Chapter 3: The Moral Climate of Health Care

Section 6. Readings

                                        MEDICAL ERRORS

1. Oops, Wrong Patient: Journal Takes on Medical Mistakes by DENISE GRADY

2. DEAD WRONG: MISTAKEN DEATH DECLARATION. by Olubunmi Olayinka

3.  How a Lucrative Surgery Took Off Online and Disfigured Patients  By Sarah Kliff and Katie Thomas   Oct. 30, 2023 NY TIMES    More surgeons are opting for a complicated hernia repair that they learned from videos on social media showing shoddy techniques. 

Oops, Wrong Patient: Journal Takes on Medical Mistakes

By DENISE GRADY   http://www.nytimes.com/2002/06/18/health/policy/18ERRO.html

he patient had been on the operating table for an hour. Doctors had made an incision in her groin, punctured an artery, threaded in a tube and snaked it up into her heart. Now they were stimulating her heart electrically, to test for abnormal rhythms.

The phone rang: it was a doctor from another department. What, he asked, were they doing with his patient? There was nothing wrong with her heart.

The cardiologist working on the woman checked her chart, and saw that he was making an awful mistake. He was performing an invasive procedure ( with risks of bleeding, infection, heart attack and stroke) on the wrong patient.

The case, described in an article in the June 4 Annals of Internal Medicine, took place several years ago at a teaching hospital. Doctors and administrators there, in exchange for anonymity, agreed to discuss the case and share the records with outside experts, who also interviewed the patient. The resulting article, by the experts, is the first of eight detailed reports on medical errors that will be published in the journal over the next year or so. The article, "The Wrong Patient," is available at http://www.annals.org.

Creating a series of articles on mistakes was the idea of Dr. Robert M. Wachter, associate chairman of the department of medicine at the University of California at San Francisco, and a colleague, Dr. Kaveh G. Shojania. They asked doctors around the country to reveal their mistakes, with the promise that no names would be published. Cases were then analyzed and written up by experts who did not work at the hospitals involved. The goal, Dr. Wachter said, is to help prevent mistakes by showing how they occur.

The series was inspired in part by a 1999 report by the Institute of Medicine, which found that mistakes in hospitals killed 44,000 to 98,000 patients a year. Departments within hospitals try to analyze their own errors, at regular "morbidity and mortality" conferences, but those sessions are private and are not written up in medical journals. Generally, the conferences are not discussed with patients. In an editorial about the new series, Dr. Wachter and his colleagues wrote that the medical profession — "for reasons that include liability issues and a medical culture that has discouraged open discussion of mistakes" — was not harnessing the full power of errors to teach.

"I can't imagine the hospital you could go to where someone with a straight face could tell you, `This can't happen at our hospital,' " Dr. Wachter said. "It shouldn't. I don't want to scare people. It doesn't happen very often. But it can."

Reports of mistakes ( amputating the wrong leg, operating on the wrong side of someone's brain, killing a cancer patient with an overdose of chemotherapy ) provoke public fear and outrage. People are often tempted to blame someone for being incompetent, careless or lazy. But the cause is rarely so clear-cut, according to the 1999 report and researchers who have studied medical errors.

Far more often, a big mistake results from a series of small ones, made in hospitals that lack systems to prevent human error or compensate for it. Singling someone out for punishment does nothing to fix underlying flaws in the system that set the stage for mistakes ; flaws like different medicines having similar names or labels, or hospitals with such poor record keeping systems that doctors lack vital information on patients they are treating.

There is little data on cases like the first one in the series, in which an invasive procedure was done on the wrong patient.

"There are more newspaper articles about it than there are journal articles," said Dr. Mark R. Chassin, an author of the article and the senior vice president for clinical quality at Mount Sinai Hospital in Manhattan. Dr. Chassin was also an author of the 1999 Institute of Medicine report. He and his co-author on the new article, Dr. Elise C. Becher, also from Mount Sinai, found that a national database of voluntary reports showed 17 such cases in the last seven years. But New York alone, where reporting is mandatory, had 27 cases just from April 1998 through December 2001. And even with mandatory reporting, Dr. Chassin said, many cases are probably never revealed.

