Archive for the ‘MEDICAL ERRORS/SAFETY WRITING’ Category


January 29, 2014

It was crazy, I knew it was, but I needed to do it.  I was depressed, it was raining hard outside, 39 F. (4 C.), but I decided to go for a 3 mile (5 km) run.  I live in Eugene; Track Town, USA, home of the Olympic Trials, NCAA championships, and a runner’s mecca.  I’ve camped in pouring rain many times; I can certainly run in this weather. I MUST run in it today.

Earlier, I got a video link from a friend showing how a former Attorney General in New Jersey used a data-driven approach to reduce crime.  I was depressed, mostly because I was jealous of her data-driven success, something for 3 decades I never could achieve.  Jealousy is one of the seven deadly sins.

I put on sweats, my rain jacket, a neck warmer, hat and hood, and went out.  I wondered if I would see others running, but it didn’t matter.  I was out there, running.  I needed to goAt the outset, I should have walked, but I immediately started running, not fast, but I wasn’t walking.

This video was on TED, and I usually look at links or books people recommend to me.  As a result, I learn a lot. I seldom, however, send links or recommend books to others, despite the fact I do a great deal of reading in both English and German.

I soon reached Alton Baker Park, feet wet, and just a bit cold, but my wool socks would soon warm me up.  This wasn’t bad so far, but it was raining harder.  Let’s see what happens.

The reason I seldom send anybody anything is I have sadly noted  that almost nobody, and I mean that word, nobody, has ever looked at any of my reading recommendations. Seldom has anybody asked for my recommendation, and I doubt those who did ever followed through.  It was discouraging, because as I learned from others, I got the feeling that others felt I have read nothing important. I taught myself to read when I was 3.

I haven’t been able to run at all for 3 months, because I had patellar tendonitis, which I had never had in 50 years of running.  I missed running.  This past week, I started again, first 100 steps at a time, 4 or 5 times.  It went well.  I walked 10 miles a day.  So far, so good, as I headed towards the Willamette River.

I recommended a New Yorker article about the new ecosystem discovered in the crown of California Redwoods, and it was unread. Same with Our Darkening Ocean, a must read in my opinion. The Khan Academy depresses me, because the man is brilliant, but basically does what I am capable of doing, but was unable to do.  I couldn’t even get local schools interested in my many skills, despite extensive efforts.

Within days, I was running 200, 300, 500, and 600 steps at a time.  It felt great.  Today, in the rain, I decided to go for 1000 when I hit the Pre-trail.  Steve Prefontaine died far too young, but I bet he would have been happy to see an old guy running in the rain.  And loving it.

When I was on the Medical Society Board of Directors, one of my detractors always gave me “reading assignments,” which I called them.  When people came to the monthly meeting, that individual was greeted warmly.  I wasn’t, but rather given articles to read, most of which I either knew about or was trying to implement.  I got the sense others felt I didn’t know much, and if I would only read these myriad books and articles, I would become more knowledgable.

I didn’t see another runner, but now my feet were warm, and I was cruising.  Five hundred steps, 600, 800, and 1000.  Wow, that wasn’t bad at all.  Nobody out here, and it is wide open and not dark, just raining. 

I was counting complications in carotid artery surgery (CEA) in my hospital in 1984, and I am interested whether hospitals track the following: CEA complication rate, non-elective readmission within 15 or 30 days, clean case wound infection rate; percentage of pre-operative antibiotics given within the proper time window, and the number of deaths where a significant medical error was causal. I tracked the first four 18 years ago and espoused the last in 2001, believing all are decent indicators of medical quality.  Yes, I know others, too.

The Pre-Trail is long, so I thought I’d do another 1000 steps.  No problem.  No runners, either.  Wow, am I crazy?  No, I am having fun in the rain, like a kid!

