I
am sympathetic to those who champion efforts to improve patient safety and am
not against exposing gross errors as examples of what not to do. However, a
recent article on the CNN website entitled “10
shocking medical mistakes” suffers from poor reporting.
The
article cites anecdotes involving patients with bad outcomes because of medical
errors. I am not trying to minimize the fact that people die or are disabled from
medical errors, including those mentioned in the CNN piece, but can we get the facts straight?
6. Mistake:
Air bubbles in blood
• Cause: The hole in a patient's chest isn't sealed airtight after a chest tube is removed.
• Consequences: Air bubbles get sucked into the wound and cut off blood supply to the patient's lungs, heart, kidneys and brain. Left uncorrected the patient dies.
• Prevention: If you have a chest tube in you, ask how you should be positioned when the line comes out.
• Example case: Blake Fought
• Cause: The hole in a patient's chest isn't sealed airtight after a chest tube is removed.
• Consequences: Air bubbles get sucked into the wound and cut off blood supply to the patient's lungs, heart, kidneys and brain. Left uncorrected the patient dies.
• Prevention: If you have a chest tube in you, ask how you should be positioned when the line comes out.
• Example case: Blake Fought
Simply
googling the patient’s name [Blake Fought] yields a number of hits. On the
first page is a story that
Fought’s tube was really a central venous catheter [not a chest tube] through
which he had been receiving nutrition. An inexperienced nurse apparently used
improper technique to remove the catheter and an air embolus occurred. Yes, it’s
a tragic and preventable mistake and the patient died. But the advice about a
chest tube is misleading.
9. Mistake:
Lookalike tubes
• Cause: A chest tube and a feeding tube can look a lot alike.
• Consequences: Medicine meant for the stomach goes into the chest.
• Prevention: When you have tubes in you, ask the staff to trace every tube back to the point of origin so the right medicine goes to the right place.
• Example case: Alicia Coleman
• Cause: A chest tube and a feeding tube can look a lot alike.
• Consequences: Medicine meant for the stomach goes into the chest.
• Prevention: When you have tubes in you, ask the staff to trace every tube back to the point of origin so the right medicine goes to the right place.
• Example case: Alicia Coleman
Googling
“Alicia Coleman tube” brings one to the third hit on Google [just below two
citations of the CNN account], which is a story from
the Omaha World Herald telling of this poor child’s demise from having been
given a drug meant for the tube in her stomach via a catheter [not a chest tube]
in her jugular vein. The advice about checking where the tube goes is not
incorrect, but the reporting is sloppy.
4. Mistake:
Fake doctors
• Cause: Con artists pretend to be doctors.
• Consequences: Medical treatments backfire. Instead of getting better, patients get sicker.
• Prevention: Confirm online that your physician is licensed.
• Example case: Sarafina Gerling
• Cause: Con artists pretend to be doctors.
• Consequences: Medical treatments backfire. Instead of getting better, patients get sicker.
• Prevention: Confirm online that your physician is licensed.
• Example case: Sarafina Gerling
How
does this qualify as a “mistake”?
5. Mistake:
The ER waiting game
• Cause: Emergency rooms get backed up when overcrowded hospitals don't have enough beds.
• Consequences: Patients get sicker while waiting for care.
• Prevention: Doctors listen to other doctors, so on your way to the hospital call your physician and ask them to call the emergency room.
• Example case: Malyia Jeffers
• Cause: Emergency rooms get backed up when overcrowded hospitals don't have enough beds.
• Consequences: Patients get sicker while waiting for care.
• Prevention: Doctors listen to other doctors, so on your way to the hospital call your physician and ask them to call the emergency room.
• Example case: Malyia Jeffers
A
crowded ER is not a “mistake,” nor is it shocking. It’s an everyday occurrence.
Calling your doctor will not alleviate crowding unless your doctor decides to
see you herself. That will at least keep you
from making the crowding worse. Don’t use the ER for non-urgent or chronic
problems. ER patients are not seen on a “first come, first served” basis. The
sickest patients are seen first. Stories [one
of which appeared on the CNN website in 2011] about Malyia Jeffers describe waiting but
more importantly what appears to be human error in recognizing severe sepsis on
the part of the ER triage nurse.
Many
of my Twitter followers picked up on the above problems with the CNN article. Reasoned
discourse about medical errors can help us all try to prevent them. This sort
of story diverts our attention from the real issues.
Maybe
CNN should ask a doctor, or at least a fact checker, to vet articles such as
this.
4 comments:
They should ask a REAL doctor. Not one of those " celebrity" MDs who never practice real medicine. I'm referring specifically tothe Dr Oz's and Dr Reys of this world
Doc-ZZZ, I am available. FYI, I am told Dr. Oz still sees patients and performs cardiac surgery. It's not first-hand information.
I just ran across this article. I happen to be the mother of Blake Fought who indeed died exactly 8 years ago due to massive air emboli after the removal of a central line. CNN did indeed get the type of tubing incorrect which I immediately informed them of the error. They were supposed to correct the story but apparently never did. I know this post is from 2012 but I wanted to let you know that the producer and the camera crew had it right and I have no idea where things got incorrect. There was a CNN TV special which I was interviewed in and you can hear me speak of the central line and then Ms Cohen speak of a chest tube. I know they got it wrong and it upset me terribly since it was important to me and my family that it was correct information. as after all we do these stories so other families don't have to go through what we do on a constant daily basis ...losing your child destroys life as you know it.
Yours,
Dr Amy Fought
Dear Dr. Fought, thank you for taking the time to comment. Please accept my condolences for your loss. I am sure that CNN's mistake was quite annoying when you were trying to make a point. it is frustrating when the media screw things up like this. That was my point in writing this post. Best wishes.
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