The tale of the wrong patient in the first article, Dr. Wachter said, "is one of these cases where light bulbs go off in people's heads and they say, `Wow, I now understand how something like this can happen.' It truly is not bad people doing bad things. It's little things coming together."

The story began with two patients who had similar names; the journal used the pseudonyms Mrs. Morris and Mrs. Morrison. Mrs. Morris, 67, had a weak and bulging blood vessel, an aneurysm, in her skull. Mrs. Morrison, 77, needed a procedure called an electrophysiology study to check out her heart. They started out on the same hospital floor, but Mrs. Morris was later moved.

Early one morning, a nurse called Mrs. Morrison's floor to say it was time for her procedure. Mistakenly — mishearing the name, perhaps — the person who answered said Mrs. Morrison had been moved to another floor. The nurse then called Mrs. Morris's floor, where another person made a similar mistake, saying yes, Mrs. Morrison was there.

At 6:30 a.m., a nurse woke Mrs. Morris — the wrong patient — and told her it was time to go. The nurse went ahead even though there was no written order for the procedure on Mrs. Morris's chart, and even though the other nurses caring for her had never mentioned it.

Mrs. Morris protested, saying she had not been told about this procedure and did not want it. The nurse, who was near the end of her shift, insisted.

"She just zoomed in and took me on out of there," Mrs. Morris later told interviewers.

In the lab, Mrs. Morris protested again. A nurse called the senior doctor, the attending physician, who then spoke to Mrs. Morris on the telephone, assuming mistakenly that she was Mrs. Morrison, whom he had met the night before. After they spoke, the doctor told the nurse that the patient was willing to proceed. No one realized that the patient was not Mrs. Morrison — who was still in her room, waiting for her heart test.

But the nurse in the electrophysiology lab noticed that there was no consent form in the chart, even though the department's records said consent had been obtained. The nurse called a second doctor. He was puzzled by the "relative lack of pertinent information" in the patient's chart, but he talked to Mrs. Morris, and she signed the consent form.

Meanwhile, a resident on Mrs. Morris's floor was surprised to find that she had been taken to the electrophysiology lab. He went there, and was told by a nurse that a heart test had been scheduled for her. He left, assuming that a senior doctor had ordered the test without telling him

The electrophysiology attending physician arrived — the one who had just spoken to Mrs. Morris on the phone and met Mrs. Morrison the night before. But Mrs. Morris's face was already hidden by surgical drapes, and he did not pause to greet her. The procedure began.

Soon after, an electrophysiology charge nurse noticed that no patient named Morris was on the schedule. She questioned the second doctor, who said, "This is our patient." The nurse backed off.

Back on Mrs. Morris's floor, a senior doctor who had begun looking for her called electrophysiology to find out why she had been taken there. Only then was the mix-up discovered, and the procedure aborted.

Mrs. Morris recovered. She did not sue. She was even magnanimous, noting that at least the test had shown that her heart was fine.

How could it have happened?

Dr. Chassin and Dr. Becher identified 17 separate errors. Doctors and nurses failed repeatedly to check the patient's identity. When she objected to the procedure, no one took her seriously. Nurses and doctors disregarded the absence of a written order or signed consent form, which should have been red flags. Though Mrs. Morris finally did sign the form, she could not have given truly "informed" consent. Indeed, she later told an interviewer that she had been awakened from a deep sleep that morning, and did not even remember having signed the consent form.

Neither language barriers nor accents caused the mix-up, Dr. Wachter said.

Whether long hours and fatigue played a role is not known, Dr. Chassin and Dr. Becher said, though the nurse who "zoomed in" on Mrs. Morris was finishing her shift and may have been in a hurry to go home. They also note that with shorter hospital stays and increasing subspecialization in medicine, patients are more likely today than in the past to be treated by doctors who have never seen them before.

