How Serious Is the Health Care Problem?

Personal tales of errors that shouldn't have happened.

Last month I provided readers with an overview of the opportunities we have to improve the quality of health care systems, particularly in the United States. Now I'll give a more personal and detailed view of the problem.

Each year an estimated 1,500 patients have foreign objects (such as sponges) left in them during surgery, leaving many to face crippling health problems. Five percent of doctors are found responsible for more than 50 percent of successful malpractice suits. (Susan Burton, "The Biggest Mistake of Their Lives," The New York Times, March 16, 2003.)

At least 150 times since 1996, surgeons at hospitals in the United States have operated on the wrong arm, leg, eye, kidney or other body part, or even on the wrong patient. The figure doesn't include near misses, i.e., when doctors have started to operate on the wrong part of the patient or even the wrong patient but discovered their error before the operation was completed. (Lawrence K. Altman, M.D., "The Wrong Foot, and Other Tales of Surgical Error," The New York Times, December 11, 2001.)

Let's take a closer and more personal look at the problem by reviewing some individual incidences.

Patricia Ann Hottois died of septic shock after an abdominal pad was left in her surgical wound. She had her surgery on June 8, 2003, at Maricopa Medical Center in Phoenix. About two weeks after the surgery, she was still complaining about pain when her doctors discovered that the pad was left inside her. (Christina Leonard, "Surgery Mistake Is Costly," The Arizona Republic, June 25, 2004.) She died on July 1, 2003. This medical malpractice case was settled for $320,000. According to a 2003 study in The New England Journal of Medicine, this type of surgical error occurs in more than one out of every 1,000-1,500 abdominal operations, a lot more than the Six Sigma goal of 3.4 per million.

In March 2004, two patients died at Foothills Medical Centre in Calgary, Alberta, because they were administered an incorrect solution during dialysis treatment. (Bill Graveland, Canadian Press, March 18, 2004.) The mix-up took place in the hospital's pharmacy. Barry Cavanaugh, chief executive of the Canadian Association of Pharmacy Technicians, Alberta Chapter, stated, "An adverse event could happen because [the hospital's pharmacists] are overworked."

In September 2003, Tawnya Brown underwent surgery at Inova Fairfax Hospital near Washington, D.C. Although the surgery went well, the patient ultimately died. Brown was given two pints of A-negative blood and her blood type was O-positive. (Amy M. Karch, M.S., R.N., "Practice Errors: Bad Blood Tragedy Can Result From an Error in Transfusion," American Journal of Nursing, February 2004.) To make the situation worse, her doctor called for more blood when he discovered that she wasn't doing well in recovery. The day before the surgery, a technician drew a blood sample so that the correct type would be available if needed. The problem occurred because the technician took the sample from the wrong patient. The phlebotomist should have discovered this, but he failed to perform two required identification screens: checking the patient's hospital bracelet and asking the patient to state her name. The financial settlement for this error was about $1.7 million, but not even this amount can make up for the loss of a mother to her eight-year-old girl.

A two-year-old boy died after undergoing a liver transplant at a large Minnesota hospital. The surgery was uncomplicated, and he initially did well. However, two days after the surgery, the boy's condition worsened. At 7 a.m., a nurse misread the table on a log of Heparin she was replacing. The new bag contained a much higher concentration of blood thinner than the one she was replacing, and the machine delivering the medication wasn't reprogrammed. The boy began receiving 10 times the amount ordered by the physician. The staff failed to notice the mistake throughout the day, even though the medication drip was checked every 15 minutes. The evening nurse finally discovered the error, but by then the boy had already experienced internal bleeding and a blood clot in the artery leading to his liver. A blood clot can trigger liver damage, which can cause swelling of the brain and brain death. Doctors determined that the patient was likely to remain in a vegetative state. As a result, he was taken off life support and died soon thereafter. The hospital's vice president for risk management stated, "It was more a system error than an individual error."

These are just four typical examples of health care errors. There are thousands of similar stories that can be told about health care in the United States. As a result, thousands of health care workers suffer restless nights thinking about what they should have done differently, and thousands of families despair because they lost a loved one before his or her time.

Next month we'll look at what should be done to stop this needless waste of lives.

About the author
H. James Harrington is CEO of the Harrington Institute Inc. and chairman of the board of Harrington Group. He has more than 55 years of experience as a quality professional and is the author of 22 books. Visit his Web site at www.harrington-institute.com.