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Alex AsayEnglish 1010December 7, 2012

Medical Errors

The number of medical errors that occur is shocking; however, most Americans are

unaware of the vast numbers that have resulted in the United States. Most patients trust their

health care physician and do not opt for a second opinion. Hospitals are currently not required

by law to report all medical errors. There have been incidences where doctors attempt to cover

their mistakes by putting a Band-aid on the problem, knowing full well that the patient will

encounter suffering from that error, at some point after they are discharged. Research from

Harvard Medical School discovered, “at least 44,000 people and perhaps as many as 98,000

people die in hospitals each year, as a result of medical errors that could have been prevented…

preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-

vehicle wrecks, breast cancer, and AIDS” (Kohn, 2000). Because medical errors are at a

significantly high rate, government health care officials should insist on making changes, such

as, teamwork and communication training, the implementation of a mandatory error reporting

system, and increase public awareness.

Teamwork and Communication

Any of these solutions could aid in decreasing the amount of medical errors that occur.

Teamwork and communication is the first recommendation that would help avoid errors.

Training in teamwork and communication should be a standard in every medical school. Each

health care facility should set up its own training geared towards a surgical procedure where a

life threatening decision needs to be made immediately. The airline industry has such training

where important decisions are not left up to one person and few hospitals have adopted this

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model. “The model aims to improve communication, develop attitudes conducive to teamwork

and minimize the hierarchy by encouraging input from every team member regarding “near

miss” or potential adverse events or errors (Alberti, K.G., 2001). If every medical facility

implemented this model then no one in the operating room would have full and complete power

to make life altering decisions. Had this model been in place at a local hospital several years ago,

then many lives including Debbie’s, told in the following true story would not have ended in

death.

Debbie’s Story

The true story told by Richard Greaves, is about a woman who died from a medical error

because her doctor was extremely narcissistic and demanded full and complete control in the

operating room. The surgeon altered surgical protocol, ignoring pleas in the operating room

from the medical staff and disregarding the sanctity of Debbie’s life. He wanted to increase his

famous reputation by trying out an alternative surgery. Because of this behavior he ended up,

making a wrong incision which would have resulted in her wearing a pace maker for the rest of

her life. The surgeon did not want this mistake to end up on his record so he simply ordered Mr.

Greaves, the Perfusionist in charge of the heart/lung machine to turn down the blood flows,

knowing full well this would eventually cause her death. The doctor then kept Debbie alive on a

ventilator for 48 hours so that the mistake would not be his, however, it would divert attention

toward other hospital caretakers. If the surgeon would have put aside his egocentric behavior

and listened to the medical staff who pleaded with the doctor to not turn down the flows, Debbie

would be alive today (Greaves, 2012).

All health professionals share a commitment to work together to serve the patient’s

interests. The best patient care is often a team effort, and mutual respect, cooperation, and

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communication should manage this effort. The medical ethics manual favors teamwork amongst

the medical team. Teamwork and communication training is a viable and necessary solution to

reduce error rates (American College of Physicians, 1998).

Error Reporting System

After the teamwork and communication training has taken place, the addition of an error

reporting system would also decrease medical errors. If video recording devices were in place

during surgical procedures, then staff members would not have fear of losing their jobs if they

stand up to their superiors. A video recording system would accurately display behaviors of

those in the room. In cases of death, these videos could be reviewed to insure that a medical

error was not the cause of the death. If in fact it was, then the specifics of these errors should be

reported. “…surgeons may be protecting their results in a reporting system by avoiding higher

risk cases if they feel that their results are drifting in a range that might attract unnecessary yet

easily avoidable scrutiny” (Keogh, 2004). In Debbie’s case, her doctor would have thought twice

about changing protocol and risking Debbie’s life in the name of research.

Public Awareness

Last of all, Public awareness may be an important key in causing changes to take place.

Patients can become more involved with their own healthcare. If the public became more aware

of the high number of medical mishaps, then they would more than likely demand a reduction in

medical errors. If patients believed that surgeons are only human and errors can be committed,

the likelihood of immediate trust would be lessened. There are numerous excellent doctors who

already incorporate safe practices, however, there are enough adverse events that have occurred

in which the public should be informed. If patients would take an active role in their own health

care, gaining knowledge of the surgeons and their procedures, and choosing only those doctors

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who have good tract records, doctors who consistently error would be forced to leave their

occupations. The Annals of Internal Medicine is taking a stand toward better health care by

encouraging those involved in or knowing of a medical error, to share their stories with them.