Underlying the cascade of errors, Dr. Chassin and Dr. Becher said, may have been "a culture of low expectations," in which hospital staff had gotten used to poor communication, a lack of teamwork, sloppy record keeping and a patchwork of computer systems that did not allow one department to transfer a patient's records to another department. Mrs. Morris observed that her name on her hospital bracelet was printed in tiny letters and buried in a mass of other data; she wondered if someone would have noticed her name if the type had been bigger.

The hospital quickly set up systems to make sure that workers checked the identity of their patients and did not perform procedures unless written orders for them were recorded in the patients' charts.

"These are good first steps," Dr. Chassin said. "But we were not thrilled with the thoroughness of the reactions at the hospital. They did not seem to address the communication and teamwork failures. We urged them to pay much more attention to the informed consent failure. That was clearly a line of defense that was very porous in this case."

Dr. Chassin said some doctors elsewhere thought the case had little relevance to them. That view, he said, fails to recognize a major problem. "Crummy communication is ubiquitous in large institutions," he said. "The same teamwork and communication failures will lead to mistakes in other parts of the hospital."

Some patient safety advocates warn people that they must be vigilant in the hospital — marking the leg to be operated on and the one to be left alone, for instance, or having a family member or even a private nurse present.

On the one hand, Dr. Chassin said, that makes sense. On the other, he said: "That's absurd. Why should we have to rely on patients to protect themselves? Hospitals ought to be the safest places in the world."

Olubunmi Olayinka QCC 2023.

 

DEAD WRONG: MISTAKEN DEATH DECLARATION.  

The topic of wrongful declaration of death upon someone is broad and has many facets to it, no matter the angle at which we are looking at it from, it will always remain very scary and sounds so unbelievable. It is sufficient to say that wrongful death declaration is a betrayal of ethical trust on the part of our healthcare professionals. Even though the patients and their family may have a share of the blame as well as we examine what could have possibly gone wrong for such a grievous error to occur, how did it happened and what led to it. 

 

There are several news stories of someone wrongfully pronounced dead by paramedics or EMT nearly every few months in the United States, whenever we hear of such news in the media, our skin shrink with fear and anger. At first it would sound unbelievable, but with evidences, it became such a bitter pill of truth to swallow. What comes to one’s mind at such a moment was “Who made the declaration in the first place, is he or she not a qualified health professional, and was there no clinical standard for arriving at such conclusion? There is no gainsaying that there are definitely some people who were wrongfully declared dead but actually woke up in the grave, coffin sealed, six feet below, buried! 

 

Declaration of death on someone who is not dead is like handing them a death sentence without an option of fine or parole. One would think an issue of such extreme importance ought to have  a standard criterion to be followed by the coroner or whoever the declaring healthcare professionals is. In some of the cases cited below in this report, can we say the declarant has any standard or criteria for any of the declaration? If all the required criteria was  confirmed and clinically checked, then what went wrong? How come dead Alice came alive a few hours into internment?  

 

While claiming that no one is actually monitoring the counts, team of reporters on Channel 4 Washington reported that 2019 social security report declared that between 7,000 to 12,000 wrong death pronouncements are still being corrected each year. There are several cases of people pronounced dead by the medics or the physician who later woke up either at the funeral home or while lying in state. Arguably, such coming back to life happens to be timely, how about those that did not wake up on time before interment? or those that has to be buried shortly after death pronouncement according to their religious practice? What becomes the faith of such people? There are many bizarre cases of  “Lazarus syndrome” in the United States and beyond. 

 

Related Cases

1.     A woman was declared dead by Chicago Southfield Firefighters only for the patient to be found alive hours later by the funeral home staff that was getting her reading for embalmment. https://www.firelawblog.com/2020/08/30/michigan-medics-licenses-suspended-by-state-following-mistaken-death-pronouncement/ In this case, one could point out that the medics was not patient enough in declaring her dead, they did not follow a thorough due process in ensuring that the patient is clinically dead. 

