Medical Errors, Past and Present

Nov. 27, 2007— -- It's every surgical patient's worst nightmare. And it happened three times at Rhode Island Hospital.

According to Associated Press reports, the hospital was fined $50,000 and reprimanded by the state Department of Health on Monday after the third episode this year involving a doctor performing brain surgery on the wrong side of a patient's head.

Fortunately, the chance of a serious mistake occurring during any given medical procedure is small. But these errors do happen -- a fact evidenced by this recent news.

Not all hospitals share this track record. But due to the sheer number of medical procedures that take place in the country every year, even isolated incidents add up. A report last April by the independent health care-ratings company HealthGrades found through Medicare hospitalization records that nearly 3 percent of patients in the nation's hospitals risk experiencing hospital errors.

The report further suggested that those patients who experience an error in treatment or care at a hospital have a one in four chance of dying from the mistake. In total, HealthGrades said, 247,662 patients studied between 2003 and 2005 died from potentially preventable problems.

And the Institute of Medicine estimates that each year 1.5 million patients suffer from mistakes with the medicine they're given.

"Every error that results in harm to the patient is something health care providers and hospitals struggle to prevent," says Nancy Foster, the American Hospital Association's vice president for quality and patient safety policy. "We want no one to be harmed in the course of their care, yet we do know that [errors] happen."

Foster says hospitals nationwide have implemented a number of measures to keep mistakes from occurring, such as marking the sites on a patient's body that will be operated on before surgery, and teamwork training for surgical personnel.

Still, open records of the errors in some states have brought to light a handful of serious hospital errors that have endangered some patients -- and cost others their lives.

According to a report last month by the Boston Globe, Massachusetts hospitals reported 36 instances since January 2005 in which doctors performed the wrong procedure or operated on the wrong site or wrong patient.

ABC News, too, has been following high-profile cases of medical errors. The examples that follow are a just a few of the very rare -- but very serious -- errors that have affected the lives of patients over the last 15 years.

The third time is far from a charm for Rhode Island Hospital. On Friday, a neurosurgeon at the hospital began a surgery by drilling the right side of the patient's head, even though a CT scan showed bleeding on the left side, according to local reports.

The resident reportedly caught his mistake early, after which he closed the initial hole and proceeded on the left side of the patient's head. The patient was listed in fair condition on Sunday.

"We are extremely concerned about this continuing pattern," noted David R. Gifford director of Health for Lifespan Corp., which runs the hospital in a written statement, according to the Associated Press. The AP reported Tuesday that the hospital has been fined $50,000 for this third transgression.

The case echoes of a similar mistake last February, in which a different doctor operated on the wrong side of a patient's head. And last August, an 86-year-old man died three weeks after a surgeon at Rhode Island Hospital accidentally operated on the wrong side of his head.

In the July incident, the man, whose name was not released, was admitted to Rhode Island Hospital on July 30 when doctors found he had blood between his brain and his skull from a fall sustained days earlier. The neurosurgeon who performed the emergency procedure mistakenly opened the right side of the man's head rather than the left side.

Once the mistake was discovered, the surgeon operated on the correct side. Three weeks after the operation, however, the patient died. Medical examiners have yet to determine whether the error contributed in any way to the patient's death.

Following a two-month suspension of his license, the surgeon was once again allowed to practice Oct. 10, according to a spokesperson from the Rhode Island Department of Health.

Dr. Mary Reich Cooper, vice president and chief quality officer for Lifespan Corp., said a number of safety measures had been put into place since that incident, not only for the neurosurgery department but for other specialties as well. These measures include procedures to ensure surgeons have access to a patient's records and charts at all times. However, only the ongoing investigation into the most recent incident at the hospital may determine what went wrong in the most recent incident.

What should have been a blessed time for actor Dennis Quaid and his wife, Kimberly Buffington, turned into a time of anguish and anxiety, after their newborn twins nearly died from an accidental overdose of a blood-thinning drug.

Zoe Grace and Thomas Boone received a massive overdose of the blood-thinning drug Heparin — used to keep IV catheters from clotting — some time after their Nov. 12 birth at Cedars-Sinai Medical Center in Los Angeles. The incident was first reported by celebrity Web site TMZ.

While not mentioning the Quaids specifically by name, the hospital released a statement Tuesday that confirmed that three of its patients had received 1,000 times the prescribed Heparin. Instead of 10 units per millimeter, the patients received 10,000 units.

"This was a preventable error, involving a failure to follow our standard policies and procedures," the hospital said. "Although it appears at this point that there was no harm to any patient, we take this situation very seriously."

But though these errors are preventable, they do happen. Medication orders for kids in the hospital have an error rate of about 6 percent -- and the majority of these errors are with IV drugs.

