We read a lot about mistakes made by doctors, surgeons, nurses, and hospitals that cause injury and sometimes death to patients. However, in some cases, it’s the healthcare system itself that creates an environment for medical mistakes.
Dr. Danielle Ofri, an internist at New York City’s Bellevue Hospital, writes in her new book, When We Do Harm, that medical errors are far more common than many people think. And the rate of medical mistakes has increased as hospitals treat a dramatic surge of COVID-19 patients.
Ofri said that many errors go unreported—especially “near misses”—where a mistake was made, but the patient doesn’t suffer any adverse effects. She believes that we’ll never know how many near misses happen every day or what number are the cause of death, But it’s not a small number, she says.
Ofri’s new book examines health care system flaws that foster mistakes, some of which are committed by caring, conscientious medical providers.
“Near misses are the huge iceberg below the surface where all the future errors are occurring,” she told NPR. “But we don’t know where they are … so we don’t know where to send our resources to fix them or make it less likely to happen.”
Dr. Ofri believes that reporting errors — including the “near misses” — is vital to improving the system. However, shame and guilt keep medical personnel from admitting their mistakes.
Dr. Ofri tells that story of a patient admitted to her hospital for so-called “altered mental status.” She says she was told that her lab work and radiology were normal. Based on this, she thought, “Let me get this patient back to the nursing home. It’s all fine.”
However, shortly after that, the patient started bleeding into her brain.
Dr. Ofri missed it because she didn’t review CAT scan herself. Somebody told her that the patient’s radiology was fine, so she took them at their word and didn’t look at the scan like she should have. Fortunately, the patient was sent directly to the operating room and recovered. This was a near-miss error because the patient didn’t get hurt, and her medical care went smoothly after the initial mistake. Nonetheless, it was an error. Had the patient been discharged and returned to the care facility, she may have died. But this error never was reported because the patient was fine. This type of mistake isn’t studied or tallied, Dr. Ofri said. As a result, it’s overlooked in the greater scheme of how to make the health system better.
When considering “near misses” and medical errors in diagnosing and treating COVID-19, Ofri explains that many hospitals pulled a lot of people from their specialties in an “all hands on deck” response. As a result, training was less than complete. For example, endocrinologists—specialists in disorders of the endocrine glands and hormones—have been asked to help with patients on the front lines of the coronavirus pandemic. It’s not something they’re prepared to do, and mistakes have been made in these situations.
Likewise, donated ventilators are made by different manufacturers, so it takes some time to figure them out. Coordinating donations to be the same type in the same unit would be a way of minimizing patient harm.
Another area of concern is patients who don’t have COVID. One group of these patients are those who are mislabeled as having the disease, especially those with respiratory symptoms. This can happen if there’s a shortage of testing in an overwhelmed health system with limited capacity to test or treat. As a result, doctors may simply assume it’s COVID-19 when the test isn’t available. This type of error creates the risk of missing other respiratory infections and non-respiratory conditions. These patients are sick, just not with COVID.
Another group are “regular” patients whose medical illnesses suffer because hospitals are short-staffed and have been forced to divert resources to intensive care COVID units. Thus, the system doesn’t have a way to take care of patients who need medical care that’s urgent, just not an emergency. These are procedures such as cancer surgeries, heart valve procedures, and hip replacements—surgeries that perhaps can wait a week or two but not serval months. So, these patients also suffered due to the impact of the pandemic.
In addition, there have been logistical problems in the healthcare system with COVID patients. That’s because patients are being transferred from overloaded hospitals, and when patients come in a batch of a dozen or more, the situation is ripe for things to go wrong.
Many “near misses” have occurred recently due to the health system itself, such as when the hospital or clinic framework contributes to an incorrect, missing, or delayed diagnosis, or even when abnormal lab test results aren’t reported promptly to the patient. This harm can also include the progression of an injury or condition that wouldn’t have worsened but for the systems inadequacies in staffing, resources, or logistics.
For a free consultation with an experienced medical malpractice attorney in Michigan, contact Buchanan Firm. We can discuss your situation if you believe you’ve been injured as the result of a misdiagnosis, missed diagnosis, or an error in lab results.
Our firm proudly serves people all across Michigan, including major cities like Grand Rapids, Muskegon, Detroit, Lansing, Holland, St. Joe, and Ann Arbor, and rural towns such as Lowell, Ada, Fremont, Newaygo, Grand Haven, Rockford, and Cedar Springs. We will meet you after-hours, at home or in the hospital to accommodate you.