They will in turn publish them in their magazine in hopes to make a difference in promoting the

systems and changes needed to make health care safer. In addition, Utah State Department of

Health states, “patient’s complaints actually drive the implementation of Utah regulations on

patient safety in hospitals. The state investigates all patient complaints” (Utah Dept. of Health,

1995-99). Getting involved by reporting any and all medical errors, could make an impact and

perhaps force hospitals to provide safer medical institutions. Since Debbie’s death in 1997, the

Utah State Department of Health has made some improvements. In 2001, the department

proposed that hospitals set up voluntary patient safety reporting programs. This is a step in the

right direction; however, these reporting systems should become mandatory.

Conclusion

Medical errors are a serious problem and there is not one quick easy fix, however,

making some changes in standard procedures such as communication and teamwork, creating a

reliable reporting system, and increasing public awareness, these erroneous errors can be

reduced. If any one of these potential solutions had been the protocol at the hospital where

Debbie had her open heart surgery, then Debbie may still be alive today. A reporting system

would have allowed Debbie the knowledge that her doctor did not have a good reporting record

as well as the fact that the doctor would have not performed a risky surgery instead of the nearly

fail proof surgery, if he knew that it would be reported. If there were video cameras in Debbie’s

operating room, then it would have revealed everything that went on that day. If there were more

public awareness, perhaps Debbie would have been more involved in her own healthcare. Any

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one of these solutions may have created a different ending for Debbie’s life and the life of many

others who have either lost their life or been drastically injured due to a medical error. Knowing

that the potential of a medical error is great, we owe it to ourselves and our families to do our

due diligence on the doctors and medical facilities that we choose. We as a public need to ask

these medical facilities if they have a reporting system in place and if they do, then ask to look at

your doctor’s surgical record. In addition, ask the medical facility if they have a teamwork

protocol or is one person left making the final decision. Doing just these three suggestions could

save your life or the life of a loved one.

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Works Cited

Alberti, K.G. “Medical Errors: A Common Problem,” BMJ, Vol. 322, March 2001, pp. 501-2.

Retrieved November 1, 2012 from <http://www.ncbi.nlm.nih.gov/pmc/articles/

PMC1119719/>.

American College of Physicians, “Ethics Manual,” 4th ed. Vol 128, 1998.

Greaves, Richard, Interview by author, November 2012.

Kohn, Linda T., et al. To Err is Human: Building a Safer Health System, The National Academy

of Sciences Press, Washington, 2000.

Keogh, Bruce, et al, “The Legacy of Bristol: Public Disclosure of Individual Surgeons’ Results,”

BMJ, Vol. 329, August 2004, pp. 450-454. Retrieved November 1, 2012 from

<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC514215/>.

Utah Department of Health. Utah Health Data Committee. Center for Health Data. Adverse

Events Related to Medical Care Utah: 1995-99. Salt Lake City, Utah.

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Alexandra Asay

Annotated Bibliography

November 5, 2012

Work Cited

Alberti, K G. “Medical Errors: A Common Problem.” BMJ 322 (2001): 501-2. Retrieved

November 1, 2012 from <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1119719/>.

This is an article from BMJ, significant English journal. Officials in England are

wondering how big the “medical error.” Problem is. The article states that there is very little

research on the matter; however, a known study was conducted in Colorado and Utah. Findings

suggest that it is indeed a problem and gives some reasons why and medical errors might be

reduced. I found this source intriguing because it uses statistics in the U.S. and more specifically

Utah to realize that medical errors are a significant problem. The source also gives some great

ideas and suggestions on how medical errors can be reduced, which is significant in “why does it

happen?” and “how can it be prevented?”

Kohn, Linda T, Janet M. Corrigan, and Molla S. Donaldson. To Err is Human: Building

a Safer

Health System. Washington: National Academy Press, 2000. From the book, To Err is

Human: Building a Safer Health System, it states that “At least 44,000 people and perhaps as

many as 98,000 people die in hospitals each year as a result of medical errors that could have

been prevented.” These are the results of one of two studies done in Colorado/Utah; the other

study was done in New York. This report was put out by Institute of Medicine and caught

President Clinton’s attention where he immediately “issued an executive order instructing

government agencies” to oversee health-care programs aimed specifically at reducing the

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number of fatalities due to medical errors. This program not only informs patients on how they

can obtain quality health care and telling them what they need to know, however, it also gives

recommendations to reduce medical error mishaps by 50 percent. The report was brought on by

an enormous number of complaints and thus an investigation into medical errors took place.

Significant investigations have been pursued based on the conclusions of these research findings.

This is a good source because it is an actual study regarding medical errors in Utah and gives

some important statistics.