And not every patient is lucky enough to survive such an overdose. Last year, a similar medical mistake killed three premature babies at Methodist Hospital in Indianapolis, including Dawn Jeffries and Demaya Nelson.

"You just don't make a mistake on nobody's kid. They're supposed to be professionals. That's not professional," said Demaya's father, Dejuan Nelson, after the deaths.

In that case, the nurses grabbed vials of Heparin for adults instead of Hep-lock for children. The two medications are nearly identical and the pharmacy technician mistakenly stocked the cabinet with the wrong vials.

"Ultimately the blame for our errors falls upon the institution. This is a system failure," Methodist Hospital CEO Sam Odle said at the time.

In what was perhaps the most publicized case of a surgical mistake in its time, a Tampa, Fla. surgeon mistakenly removed the wrong leg of his patient, 52-year-old Willie King, during an amputation procedure in February 1995.

It was later revealed that a chain of errors before the surgery culminated in the wrong leg being prepped for the procedure. While the surgeon's team realized in the middle of the procedure that they were operating on the wrong leg, it was already too late, and the leg was removed.

Court documents show that both of King's legs were unhealthy, and even the healthier leg of the two would likely require amputation eventually. Still, as a result of the error, the surgeon's medical license was suspended for six months and he was fined $10,000. University Community Hospital in Tampa, the medical center where the surgery took place, paid $900,000 to King. The surgeon involved in the case paid an additional $250,000 to King.

In the 12 years since the incident, according to a statement released by the hospital, the episode prompted a new wave of precautions, including a double back-up identification system, a computerized error-tracking system, patient safety measures, and the placement of Unit-Based Patient Safety Officers throughout the hospital to monitor and educate doctors and other medical professionals.

In yet another case of a wrong-sided operation, surgeons mistakenly removed the healthy right testicle of 47-year-old Air Force veteran Benjamin Houghton.

Houghton had been complaining of pain and shrinkage of his left testicle -- concerns that prompted doctors to schedule surgery for June 14 to remove it due to cancer fears. However, according to Associated Press reports, the veteran's medical records suggest a series of missteps -- from an error on the consent form to a failure on the part of medical personnel to mark the proper surgical site before the procedure.

The error, which took place at the West Los Angeles VA Medical Center, spurred a $200,000 lawsuit from Houghton and his wife.

When contacted, the medical center had no comment on the progress of the case or on subsequent safety measures that were implemented at the hospital.

In June 2006, a surgeon at the Milford Regional Medical Center in Massachusetts mistakenly removed an 84-year-old woman's right kidney instead of her gallbladder.

According to local news reports, the surgeon made the error after misinterpreting test results that were intended to help guide him in operating amid internal bleeding and swelling. Complicating the situation was the fact that the women's organs were in such poor condition that it was only after the kidney had been removed and was being examined after the surgery that doctors learned the organ was not the patient's gallbladder.

Fortunately, the patient recovered, and even though her gallbladder remained intact doctors determined that it would not need to be removed after all. The Massachusetts Board of Registration initially suspended the surgeon's license, but he was later allowed to practice surgery on a probationary basis for a five-year period -- a probation that is still in effect.

A spokesperson from Milford Regional Medical Center said that in the time since the incident, the hospital has taken steps to ensure patient safety in the operating room to reduce the likelihood of such a mistake happening again. A lawsuit was never filed in connection with the incident.

On Feb. 23, 2003, 17-year-old Jésica Santillán died after receiving the wrong heart and lungs in a transplant operation Feb. 7. After a rare second transplant operation to attempt to rectify the error, she suffered brain damage and complications that subsequently hastened her death.

Santillán, a Mexican immigrant, had come to the United States three years before to seek medical treatment for a life-threatening heart condition. The heart-lung transplant that surgeons at Duke University Hospital in Durham, N.C., hoped would improve this condition instead put her in greater danger; Santillán, who had type-O blood, had received the organs from a type-A donor.

The error sent the patient into a comalike state, and she died shortly after an attempt to switch the organs back out for compatible ones failed. The hospital blamed human error for the death, along with a lack of safeguards to ensure a compatible transplant.

Dr. James Jaggers, the transplant surgeon who made the error, issued a statement the day following Santillán's death accepting responsibility for the mistake.

In the four years since the incident, Duke University Hospital has implemented a number of changes to ensure patient safety. Gail Shulby, the head of patient safety for the hospital, notes that Duke instituted a system of double-checking blood types and organ suitability before organ acceptance and before the organ was transplanted -- a change that also affected United Network for Organ Sharing policy on organ acceptance.

Additionally, Duke created a new chief patient safety officer position and established a patient council that provides the hospital with patients' perspectives regarding issues of safety and quality. The hospital also reorganized and strengthened its patient safety infrastructure, creating interdiscplinary teams that monitor patient safety and quality at services levels.

