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Saturday, June 11, 2016

Medical Errors: A Matter of Life and Death





I open this post by saying that we all need to remember that healthcare is delivered by human beings, and humans make mistakes. Today there is an intense focus on working to find ways to identify, address, correct and prevent medical errors in every sector of the healthcare system. Addressing medical errors and changing the systems that allow medical errors to occur is such an important goal that the Centers for Medicare and Medicaid have said they will not pay for care that results from medical errors. The patient cannot be billed for these cost either, so when an errors occurs, the organizations where the error happened is held responsible for those costs. 

An interesting report was recently released stating that medical errors are now viewed as the 3rd leading cause of death after heart disease and cancer. To put this into perspective, take a minute listen to this podcast from NPR with the author of the study. His message is clear, in that we all need to do better. He also points out the patient needs to take an active role in helping to prevent medical errors. It is widely recognized that we can only meet this challenge by being fully aware that medical errors do occur, that when they do occur they need to be reported and all stakeholders need to do their part in minimizing them.

Recently I experienced a medical error. I did not die, but I wasted time, underwent a lot of unnecessary stress and lost a little more faith in the healthcare system. 

Here is my story.  

Over the past few weeks, I have been treated for a basal cell carcinoma on my back. The suspicious lesion was found during a routine visit to my primary care physician. She suggested I see a dermatologist to have it examined. I asked a few friends who I knew have had experience with skin cancer and asked them who they saw as I did not have any experience with a dermatologist close to home. I received a few names, did some research and chose a doctor.

I met the doctor and his office staff at my first visit. My first impression was that the staff was very young and diverse. The feel of the office was casual and a little haphazard.  The Dermatologist was professional and took the time to get to know me before examining me. He introduced himself, and as we talked about why I was seeing him he listed to my fears and concerns of being diagnosed withe another form of cancer again after being treated for a brain tumor one year ago. He reassured me that skin cancer is very treatable, so I should try not to worry. He looked at the lesion and felt that it was a basal cell carcinoma. He said that if I had to get skin cancer, this was the type to get as it was very treatable. He said he was going to take a biopsy of the lesion and send it to the lab. He said not to worry as he was confident the biopsy would take care of removing it. 

Fast forward a few days. I received a call from the dermatology office to tell me that I would need to come back to see the doctor for deeper scraping of the lesion as there were still signs of cancer so I made another appointment. On the second appointment, the doctor said he was going to go a little deeper, but was confident that all would be okay. Once done, the doctor told me that someone would call me with the results in a few days.  As promised, I got a call from the office a few days later from the medical technician, Steve. Steve is a paramedic who worked with the doctor. I took a liking to Steve as he seemed to be the doctors right hand person. He explained that I would need to come back to the office to see the Dermatologist as the pathology report showed that the margins were still not clear. I asked Steve to explain what margins were. He was able to tell me that the margins are the area around the incision that allows the doctor to know if he got all of the cancer. As my margins were not clear, the doctor would need to cut deeper to try to get clear margins. I made the appointment and started to do some research.  

On the next appointment, when the doctor came in, I asked him about a procedure that I had read about called Mohs Surgery. He explained what the procedure was, but because my lesion was on my back, it was not recommended and probably would not be covered by the insurance company. He said they (Dermatologists) usually save Mohs surgery for lesions on the face or chest areas to reduce scarring. My lesion was on the back where scarring was not viewed as a problem.

I was not so worried about scaring, but was more concerned that the margins were not clean after two biopsies and that now I was having a third procedure. I was worried that having another blind biopsy might not be the best way to handle this. The doctor reassured me and since I was in the office, I put my trust in the doctor and agreed to have the procedure.   

As the incision was quite large, I had to have stitches which were o stay in place for ten days. On day 10 I went to the office to have the stitches removed. While there, I asked about the biopsy (as I had not been called and was anxious to learn the results).  As it happens, some of the key staff were off so there was a lot of confusion and no one could find my pathology report.  The doctor explained to his staff member that he reviewed some pathology reports earlier and my report should be in the office and to please check the file. After waiting a while, I was told they could not find the report. The doctor came in and said he was sure everything was okay, and he would have the staff call the pathology office and have the report sent over. He said he would call me with the results.  

The next day the doctor called me to tell me that the margins were still not clean, and I would need to come back for additional treatment.  He said I had three choices one of which was Mohs Surgery! I said that I wanted to do the Mohs Surgery as it would allow me to have the tissue tested at the time of the procedure and to continue tessting if needed till there were clear margins. He agreed and said someone would call me from the office to set up the procedure. 

