Prologue to Anatomy of Medical Errors: The Patient in Room 2

By Donna Helen Crisp | 07/12/2016

More than a narrative, 
Anatomy of Medical Errors: The Patient in Room 2 shines light on the dysfunction that underpins many hospital organizations, especially teaching hospitals, including silencing of the patient, provider arrogance, flawed coordination of care, poor communication, and lack of ownership for outcomes.
 

“My tongue will tell the anger of my heart or else my heart, concealing it, will break.”
–The Taming of the Shrew, Act 4, Scene 3

No one ever acknowledged or apologized for the medical errors that changed my life. I came out of a long coma and off the ventilator in a surgical intensive care unit (SICU) at a large teaching hospital with no idea where I was, much less what had happened to me. Although temporarily psychotic and hallucinating, I was somehow able to form one important rational thought: I had to survive and get out of the hospital so I could discover what almost killed me. Then, I had to share my story so others might learn from my tragedy. I did not realize it would take years to learn how I ended up unconscious and dying in a hospital for weeks instead of coming home the day after admission as planned.

Anatomy of Medical Errors bookAlong the way, I learned the truth about medical errors inside hospitals. The Institute of Medicine’s (IOM) 1999 report, To Err Is Human, generated a national conversation when it reported that 98,000 people die each year because of medical errors in hospitals (Kohn, Corrigan, & Donaldson, 2000). The initial reaction from the medical community was disbelief, dispute, and argument over the numbers. However, hospitals eventually became less critical of this terrifying statistic, though they did little to adequately address the problem that has continued to grow worse.

A 2012 report (Andel, Davidow, Hollander, & Moreno) published in the Journal of Health Care Finance suggested that preventable medical errors might cost the U.S. economy as much as $1 trillion each year in lost human potential and contributions, an estimate much higher than patients’ direct medical expenses, whether they died or lived.

A 2013 article by James in the Journal of Patient Safety suggested that preventable hospital medical errors had become the country’s third leading cause of death, after heart disease and cancer—an estimated 440,000 hospital patients died each year from preventable errors. In a transparent system, actual numbers would likely be much higher.

On July 17, 2014, a U.S. Senate Subcommittee on Primary Health and Aging declared that “medical harm in this country is a major cause of suffering, disability, and death, as well as a huge financial cost to our Nation” (U.S. Senate, 2014, para. 12), and that hospitals had been too slow to make improvements. Peter Pronovost, MD, PhD, FCCM, of Johns Hopkins University, testifying at the hearing, reported that although there had been some progress, thousands of patients were still dying unnecessarily from infections, preventable blood clots, adverse drug events, falls, overexposure to medical radiation, and diagnostic errors.

The Senate hearing referenced other reports concerning the impact of medical errors on segments of America’s patient population:

  • A 2010 Department of Health and Human Services report that stated 180,000 Medicare patients die each year from preventable hospital adverse events
  • A 2011 finding by the Centers for Disease Control and Prevention, which estimated that 722,000 patients in U.S. acute care hospitals acquired an infection (1 in 25), resulting in at least 75,000 deaths that year (Magill et al., 2014)

In addition to patients who die from hospital errors, thousands more suffer serious complications from such errors. Preventable medical errors are expensive, both in human suffering and dollars spent. The Senate hearing estimated the financial cost of injury and death due to such errors to be in the billions of dollars each year (U.S. Senate, 2014).

American hospitals need to declare war on preventable adverse events. Yet how can hospitals accomplish this when, as I believe, the simplest practices—like good handwashing—are often ignored or poorly performed, thus increasing the patient’s risk for infection (O’Connor, 2011)? Or when, as happened to me, patients and their families are kept in the dark and not told about the preventable errors that caused injury or possibly death to them or a loved one? Or when, as I experienced, hospitals remain silent, failing to take responsibility for or even acknowledge—much less apologize for—avoidable errors that are committed in environments where fear of financial loss often supersedes the patient’s or family’s right to know?

I believe it will be difficult, if not impossible, for hospitals to shift from a paradigm of corporate interest and financial health to one that makes patient safety the highest priority; as long as a hospital’s money engine runs the system, patient safety may be compromised without anyone ever knowing.

Every day, innocent patients are unknowingly pitted against the power and secrecy of a healthcare system run by the hospitals, insurance companies, and, largely, doctors. Most hospital patients who were victims of preventable hospital medical errors continue to be further victimized within a system that encourages silence by the responsible parties, contributing to ignorance and complicity in a system most people mistakenly believe to be better than it is. Financially, it is in the best interest of hospitals to maintain their code of silence.

I went into a hospital for healing and came out more wounded than before. I believe it is incorrect, even foolish, to trust that doctors and nurses will necessarily honor our safety and well-being at all times. Inasmuch as we can be advocates for our healthcare services, we need to be proactive and skeptical—and question and verify what is happening to us. Assumptions are often unconscious. Fear impedes critical thinking. Anxiety narrows perspective.

Sadly, it can be difficult, if not impossible, to be our own patient advocate in a place where we are surrendering ourselves to the safekeeping of mostly strangers at a time when we are vulnerable, hurting, and afraid. Even if a trusted family member is present, that person may not have the knowledge and fortitude to oversee his or her loved one’s care, to ask the right questions, and to go up the chain of command, especially when the nurse is unable to perform as advocate. So, where does that leave suffering patients? What are we to do?