Greaves, Richard. Personal interview. September 2012. This interview revealed some

personal

stories about surgeon’s behavior in the operating room. Richard is a Perfusionist and has

had 12 years experience running the heart lung machine at all the hospitals in Salt Lake City that

perform heart surgery. His personal accounts range from stories of heart surgeons yelling and

violently shaking the patient’s sternum, using profanity towards the patient to surgeons covering

up mistakes made by killing the patient. Richard believes that there is little to no democracy in

the operating room that is necessary in order to reduce medical errors. He also accounts for the

narcissistic behavior as a significant problem leading to medical errors and calls this behavior

“the O.R. family illness,” or the “Captain of the Ship Rule.” I was completely unaware that

doctors could have a lack of conscience when it comes to patient care until I heard some of the

stories in this interview. Richard has good ideas as to how medical errors of this type can be

prevented. This interview has been important to my research and has helped substantiate some

of my suspicions with the question, “what goes on behind closed doors?”

Thomas, Eric J., et al. “Incidence and Types of Adverse Events and Negligent Care in

Utah and

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Colorado.” Ovid Technologies, Inc. 38(3) March 2000: 261-271.This was another study

done in Utah and it outlines the basis of their research, the questions that were asked physicians,

nurses, etc., the people that were involved in the interview process and their training. Then it

outlined their basic findings. “Our study found that morbidity and mortality associated with

iatrogenic injury remains high, mostly because of operative complications and adverse drug

events.” It gives some psychological theories as to why errors happen and how they can be

prevented. This is significant in the research of medical errors because it gives actual statistics of

medical errors, how they achieved those statistics and specific solutions on what needs to be

done.

Utah Department of Health. Utah Health Data Committee. Center for Health Data.

Adverse Events Related to Medical Care Utah: 1995-99. Salt Lake City, Utah. Retrieved

November 1, 2012 from < http://health.utah.gov/hda/reports/adverse_events.pdf.>

This is a report put out by the Utah Department of Health regarding the significance of

“adverse events” due to medical errors. This research was put together by a team of experts in

various fields of study, with a high level of credentials. It discusses it’s limitations to the report

for example “our inability to separate adverse events prior to hospitalization from those

occurring during hospitalization.” It also discusses the result from their findings, for example,

“about one in 250 hospital discharges or 4, 248 patients had a ‘misadventure of surgical and

medical care.” Then the report concludes, despite their limitations, this data adds to the evidence

presented in the Institute of Medicine’s report, “To Error is Human,” that the healthcare system

can be made safer.” The report also gives the patient some guidelines on how they can become

safer in this environment. This report supports the study, “To Err is Human,” performed

specially in the states of Utah and Colorado.

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Alex Asay

November 21, 2012

Issue Summary

The medical industry is one of the largest industries in the world. Many lives have been

saved and many more individuals will continue to live because of the ongoing research and

development of modern medicine. The medical industry in the United States is considered to

have some of the world’s best medical break-through and health care professionals. However,

with the amount of money that is spent each year to the medical industry, it should be a top

priority but that has not been the case. Research conducted by Harvard Medical School has

found that “at least 44,000 people and perhaps as many as 98,000 people, die in hospitals each

year as a result of medical errors that could have been prevented…preventable medical errors in

hospitals exceed attributable deaths to such feared threats as motor-vehicles wrecks, breast

cancer, and AIDS.” (Kohn, 2000.) This study brought a shockwave over the medical industry

and a reality check.

It has taken researchers and government health care officials decades to come to

the realization that additional research on the problem of medical errors is needed. In an effort

for government health care officials to address these issues, research was done in two states,

Colorado and Utah. The state of Utah has a significant medical research foundation; therefore

the results of this research were surprising and suggest that medical errors occur in huge numbers

in these two states, as well as other parts of the U.S. This research found, “180,000 people in the

United States die each year from iatrogenic injury (caused unintentionally by medical

treatment).” (Thomas, 2000). One-third of all patients who are hospitalized in the state of Utah

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suffer an adverse event, meaning that a medical error has occurred and either death or severe

injury was the end result. The studies from Utah and Colorado attracted International attention.

In response, the Utah State Department of Health performed its own findings saying that “one in

250 hospital discharges or 4,248 patients had a misadventure of surgical and medical care.”

(Utah Department of Health, 1995-99).

In an effort to produce possible causes to the shocking numbers of medical errors,

many articles have been written suggesting a couple of guesses, such as, equipment failure,

difficult surgeries, high stress, anxiety, diagnostic errors, lack of training and so on. However,

medical errors cannot be blamed solely on constant equipment failures. Every patient is not

misdiagnosed. Not all doctors lack proper training. Although these causes may have assisted in

a few cases, however, in the research findings, they do not appear to be constant. Lack of

teamwork and communication in the operating room could be a potential cause of medical errors

to any surgical procedure. If all medical personnel in the operating room do not have the same

vision for how the standard operating room procedures are to take place, then there could

possibly be an accident waiting to happen. Particularly when a patient starts to respond

negatively and tensions become extremely high, could result in many medical mistakes by

anyone in the operating room. The following true story is an example of a medical error at a

Utah hospital, which ended in an avoidable death.