For those who are concerned about obesity, do you know the percentage of obese 6th graders in one district in your local school system?  I knew it in Tucson in 2010.  It was easy; the data were obtained, I analyzed them, and the results frightening.  I showed the results to the administrators.  They assured me there would be a meeting with other district superintendents. I never heard another word; the Medical Society’s Executive Director wrote, also hearing nothing.

I’ve always been a kid, curious.  Maybe that’s why I read what people send me,  until I either finish it or find it so poorly written or wrong that I stop.  I will read climate change articles until the first pejorative word.  Then I’m done.  It has never, and I mean never, taken long.  Sometimes, I don’t get past the title.

I am now out of date, but I wonder if medicine has a reporting system for medical errors akin to aviation.  We do not have a decent estimate of deaths with a known margin of error (a necessary requirement for every estimate), and with simple sampling techniques, we could know.  I promulgated this from 2001 until I quit in 2006.  Sadly, I was not an attorney general.

I left the Pre trail, went to MLK Blvd. and headed home.  Wow, this is great.  The people in the cars must think I’m nuts.  I saw no other runners, either.  I might be the craziest guy in Eugene! Or maybe one of the happiest.  What happened to the depression I had?

So, when I see an young, former attorney general of a populous state talk about data-driven crime statistics as if this were something new, I get a bit jealous and depressed.  I was pushing this stuff when she was in high school, and we still aren’t doing it the way we should.

Where did I go wrong?  You didn’t, guy.  Many try; few succeed.  Today, nobody, it appeared, tried to run the Pre-Trail.  You did, and you succeeded.  You are now happy, and many who own more would give a lot to feel the way you do.


November 25, 2013

A German movie made me cry.  It was the first time I had ever cried because of what I saw in the language I am teaching myself.

The movie:  Engel der Gerechtigkeit Ärztepfusch, or Justice Angel for Doctor Screw Ups, I found exceedingly moving.  The ending was beautiful. I knew music could be powerful; I had no idea the effect it could have on me. I was in tears, and I didn’t care.  I cry, and when I let go, I feel perhaps more human than at any other time.

I’ve seen the ending at least 40 times.  For the next week, it is on (24 November).

The movie opened with a woman standing in the middle of railroad tracks, wondering whether to commit suicide.  Later, we learn why, as she comes out of the shower, learning that she had breast cancer, and the wrong breast was removed.  She had therefore a double mastecomy, brief clips being shown of ugly scars where her breasts once were. The woman had to pay for the surgery, had no recourse to justice, until she finally met the lawyer.

The hospital stonewalled, saying the doctor was Spanish, didn’t speak German, and no longer lived in Germany.  The fact that nobody else spoke up, in the OR or anywhere else may be surprising to some, but the culture of silence of medical errors in Germany may parallel that here in the US, where I saw errors hidden, denied, and blamed, in some instances, upon me, as medical director of a hospital.

Back to the movie:  at the end, the lawyer for the woman said she would go to the press before the end of the day.  The hospital administrator said that he would allow the breast reconstruction, but no blame was to be levied.  The lawyer started to think, then smiled, and the music began.  The lawyer walked to the dry cleaners, where the woman and her husband worked.  In the crowd of people waiting for clothes, the woman spotted the lawyer, who had a smile on her face.  The husband, working, looked up, surprised.  The woman said, “Enschuldigen Sie mich, bitte” (excuse me, please) and came to the lawyer.

“The operation will be next week. The papers were signed.”  The woman was stunned, the music continued, as the woman broke down and hugged the lawyer.  The smile on her husband’s face was wonderful.  It was an incredibly powerful scene.

I saw three cases of wrong side surgery during my time as Medical Director of the hospital–the wrong knee, the wrong side of the colon, and the wrong side of the brain.  The last, I had to explain to the woman’s friend, since the woman had no family.  The internist taking the case wasn’t told and was so angry, he signed off the case, without finding another physician.  This unethical practice was not uncommon where I worked, where it meant that I had to find somebody–sometimes myself–to take over.  My colleagues never sanctioned the physician.  Indeed, at a Medical Executive Committee meeting in 1998, one blamed me for taking care of a patient who had no doctor.  I left the meeting, went outside where nobody could see me and cried.  That is the medical culture I was part of.