 

2.    Jose Ribeiro da Silva, 62, a Brazilian, was discovered by the funeral home worker to be awake and breathing in his body bag 5 hours after he has been pronounced officially dead and death certificate handed to his family. https://nypost.com/2022/12/05/man-discovered-alive-in-body-bag-after-being-declared-dead/   

3.   It was a case of bad timing for Walter Williams a 78 years old Mississippi resident that the coroner confirmed was breathless and lifeless, he signed all the paper works and certified him dead and sent to funeral home only for him to move in the body bag, he was found breathing when checked. He was sent back to the hospital and released a few days after. When the coroner was asked what went wrong, he said Mr. Williams’ case has taught him a lesson. Now the question is what if he had woken up in the grave? https://www.cnn.com/2014/03/13/us/mississippi-walter-williams-dead/   

4.     Stephen Hughes wrote on his article titled “Being declared dead while still alive” about another case of an 81-year-old woman that was declared dead in a New York Nursing home only to wake up at the funeral home hours later and another 66 years old dementia woman declared dead by the Nurse only for her to start gasping for air in the body bag at the funeral home. Being declared dead when you're still alive—why these very rare events occur (medicalxpress.com)   

5.     This might account for a very sad case reported from Honduras. A pregnant teenager was thought to have died from shock after hearing gunfire in her neighborhood. She was heard screaming within her tomb a day after her funeral. It is quite possible that she had woken up after a prolonged fainting. Being declared dead when you're still alive—why these very rare events occur (medicalxpress.com)   

    See here https://www.everplans.com/articles/8-people-who-were-mistakenly-pronounced-dead for several other cases as the ones above, some dated back as far as 1997 spanning between patients of few days old to patients in their 90s.    

  I quite agree with Mike McEvoy in his article titled “Dead Wrong” “ Perhaps some formal training in death pronouncement would help pre-hospital providers avoid such humiliation.” The issue is turning the health care professional into a laughingstock and a profession once well respected is becoming a shameful and untrustworthy one. It is however good to point out here that this issue did not start today, people being buried alive concerns prompted the state of New York to pass legislation in 1899 requiring death pronouncement by a physician. Meaning there was such cases way back then. Fast forward to over one hundred years later, one would expect that with all the medical technological advancement, such error would have become a thing of the past. However, consistent standards for pronouncement of death were actually not developed until 1981.  The report, "Defining Death on the Medical, Legal, and Ethical Issues in the Determination of Death," was published by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. That report remains today the basis for death pronouncement in the United States, and also describes the criteria in existence at the time in other countries.  

SO, WHAT GOES WRONG  According to this ethical standard for determining human death established in 1899, and developed in 1981, death pronouncement can no longer based on traditional presumptive signs of death like unresponsiveness, apnea, cyanotic and cold skin, fixed pupils, or lack of carotid pulse. It  should be based on some stringent criteria like complete brain dead and some detailed physical examination. Such sophisticated medical equipment like ECG machine, Oximeter that are able to measure in low flow rate should be used to confirm physical examination findings with some crucial laboratory tests. After their research on similar topic, Leah M Schuppener and her team said “Despite many diagnostic medical advances, recent studies still report autopsy to reveal major missed diagnoses in roughly 17.7%–29% of cases. Even in cases in which autopsy was not performed, review of death certificates and corresponding medical records by autopsy pathologists reportedly reveals certification errors in up to 48%–96% of cases, of which 34%–51% are major errors”.  Death pronouncement ought not to be a decision made in a rush, because this is a decision that has to do with human lives as it comes to end. Hence the steps taken in making such an important pronouncement must be detailed, meticulous and completely ethical. Mike said in his report, and I quote “EMS providers don't pronounce brain death, nor does a lone physician in the middle of the night. Such decisions take time, require laboratory testing, and should be made by physicians with experience in assessing the brain, such as a neurologist.” But here's the warning: complicating conditions may resemble death. Drug intoxication has the ability to produce complete cessation of brain function and can be completely reversible. Total paralysis can also closely simulate death. Medication overdose, and several other sedative medications has the capacity to make human brain go into a limbo, and that could deceive medical personnel into making an erroneous death declaration. 