Having lain in a bed dying, existing in a coma on a ventilator, suffering from psychosis, living in bewildered confusion inside a broken body and wounded spirit—tended to by many nurses, doctors, aides, and students—I know firsthand how it feels to be powerless, hopeless, and fearful in a hospital: to be betrayed by the very professionals who are supposed to heal you, to be seen as an object or task to be handled, instead of a suffering individual who needs compassionate care. I used to take care of patients like me.

Inside a huge medical center, my life as a patient was centered in my psyche; I sensed whether a caregiver viewed me as a body to handle or as an individual whose body was broken. It was the exception when someone saw me as a real person who was suffering and alone. Long after I left the hospital, I learned that while I was in the SICU, everyone had referred to me as “the patient in Room 2.” Since official room numbers were too long to use, staff referred to patients by their room order along the hall—the patient in Room 2, the patient in Room 11, and so on. The following year, as I awaited my bus on a cold winter evening after teaching my ethics class, I struck up a conversation with a young woman dressed in scrubs who was waiting for the same bus. I asked if she was a nursing student. “Oh no,” she replied, “I’m a nurse.” When I asked where she worked, she said, “in the surgical ICU.” Suddenly, before I could identify myself as having been a patient on that unit, she exclaimed, “Oh, you’re the patient in Room 2!” A few weeks later, while she and I were again waiting for the bus, another nurse approached us at the bus stop. The first nurse called out, “Hey, this is the patient in Room 2!” Then the new nurse came up to look at me and exclaimed, “I took care of you for 2 weeks!” She did not recognize me awake and without my tubes and machines. That is how I began to think of myself as the patient in Room 2.
 
As a nurse and teacher—and as the patient in Room 2—I felt compelled to write this book, to use my story to shine light on hospital dangers and a broken system that needs to be drastically improved. Even though I taught and worked in various hospitals before I became a patient, I had no idea that preventable medical errors happened so frequently or that hospitals often value money over truth-telling.
 
It is impossible to know how many preventable medical errors occur, because deaths caused by medical errors are unmeasured. Talking about preventing such errors takes place in confidential hospital meetings where only those in attendance hear the details. In their 2016 analysis of medical errors, Martin Makary and Michael Daniel, both from the Surgical Department of Johns Hopkins University School of Medicine, explain how the Centers for Disease Control and Prevention compiles the annual list of the most common causes of death:
 
The list is created using death certificates filled out by physicians, funeral directors, medical examiners, and coroners. However, a major limitation of the death certificate is that it relies on assigning an International Classification of Disease (ICD) code to the cause of death. As a result, causes of death not associated with an ICD code, such as human and system factors, are not captured. The science of safety has matured to describe how communication breakdowns, diagnostic errors, poor judgment, and inadequate skill can directly result in patient harm and death (p. 1).
 
The authors outline three strategies to reduce deaths from medical care:
  1. Make errors more visible when they occur so their effects can be intercepted.
  2. Have remedies at hand to rescue patients.
  3. Make errors less frequent by following principles that take human limitations into account.

Makary and Daniel also write that, when death results from medical error, “both the physiological cause of the death and the related problem with delivery of care should be captured” (p. 2).

It is my hope that this book will enlighten readers and lead to greater awareness of what happens in hospitals—so they can protect themselves before becoming patients.

Donna Helen Crisp,JD, MSN, RN, PMHCNS-BC, is retired from the University of North Carolina School of Nursing in Chapel Hill, where she was an assistant professor. She now works part time as a nurse and is planning her next book.

Information on purchasing Anatomy of Medical Errors: The Patient in Room 2

DO YOU HAVE A STORY?
Do you have a story of surviving preventable medical errors or adverse medical events? Or do you know someone affected by, or who died from, medical errors or adverse medical events? If so, please send the story to Donna Helen Crisp at thepatientinroom2@gmail.com.

References:
Andel, D. M, Davidow, S. L., Hollander, M., & Moreno, D. A. (2012). The economics of health care quality and medical errors.Journal of Health Care Finance, 39(1), 39-50.

James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital care.Journal of Patient Safety, 9(3), 122-128. doi: 10.1097/PTS.0b013e3182948a69

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000).To err is human: Building a safer health system.Washington, DC: National Academies Press.

Magill, S. S., Edwards, J. R., Bamberg, W., Beldavs, Z. G., Dumyati, G., Kainer, M. A. ... Fridkin, S. K. (2014). Multistate point-prevalence survey of health care-associated infections.New England Journal of Medicine, 370(13), 1198-1208. doi:10.1056/NEJMoa1306801

Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US.BMJ. doi:10.1136/bmj.i2139

O'Connor, A. (2011), September 1). Getting doctors to wash their hands.The New York Times.Retrieved from http://well.blogs.nytimes.com/2011/09/01/getting-doctors-to-wash-their-hands/?_r=0
 
U. S. Senate. (2014, July 17).More than 1,000 preventable deaths a day is too many: The need to improve patient safety(Senate Hearing 113-787). Washington, DC: Government Printing Office. Retrieved from https://www.gpo.gov/fdsys/pkg/CHRG-113shrg88894/html/CHRG-113shrg88894.htm
 

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