I was told by the head of the OR that 99.9% of the cases had no problem.  No, I retorted, it was 99,99% of cases, and per cents didn’t matter, counts did.  There are certain things where the counts should be 0, not a high percentage of successes.  The hospital administrator used the same words, and the lawyer pointed out 160,000 cases of errors and 20,000 deaths in Germany every year.  Wow.  They count.

Medicine here never really changed.  We have at least 20 wrong side cases annually nationwide.  True to medicine, everybody began his or her own process for ensuring safety, which of course meant in some places the proper limb or breast was marked for surgery, or the improper one was marked.  This leads to confusion as well.

When I objected to just a letter being sent to the neurosurgeon, I was told I was no longer welcome to attend department of surgery quality assurance meetings.  At first, I was incensed, because I knew about systems, and my knowledge should have been desired, not forbidden.  I also had discovered our carotid endarterectomy complication was far too high to warrant surgery.  I literally was screamed at, when my data were presented. My patients got statistics, probability, and my recommendation; other patients were not told of these risks.

After I left medicine, my mother refused a CT scan after a fall, and we were not told of the refusal  When she later died of dementia, we discovered during her final illness that originally she had refused the scan.  I was furious and published an article about it in Medical Economics.  My father, before he died, had weeping edema, swelling so bad that it went through the skin of his legs.  The nurses called it a weak heart, when in fact low protein in his blood caused the problem–simple osmosis.  Had he been diuresed, he would have become hypovolemic and died.  He did die, but from pneumonia.  I had to tell the Nursing Home Director that I was not the enemy, but I was trying to be my father’s advocate. My oldest brother had a brain tumor missed, causing him blindness in one eye.  He was a professional photographer. I had a medical error occur in me.

Engel Gerichtigkeit was only a movie, but it was powerful and beautiful; the medicine well portrayed. 

In 2001, I developed a reporting system for medical errors. Sadly, I was naive enough to believe I could implement it.  Looking back, I didn’t have a chance against the entrenched system of hospital and medical associations.  I wrote legislation for two years for the Arizona House, with 10 co-sponsors but went nowhere.  Doctors shunned me.  One response was, “We aren’t like aviation.”

“Yes, “ I replied. “Aviation deals with their problems honestly.  You sweep them under the rug.”


October 24, 2012

A 28 year-old woman comes to the hospital with significant left-sided abdominal pain, and the imaging study is read as showing a small left-sided inflammatory process felt to be diverticulitis, despite no diverticulae being seen.  No comment was made about the appendix. Diverticulitis with perforation in the large bowel may occur in the young, but it is an older person’s disease.  As a former clinician, I would be bothered about that diagnosis.

But, four days later, the patient was better.  A repeat study was performed just to be certain nothing was awry.

Something was.

The patient now had an abscess in her left side of the abdomen, and there was inflammation throughout the peritoneum.  This time, a different radiologist looked at the scan in a different plane.  There are 3 anatomical planes for viewing: sagittal, coronal, and  transverse.  In the coronal plane, it was clear that the appendix had ruptured.  In the sagittal plane, where the prior reading had been made, the appendix wasn’t visible.  Radiologists don’t always look at all the planes.   They get paid by numbers of cases reviewed, just like most physicians, and there is a lot of pressure to take care of many patients.  Before you say this is wrong, remember that many people complain of emergency department waits.  If a radiologist takes a lot of time to read a scan, people wait.

But the appendix is on the right side of the abdomen.  What gives?