According to reports, Duke reached an agreement on an undisclosed settlement with the family. The terms of this settlement were sealed, but they included a stipulation that neither the hospital nor the family is allowed to comment on the case.

Last April, a West Virginia man's family said inadequate anesthetic during surgery allowed him to feel every slice of the surgeon's scalpel -- a trauma they believe led him to take his own life two weeks later.

Sherman Sizemore, 73, was admitted to Raleigh General Hospital in Beckley, W.Va., Jan. 19, 2006 for exploratory surgery to determine the cause of his abdominal pain. But during the operation, he reportedly experienced a phenomenon known as anesthetic awareness -- a state in which a surgical patient is able to feel pain, pressure or discomfort during an operation, but is unable to move or communicate with doctors.

Some medical experts say between 20,000 and 40,000 patients every year may experience anesthetic awareness, which can be brought about by physician error or faulty equipment.

According to a complaint by Sizemore's family, anesthesiologists administered the drugs to numb the patient, but they failed to give him the general anesthetic that would render him unconscious until 16 minutes after surgeons first cut into his abdomen.

Tony O'Dell, the attorney representing Sizemore's family says the case is still in progress and no further details could be provided. However, Sizemore's daughters appeared on ABC's "Good Morning America" in May to discuss their side of the case.

"Dad had said he said, 'You know I felt them cut me open, I felt that,'" his daughter, Sheila Dickens, says.

And this experience, his daughters say, turned Sizemore into a different man.

"There was something there that changed him so profusely that he was not the same man," says Lenoka Graham, Sizemore's other daughter. "He was scared to be alone, he had nightmares. ... [He] thought he was falling in a hole."

Raleigh General Hospital had no comment on the case when contacted.

Donald Church, 49, had a tumor in his abdomen when he arrived at the University of Washington Medical Center in Seattle in June 2000. When he left, the tumor was gone -- but a metal retractor had taken its place.

Doctors admitted to leaving the 13-inch-long retractor in Church's abdomen by mistake. It was not the first such incident at the medical center; four other such occurrences had been documented at the hospital between 1997 and 2000. Still, such cases are uncommon; a press release issued by the hospital following publicity over the event estimated that such cases represent one in approximately 12,000 cases per year at the medical center.

Fortunately, surgeons were able to remove the retractor shortly after it was discovered, and Church experienced no long-term health consequences from the mistake. The hospital accepted full responsibility for the error and agreed to pay Church $97,000.

And in the seven years since the incident, notes the center's medical director Dr. Edward Walker, a number of initiatives at the hospital have significantly lessened the chance of future mistakes of this kind. In particular, the retractor incident spurred routine counting of instruments and sponges before and after all surgical procedures.

When Nancy Andrews, of Commack, N.Y., became pregnant after an in vitro fertilization procedure at a New York fertility clinic, she and her husband expected a beautiful new addition to their family.

What they did not expect was a child whose skin was significantly darker than that of either parent. Subsequent DNA tests suggested that doctors at New York Medical Services for Reproductive Medicine, the now-defunct Park Avenue clinic whose services they sought, accidentally used another man's sperm to inseminate Nancy Andrews' eggs.

The couple has since raised Baby Jessica, who was born Oct. 19, 2004, as their own, according to wire reports.

But the couple still filed a malpractice suit against the owner of the clinic, as well as the embryologist who allegedly mixed up the samples Oct. 14, 2005. In the suit, the couple accused the owner of the clinic and the embryologist of negligence.

Darrie Eason, a 35-year-old single mother on Long Island, N.Y., filed a lawsuit against a CBLPath medical laboratory earlier this month after a mix-up at the lab prompted her to have both her breasts removed.

In 2006, Eason received a report indicating she had breast cancer, and she said she was told she should have both of her breasts removed. She said she sought a second opinion, but the next doctor she consulted relied on the same set of records as the first and reiterated her cancer diagnosis.

A state report blamed the mix-up on a technician who admitted cutting corners while labeling tissue specimens. Both this technician, as well as the doctor who signed off on Eason's diagnosis, no longer work for the company, according to statements by CBLPath's chief executive William Curtis.

When contacted, CBLPath spokespersons declined to comment on the case. However, they cited a statement issued by the company Oct. 3 that noted that CBLPath cooperated with New York state authorities to ensure all appropriate patent care and safety measures were in place.

"After their investigation, the New York State Department of Health found no systemic problems, and no deficiencies were cited against the lab," the statement reads.

"I remember the words, 'You don't have breast cancer, you never did,'" Eason told ABC's "Good Morning America" Oct. 4. "I have a philosophy that you have to laugh to keep from crying, so I try to laugh as much as I can."

But the outcome of Eason's case will no doubt leave her -- and many other women -- worried over the safeguards routinely used at such labs.

"Second opinions are good, but second biopsies are better," she said.

Reporting from "Good Morning America" was also used in this report.