Debbie was a 37-year-old mother of four who lost her life due to medical errors.

Debbie needed double heart valve surgery, which has an extremely high success rate, requiring

only a few restless days in the hospital for recuperation. With Debbie, that would not be the

case. The surgeon altered surgical protocol, ignoring pleas in the operating room from medical

staff. Some in the operating room who opposed the physician’s recklessness were told to “Shut

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up and do as you’re told!” When asked by a staff member who was in the operating room if this

procedure was beneficial to the patient, the doctor replied, “No, there is no benefit to the patient,

it just makes it more difficult for. Trust me to make things more difficult.” The doctor described

in Debbie’s case was believed to have changed protocol because he had an interest in ground-

breaking alternative surgery to increase his already famous reputation. During an interview with

Richard Greaves, who was a prefusionist, (one who runs the heart lung machine”, hired to assist

in Debbie’s surgery, claimed, “The ability for one doctor to have the power to change procedure

without the majority consensus from the other surgeons in the room, coupled with the lack of

communication and teamwork brought on by the behavior of one powerful man, I believed

caused Debbie’s death.” Mr. Greaves believes that no single person should have sole power in

critical decision making processes. Rather, he said, “teamwork should be insisted upon when it

comes to making life altering decisions.” Unfortunately, it is not. When Mr. Greaves attempted

to direct the hospital to this idea he was told, “Either follow or leave.” Mr. Greaves decision to

terminate his employment came after more deaths like Debbie. He also states that doctor’s

behavior was a serious concern in the operating rooms where he has worked. “Too many times,

patient’s lives were in danger because of the outrage of certain doctors during surgery.” When

talking to administrators about this problem, they acted like there was nothing they could do,

according to Mr. Greaves. He was nonchalantly told, “We’ll just have to live with it.” Greaves

stated, “The problem of the tyrant became so bad, that no one wanted to work with doctors who

exhibited narcissistic behavior.” He goes on telling more about Debbie’s case and how her

surgeon tried covering up his error. The change in open heart surgery protocol, resulted in the

doctor making a wrong incision in her heart that would have made it so Debbie would have had

to wear a permanent pace maker. He didn’t want anyone to know about his mistake so he

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ordered Mr. Greaves to turn down her blood flow which caused inadequate blood flow to her

brain. She became brain dead. “For 48 hours, the doctor kept Debbie’s body alive by putting

her on a machine diverting attention toward other hospital caretakers and away from him.”

Because Debbie didn’t die in the operating room, but rather two days later, the error was not

reported.

If a reporting system were in place and made mandatory by law, everyone in the

room would be required to provide a statement of all that went on in the operating room during

surgery. This would hold everyone accountable and mistakes would be less frequent. An article

that was found complimented the airlines, it states, “the airline industry spends a much higher

proportion of revenue on training, they report all incidents with blame being minimized. This is

a habit, we should adopt.” (Alberti, 2001). He believes that the medical industry should start a

“no blame” reporting system where medical personnel can report their errors without the chance

of pointing a finger. Not only could doctors learn from each other’s mistakes, but health care

workers could report suspicious behavior and remain anonymous.

In conclusion, how the medical industry is, too many lives are at risk. There

needs to be a change whether it may be, reporting the errors, improving teamwork and

communication, making sure doctors get proper training, and so on. A report caught President

Clinton’s attention where he “issued an executive order instructing government agencies” to

oversee health-care programs aimed specifically at reducing the number of fatalities due to

medical errors. It gives patients information on how they can obtain quality health care and

making sure they know all the facts. (Kohn, 2000). It may take time to get the issue in control

but at least it isn’t going unnoticed anymore.

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Work Cited

Alberti, K G. “Medical Errors: A Common Problem.” BMJ 322 (2001): 501-2. Retrieved

November 1, 2012 from <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1119719/>.

Greaves, Richard. Personal interview. September 2012.

Thomas, Eric J., et al. “Incidence and Types of Adverse Events and Negligent Care in Utah and

Colorado.” Ovid Technologies, Inc. 38(3) March 2000: 261-271.

Utah Department of Health. Utah Health Data Committee. Center for Health Data.

Adverse Events Related to Medical Care Utah: 1995-99. Salt Lake City, Utah. Retrieved

November 1, 2012 from < http://health.utah.gov/hda/reports/adverse_events.pdf.>