I have a book from my late father-in-law called “The Early Diagnosis of the Acute Abdomen,” by Sir Zachary Cope, the 8th edition, written in 1940.  It should be required reading for every medical student.  The appendix is attached to the cecum, and the cecum is on one side of the iliocecal valve, leading from the ilium to the large bowel.  The first radiological report did not mention the cecum.  This was a major oversight.  Unless the cecum is identified, the appendix cannot be identified, either.  If those two cannot be seen, appendicitis as a cause of the problem cannot be excluded.  In a young person with significant abdominal pain, appendicitis is always a consideration until proven otherwise.  When I was a shipboard doctor, I had read Cope’s book 5 times, because diagnosing appendicitis meant either an operation on board (I did two, one by myself) or an expensive Mede-vac, with a helicopter landing on the small flight deck of a ship.  I’ve done that many times, and it requires skilled pilots.

The cecum can be not only in the right side of the abdomen, but in the middle or other parts.  The appendix, therefore, can be anywhere in the lower abdomen, the pelvis, in the middle, and even in the right upper abdomen, mimicking gall bladder disease, should it be retrocecal, or behind the cecum.  The appendix can irritate the bladder, mimicking urinary infection.  If the appendix is pelvic, ruptures, and forms an abscess, the abscess will move up the left side of the abdomen, the path of least resistance, exactly what happened here.  Two of the best medical adages are: first, uncommon manifestations of common disorders are more likely to occur than common manifestations of uncommon disorders; second, when you hear hoofbeats, think horses, not zebras.

The woman will be operated upon and should survive, but she will have extensive scarring in her abdomen, which will likely lead to future bowel obstructions and multiple operations.  If she has children and needs a C-section, it will be a very difficult procedure, since bowel may adhere to the uterus and perforate during surgery.  She would have had future problems had she been diagnosed promptly, but not nearly to the extent that she is likely to have now.

It just isn’t the fault of the radiologist, however.  Where were the clinicians?  Why would a clinician accept diverticulitis in a 28 year-old with no other diverticula being visible? Why was there no statement why this could not be appendicitis?  Such a statement would show that the clinician had at least thought of the diagnosis.

I made a lot of mistakes in practice, but any time I was bothered by a diagnosis, I either kept looking at the patient or asked a colleague what he or she thought.  I also wrote a provisional diagnosis on my reports for X-Rays, not just “headache” or “abdominal pain.”  I wrote, headache, slight left sided weakness, glioma a possibility,” or “abdominal pain, left-sided, high white count.”  The radiologists loved having the information I provided them, and I got better reports, too.

I recently learned from a pathologist the astounding fact that with the advent of imaging procedures that supposedly allow us to look inside the body without surgery, that autopsies, the few that are done, show NO CHANGES, repeat, NO CHANGES in the pathology that was MISSED by the clinician and the radiologist during life.  This is scary.  It means that our assumption that we know what is going on with a patient on the basis of an imaging test may not be correct

This is the second time I have discussed a major problem with appendicitis in a young person.  The first patient died.  This person walled off the abscess, which the body used to do fairly successfully, in the days before good diagnosis and good surgery.  My grandfather had unoperated appendicitis and survived.  It can happen, and it did in 1940.

I would like to think in 2012 that we might be a little better.  I’m not really so sure we are.  And that bothers me as much as a diagnosis that doesn’t make sense.  It makes me worry and think, “What else could be going on?”

There is one other adage we would do well to remember, the most basic rule of all:  “Listen to the patient.  She is trying to tell you what is wrong with her.”


July 12, 2012

I needed a prescription refill for a medicine I have taken for 3 years.  My prior physician allowed calls to be made by the pharmacy to refill the prescription, so I didn’t have to go to his office to get one.  Unfortunately, he left practice to do concierge medicine.  I didn’t wish to pay $1500 annually for 24/7 access to a physician.  For years, I thought that went with the territory, along with not charging for the thousands of telephone calls I returned.  I can’t tell you how important it is as a patient to get a physician’s call.  I can’t put a dollar value on it, other than to say a big “Thank You” to the physicians who have called me back.  That has no dollar value, either, but I think they appreciate it.