As I was thinking about my situation, I realized I was due for my three-month checkup with my Hematologist at Sylvester Cancer Center the following week. I decided to call the office and talk to the doctor or nurse practitioner who knew me and see what they recommend. They suggested that I see another dermatologist for a 2nd opinion. They said they would set up an appointment with the following the appointment with the hematologist. 

On the stated date, I saw the second dermatologist who examined me and reviewed the pathology reports from my previous biopsies. I was glad I had the reports in my binder so the doctor could see my history and what had occurred before coming to see her. 

After reviewing the information, the dermatologist said she was concerned with the treatment I had received and recommended Mohs Surgery. She said she could not understand why this procedure was not done from the beginning, as it is the standard of care. She just shook her head and said that she did not understand why these things happened. I was mad at myself as I had had the same thought. As a result, I had wasted time and put myself under undue stress. I should have gone with my gut and seen the dermatologist at the University of Miami versus seeing a doctor that was more convenient.  I had tried to save time but in the end, I had wasted time and might have put myself at risk.

The doctor said she would make an appointment with the Mohs Surgery Center at Sylvester. The plan was for me to see the Mohs surgeon for an evaluation and then set the date for the Mohs surgery.

For some reason, I did not cancel the original Mohs procedure with the first doctor. As the time of the procedure was approaching I had it on my ‘to do list’ to cancel this procedure as I made up my mind I would go to the University of Miami, Sylvester Cancer Center. As I was looking for the number, a staff member from the first office called me. She said that she was working on the schedule for next week and had me on the list for Mohs surgery. She was confused at this as she was looking at my pathology report that showed clear margins so she could not figure out why I was on the list. I told her that the dermatologist has told me I needed the Mohs procedure done as my past biopsies did not result in clear margins. She said she would call the doctor's office, and he would call me.

I want to note here, that if I did not get this call, I would have had unnecessary Mohs Surgery. I was glad that the Mohs Surgery office takes the time to check to see that the people coming in for testing are appropriate and in need of the surgery. This is one example of having a system in place to check reports and confirm patients are appropriate prior to the procedure that can prevent a medical error.   

I did get a call from the first dermatology office, but not from the doctor, but from Steve. Steve explained that the doctor was busy and asked him to call me to tell me that the last path report did show clear margins, so I did not need to have the Mohs surgery and to follow-up in 3 months! I asked Steve to send me the path report that showed the clear margins so that I could have for my records. 
Once I got the report, I read it over and over to be sure I was reading it correctly. I also called the 2nd dermatologist to give her the information, and she said she would cancel the appointment with the Mohs physician at the University of Miami and would see me in three months for a checkup.  I breathed a sigh of relief and said a little prayer as I was grateful that everything was ok.

What I learned from this experience
  • Do not choose a doctor based on distance. If you are with an established organization that you trust, stay with them if new problems arise.
  • When you get copies of your records, look at the dates of reports and highlight them. When I went through my paperwork, I realized what happened. The first dermatology office sent me the 2nd pathology report twice instead of the 3rd report. I did not pick up on this as the doctor listed the three options that were open to me so I ‘assumed’ it was the third report. If I would have looked at the dates, I would have noticed seen the problem.
  • Going forward I am going to highlight the dates so I can make sure the dates standout. This would help pick up duplicates and ensure the date of the report coincides with the visit. I also recommend doctors’ offices/hospitals and other settings highlight the dates as well. Dates are critical to make ensure you are looking at the right information in order to make correct decisions.
  •  Insist on communicating with one person at the office to avoid mix-ups. My primary contact at the dermatologist office was Steve. Steve was off the day I was in the office for suture removal and the day they could not find my results. What I should have suggested was that we wait for Steve to returns the next day as he was familiar with my situation. By talking to another person (other than Steve) who was not familiar with my case, it may have set up a situation for an error to occur.   
  • Follow up in writing and keep a copy of all communications.
  • Stay calm and try to rectify the situation the best you can. 
The key is to learn from our mistakes and find ways to prevent them from happening again. All healthcare settings and organizations need to promote a culture of safety so everyone feels safe to report problems so they can be addressed.  

As stated at the beginning of this post, the bottom line for everyone to remember is that healthcare is delivered by human beings and we all can make a mistake. Everyone needs to remain vigilant to identify, correct and report errors when they occur so quality improvement initiatives be considered and put into place.

Thank you for reading Nurse Advocate. If you have an example of a medical error you experienced, please share your experience in the comment section or email me at allewellyn5@bellsouth.net. 

If you are a patient, stay alert and stay safe!  If you are a healthcare professional - please double check your work and don't be afraid to report an error so it can be addressed. It is important!

Have a good week.