Ten Medical Mistakes That Changed The Standard Of Care

We learn most from our painful mistakes

It was a cold February in 1976. Dr. Jim Styner, an orthopedic surgeon, crashed his small plane into a cornfield in rural Nebraska, sustaining serious injuries. His wife was killed instantly. Three of their four children were critically injured; the fourth was spared. At the local hospital, the care that he and his children received was inadequate, even by standards in those days. Afterward, Dr. Styner stated, "When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system, and the system has to be changed." Their tragedy – and the medical mistakes that followed – gave birth to Advanced Trauma Life Support (ATLS) and changed the standard of care in the first hour after trauma, in the United States and in much of the rest of the world.

Standards of Care - How they evolved

Allopathic (western) medicine’s first standards of care are found in the Corpus of Hippocrates, compiled more than 2,400 years ago. For the first time (in the West), earthly causes – rather than divine – were sought for all diseases. Hippocrates standardized diagnosis and treatment for a wide variety of recognized disease states, including epilepsy, fractures, ulcers, and hemorrhoids.

Modern allopathic medicine began in earnest after 1910, when Abraham Flexner, sponsored by the Carnegie Foundation, researched the state of medical education in the US and Canada and published his Flexner Report. At the time, only 16 of the existing 155 medical schools required more than a high school education for admission, most of these schools were no more than apprenticeships, and germ theory was not accepted. In 1910, standard of care was an elusive concept.

Fast forward one century to 2011. The practice of medicine across the US is much more standardized, thanks in large part to changes made by medical schools in response to the Flexner Report, to standardization in the qualifying exams for US-trained physicians (the United States Medical Licensing Examination® – a three-step examination for medical licensure in the United States – sponsored by the Federation of State Medical Boards and the National Board of Medical Examiners®), and to medical malpractice law.

Today’s standards of care are now – mostly – based on scientific evidence, but still reflect three basic differences in the practice of medicine:

• level of training of the physician
• level of services and support available to that physician
• level of local practice

In the court of medical malpractice law, this translates to

• specialty training and Board certification
• specific services available and/or advertised by the health care facility or physician
• the way most physicians practice medicine, in a given region, i.e., the local standard of practice. In the past two decades, the courts have held physicians and hospitals to national standards of care, rather than accepting local variations in the practice of medicine.

Given this background, it’s important to remember that we learn most from our painful mistakes.

Nine more mistakes that have changed the way we practice

  Judy was 39 when she went to the hospital for a routine hysterectomy. After she died on the operating table, autopsy revealed the anesthesiologist had placed the endotracheal tube in her esophagus, not her trachea.

Today, anesthesiologists measure a patient’s carbon dioxide levels – much higher from the trachea than from the esophagus – through the use of an end-tidal CO2 monitor.

  Sally and Ed looked forward to their first-born. Sally’s labor was long, so her obstetrician added Pitocin to speed things up. Unfortunately for Esther, their newborn daughter, the Pitocin led to unrecognized fetal distress, and she suffered severe brain injury and cerebral palsy.

Fetal monitoring to test both uterine contractions and fetal heart rate is now the standard, with a 30-minute response time from recognition of fetal distress to delivery.

  Bill suffered a seizure and crashed his car into a tree, crushing both legs. Arteriography revealed his right leg was salvageable, but his left leg was not. Unfortunately, the x-ray technician mislabeled the films, mixing left for right, and the orthopedic surgeon amputated Bill’s right leg, first.

Today, multiple health care providers interview each patient undergoing surgery and actually mark the patient’s surgical site.

  Tom was 12 years old when his appendix burst and he went to the local pediatric hospital. Three days after the appendectomy, he spiked another fever. After one week, the surgeon performed a second procedure and found the cause: a surgical sponge had been left inside.

Today, post-operative sponge and instrument counts are routine. In addition, threads visible on x-ray are woven into surgical sponges, so post-operative x-rays will reveal them.

  As a young child, Betty had been given penicillin, turned blue, and was rushed to the hospital. She was 15 when she got Strep throat, was given penicillin, and died. No one had asked her about medication allergies.

Medical questionnaire forms now include a high-profile space for allergies.

  Linda wasn’t doing well in her first trimester – the nausea and vomiting left her severely dehydrated and low on potassium. In the busy emergency department, her nurse made a simple mistake in arithmetic and added too much potassium to the IV. Within an hour, Linda was dead.

Potassium is now added to IVs by the manufacturer and labeled.

  Frank was 72 when he broke his right leg in a car accident and had to recover for a few weeks in a rehab facility. The nurses didn’t know to move him from time to time and he developed deep decubitus (pressure) ulcers. After these became infected, Frank’s leg had to be amputated.

Decubitus ulcers are – mostly – prevented by regularly repositioning at-risk patients every two hours, to allow blood flow to the skin.

  Lillian was all of 68 years and 250 pounds when she underwent surgery to remove her gall bladder. The second day after surgery, she needed help to walk to the bathroom. Lillian’s nurse, Millie, wasn’t strong enough and they both fell, breaking Millie’s right arm and Lillian’s left leg.

Proper lifting techniques are taught and practiced.

  Christy was 42 when her doctor discovered a large lump in her left breast, one that would have been evident during Christy’s two previous annual exams, had the physical exam been complete. By the time it was diagnosed, the cancer had progressed beyond cure.

Breast exams by the physician, teaching breast self-exams, and recommending mammograms are now the standard.

These are but a few examples of medical mistakes that have led to injuries or death – and have led further to changes in the way we practice medicine. Recognizing that all of these mistakes could have been prevented, the US Government and various medical academies have developed guidelines for prevention and treatment of many diseases. Chief among these is the Agency for Healthcare Research and Quality (AHRQ), part of the US Department of Health and Human Services.

References

• Hippocratic Corpus  classics.mit.edu/Browse/index-Hippocrates.html
• Flexner Report  www.carnegiefoundation.org/sites/default/files/elibrary/Carnegie_Flexner_Report.pdf (PDF 18MB)
• Agency for Healthcare Research and Quality's (AHRQ) Mission  http://www.ahrq.gov/about/ataglance.htm
• U.S. Preventive Services Task Force (USPSTF)  www.ahrq.gov/Clinic/uspstfix.htm

About the Author

Barry Bialek, MD

Barry Bialek, MD is a board-certified family physician living in Boulder, Colorado. His practice includes both family medicine and emergency medicine. For the past 10 years, Dr. Bialek has served as the in-house medical consultant to one of the most successful plaintiff's personal injury law firms in the US. His job was to advise on every medical step of every medical malpractice case. This gives Dr. Bialek a unique perspective on medical malpractice and how best to avoid it.

Dr. Bialek has held clinical faculty positions with the departments of family medicine at both the University of Toronto (Canada) and the University of Arizona. Dr. Bialek is currently a member of the faculty of the University of Colorado, College of Engineering, where he teaches his other passion: sustainable community development in Nepal.