Physician #2 left practice to become a hospitalist, because he was unable to afford continuing the practice he was in.  Physician #3 required a visit to refill this particular prescription, which is neither addicting nor dangerous.

We don’t have standardization in medicine for those things that need to be standard.  We disparage it as “cookie cutter” medicine, when in fact, cookie cutter approaches ensure good cookies.  “People are different,” I hear. No, we really aren’t as different as many would like to think.  Most men have similar anatomy; most women have similar anatomy.  Our physiology is the same, and our bodies react to insults in predictable ways.  That is why we study pathology.  Surgeons take out gall bladders the same way, and as a neurologist, I had a standard history and “cookie cutter” neurological exam.  I seldom forgot anything important.  What does differ is how we personally react to disease, and in a short office visit, time spent on that is virtually nil. I practiced for 20 years, so I know the difficulty in trying to diagnose, treat, and understand the patient’s reaction to an illness in a short office visit.

I drove to the physician’s office and asked for a prescription for 2 pills twice a day, 120 pills in all, with 5 refills.  I had my request written on a piece of paper.  I had to come back 2 days later to pick up the prescription.  The office could have sent it, but that requires something to be done by somebody else.  If I do it myself, it is more likely to get done right. Prescriptions can be lost and not sent.  It is only 45 minutes round trip, so it is nothing important, only my time.  When I returned, two days later, I was given my prescription, written for 1 pill twice a day, not 2, as I had asked for, but 120 pills in all, with 3 refills, not the 5 I had asked for.  I could have asked for the prescription to be written the way I had written it down, but the 120 pills a month was right, so I took it to the pharmacy, explaining carefully that this was a new prescription from a new doctor, who would be henceforth refilling future prescriptions.

The pharmacy normally calls me when my prescription is ready.  They didn’t call.

So, I walked to the pharmacy, 10 minutes fortunately, and was told that I could only get 60 pills, not 120, because the prescription was written for 1 pill twice a day. They said they couldn’t reach my doctor, but they mistakenly had called my previous one, who was no longer in practice, despite my having told them I had a new doctor, whose name and telephone number was on the prescription.

The pharmacy said they would call the doctor’s office.  I left the pharmacy empty-handed, because if I got 60 pills, I would have to explain to the insurance company why I needed a new prescription, should I again want 120 pills, which I do. The next day, the pharmacy said nobody picked up the phone.  I drove to the office, handwritten note again, and asked for another prescription, either to be called in or given to me to pick up.  While there, I asked if they had been called.  They said no, and they answer, so I am not clear whom the pharmacy was calling.

The following day, I got the prescription filled, a week late.  What would have happened if I did not have extra medication?  What would happen if I were 85, no medical background, not thinking clearly, because I was 85 and in ill-health, and on several medications?  I might end up in the hospital, which would be a five figure cost, because of breakdown of a really simple system.

I ask:  what is so difficult about writing and filling a prescription correctly?   Frankly, insurance companies should be trying to fix bad systems in medicine, which would save them far more money, than worry why a 63 year-old is taking 120 pills of Drug X every month, the same amount, and is doing just fine.  I am unable to refill a week in advance, should I go out of town during the time the refill is “allowed.”

No, insurance companies should fix bad systems, like ensuring antibiotics are given in a certain time window before elective surgery, which would save them far more money, as would standardizing the antibiotic. When I was medical director, we met the time window only a quarter of the time, and we had a post-op infection rate 4 times higher than Salt Lake City.  That amounted to about 20 extra infections a year, or a few hundred thousand dollars.  Those are all facts.  We had one doctor use a very expensive antibiotic for his patients, increasing the possibility of resistance, and I was unable to get the Surgery Department to deal with it.  We also had 3 wrong-side surgeries: on the head, knee, and bowel.  The first one was not communicated to the internist following the patient, who resigned from the case, he was so angry.  Bad systems cause trouble.