 

WHEN THIS HAPPEN TO YOU 

So, what happens if you are pronounced dead but are still alive? How often does it happen?  

Maris Fessenden reported on Smithsonian magazine in 2015 that “in 2011, the Office of the Inspector General conducted an audit of the Death Master File, and found that, from May 2007 to April 2010, 36,657 living people (12,219 per year) had been prematurely added, nulling them legally dead. After probing deeper, officials estimated that between 700 and 2,800 people were erroneously declared dead every month since the list’s inception. Over the file's 35-year history, the Inspector General suspects that more than 500,000 Americans have been affected”. 

Leah M Schuppener and her team commented in their article “Death Certification: Error and Intervention” stated that Death certification are the basis from which disease prevalence data and national morbidity and mortality data are derived in the United States. Thus, death certification accuracy is key in ensuring that governmental prioritization of public health priorities and allocation of health funding for a multitude of conditions such as coronary heart disease, dementia, and various infections to name a few is appropriate.  

Data management in the US is known to be highly connected and form the basis for which social benefits and records of citizens are being effectively managed. Therefore, when someone is declared dead and certificate of death issued on that person, the department of social security administration and is notified, the individual record is updated as “DECEASED” meaning all social benefits to such person stop immediately. All social benefits, payments, medical insurance, every governmental record in respect of that individual is shut down. So, being dead while alive is exceedingly difficult. Maris Fessenden said in their article above and I quote “Being dead makes it extremely hard to do the things needed to live. Americans have been told they are actually dead while trying to get a new driver’s license, retirees have waited for checks that never came they needed to pay for vital medications and while trying to open a bank account. People who rely on their social security benefits are especially vulnerable.”   Blake Ellis at CNN reports on the experience of Laura Brooks, a 52-year-old mother of two who was on permanent disability due to her severe depression. Ellis writes: When she went to the Social Security office in January 2001, she found out she was declared dead on Dec. 6, 2000. To correct this, she had to submit the pay stubs she was receiving from a program that helps people on disability get back to work. Even then it took two months, and she wasn’t able to receive the disability payments she had missed while "dead." Citation: https://www.smithsonianmag.com/smart-news/about-12200-people-are-erroneously-declared-dead-every-year-us-government-180955549/ The psychological effect of such an error could be devastating on the patient and their family, especially when it was an outright mistake on the part of the medics or physician on whom so much confidence has been entrusted. 

WHAT NEED TO BE DONE: The big question is “whose duty it is to confirm and pronounce death of an individual and patients? And is there certain statutory training and qualification to attain before a healthcare professional is qualified to declare someone’s death? Also is declaring death and signing the death certificate done by same person? While going through Maris Fessenden’s article, she mentioned that a Nurse pronounced the 66-year-old  woman with dementia dead. Does it mean that anyone can declare death? If there is a due process to be strictly followed before death can be pronounced, then why is it not being followed strictly. Why are health care professionals, whom so much is entrusted hurriedly rushing people they swear to care for into grave? 

Should death declaration be a course in our curriculum in the school of medicine or healthcare sciences? And  should it be a stand-alone profession? So that when healthcare professionals has formed their opinion on any death instance of any patient, such qualified professional (for the purpose of this report let’s say they care called “Death Certifiers)” is invited to examine the body and declare that the patient or individual is officially clinically dead and sign the death certificate. So that if there is an error in that aspect, the declarant is held responsible. Penalty such as license withdrawal, fines and various degrees of jail term will make these professionals do a thorough and diligent job, saving the whole health care system this embarrassment.  

 

 

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