In our previous post, we introduced Dr. Elaine Goodman, who observed numerous medical mistakes while her mother was hospitalized for six months when fighting breast cancer. The second half of her story follows.
Medication Not Adjusted as Required
The mom experienced frequent medication errors that could have been avoided there been fewer doctors involved in treating her. For example, she received a drug that required frequent monitoring to adjust the dosage in relation to the patient’s nutritional status. A doctor ordered a larger dose without checking the patient’s nutritional status, resulting in a overdose that made the mom sleep for days. With fewer doctors with more awareness of the monitoring requirements of the specific medication, this might not have happened.
Wrong Chemo Drug Ordered
A similar problem arose when the mom’s oncologist was out. A covering doctor administered the regularly scheduled chemotherapy. Unfortunately, it was the wrong drug, which meant that Dr. Goodman’s mom had gone untreated for a week before the error was discovered.
Dr. Goodman learned that the incorrect drug had almost the same name as the correct drug, with the labels being almost identical.
Errors Lead to Changes in Hospital Medication Procedures
It turned out the drug that had been incorrectly administered had a name that was almost identical to the name of the correct drug, and the labels were almost identical. There were no systems in place to catch errors like this before they affected patients. Moreover, the hospital pharmacist did not have in-depth knowledge of chemotherapy drugs. Eventually, the hospital hired a new chemotherapy pharmacist, provided nurses with more training, and changed how the chemotherapy drugs were ordered and labeled.
Dr. Goodman believes that medical and hospital training and techniques have not kept up with increasingly complex treatments, medications and procedures. Moreover, nurses’ and doctors’ abilities are affected by overbooking, multitasking and functioning on very little sleep. Even the most well-trained, careful and caring provider is bound to burn out and make mistakes in such circumstances. Given the facts, it’s suprising that there are not more instances of medical malpractice.
Doctors Need Training in Patient Safety
According to Dr. Goodman, the entire system needs revamping, beginning with appropriate training in patient safety for doctors and nurses. Most medical and nursing schools, if they offer such a class at all, classify it as an elective. It should be required, she says. The culture should change to allow staff members to report events and situations that could affect patient safety – without negative consequences to the person reporting the problem.
Source: ProPublica, “What a New Doctor Learned About Medical Mistakes From Her Mom’s Death,” by Marshall Allen, Jan. 9, 2013.