My pharmacy experience is is one reason why so many of us are so angry about medical care today.  It doesn’t work properly.  Systems are broken, and it costs money and time, and makes people frustrated and angry.  While time is supposedly money, it isn’t to me.  It has uncountable worth.  Unnecessary anger and frustration are uncountable expenses.  Being uncountable does detract from their importance, a fact lost upon many today.

Thirteen years ago, I bet my career on becoming one who taught people how to fix bad medical systems, and I lost.  Here is how medical errors have affected my small family:

My mother’s final illness began with a fainting spell.  She was taken to the hospital where we were told her CT head scan was normal. Five months later, 1500 miles from home, her rapidly progressive dementia led to a fall, breaking her hip, and she was delirious after surgery.  I had to fly to Portland, put my abulic (more than dementia, destruction of personality) mother, recovering from a broken hip, on a plane, and bring her home.  At the same hospital, we discovered she had refused the initial CT scan, and nobody had told us.  Worse, the attending physician later changed the note on the chart (the note that said “CT normal”), which is illegal.  Three more days (uncountable cost) were spent in flying to Portland (countable), to bring my parents’ car home.  My mother died soon after, so the error probably didn’t matter much, although the way she died still bothers me (uncountable cost).

My oldest brother’s meningioma was misdiagnosed until he went blind in one eye.  He is a professional photographer, so this is a significant issue (uncountable cost).   I am hoping the meningioma doesn’t grow further and kill him, because he refused surgery.  That might not have been a bad idea, given the location of the meningioma and given how complex medical procedures are.  After all, if we can’t deal with prescriptions properly, what is the probability of a successful operation?  Are there data? Or is it just anecdotal?

During my father’s final illness, he had low protein and edema so extensive that it literally wept through the skin on his legs.  Despite that, his nurses said he had heart failure.  I tried to explain to the head nurse that a lab test to measure protein was overdue,  that I was not the enemy, only wanting to ensure my father got the care he needed (uncountable cost, except for the lab test).  The response from the head nurse was “Let doctor take care of it.”

In my language, doctor takes a definite article.  For an unknown reason, omitting it annoys me.

I had a significant mistake made in my own medical care which led to 2 months of the worst misery I have ever experienced.  The medication for this condition is the one I have been trying to get at the pharmacy.

We argue about insurance reform, but we waste countable billions on bad systems;  suboptimal care, unnecessary deaths, and the uncountable cost of unnecessary frustration.  A family member of mine may need chest surgery and stay overnight in the ICU.  I will sleep there.  Many doctors would agree with my decision.  If you can possibly afford the time, and remember, my time is not important, you need to check everything that is done.  Medicine is complex, although we have other complex systems in society which work a lot better.  “We’re different from them,” say my colleagues.

Yes, we are different.  We don’t fix our bad systems, and we marginalize those who try.  I am proof of that.  Once I left medicine, I heard horror stories from just about everybody I spoke to.  Many of these may not be true, but tell me:  how many people each year die from medical errors?  We have estimates, but they are poor, which to me is a travesty.  With sampling or a census, ability to keep the findings from discovery, we could review each death from each hospital and sort it into:  definitely caused by medical error; significant, but not fatal, medical error; not significant medical error; no medical error.  Each chart could be reviewed, and we would have a superb estimate of the number for a calendar year by January 31 the next year.  Additionally, we would know what the errors were, and we could learn from them.  Legislation to do this was written by me, had 10 co-sponsors in the Arizona legislature, which was 8 more than the number of doctors who supported it.  The Hospital Association killed the legislation.

We physicians want malpractice reform, yet we act as if bad outcomes are just bad luck.  They are usually due to a concatenation of bad systems that can be fixed, not tolerated.  How many and what kind need only to be counted.  To people like me, who live and breathe numbers, “count” is always modified by the adverb “easily”.

Instead, I have encountered verbs: to marginalize, to ignore, to frustrate and to fail.


October 18, 2009



October 8, 2009



October 8, 2009



October 8, 2009



October 8, 2009



October 8, 2009