us with a formal response to the lawsuit or the allegations.
As soon as we receive that response, we will pass pass it on to you.
(© MMVIII, CBS Broadcasting Inc. All Rights Reserved.)
10 years ago at UTMB I was the resident rounding on the nephrology service with a not so sharp intern. This was actually his 2nd trip through internship and this night only added to his demise. The attending and I finished up then chatted about a few issues with the intern. This glassy eyed nitwit listened carefully and jotted down notes as if things were actually registering.
The main issue we chatted about was BP control on these vasculopaths. “Most of them will need PRN clonidine” still rings in my noggin to this day.
The next morning our little re-treaded intern was beaming with joy. “They all did great!” Sure enough that ward of 16 patients was the calmest I had ever seen…..then we discovered he had placed them all on Clonopin!
I hit the deck laughing, my program director (Tom Blackwell) was not so pleased. It still makes the Drs. lounge roar when I tell that story.