Why doctors make medical mistakes and how we can prevent them

We did a show about medical mistakes and the 200,000 deaths they cause every year. Our guests, Brian Goldman and David Goldhill, concentrated on how acknowledging mistakes would be good for patients, doctors, and our entire health care system.

We also heard from a lot of ideas from our audience about why doctors make mistakes, how we could help stop errors from being made, and how they were affected by a doctor’s mistake.

Hambdiscus:

My father died as a result of a misdiagnosis of a ruptured stress ulcer, bleeding to death internally over a period about a week. His doctor was an 82-year old who was showing signs of senility but because he was one of my father’s closest friends, my father trusted him explicitly and even though he was not felling better, followed the doctor’s ll-considered treatment and advice.

I came away from this sad experience with three thoughts.

One, a doctor should not be viewed as a friend, particularly a close friend. The doctor is a professional with specialized knowledge and skills and your relationship with him should be kept on that level.

Two, doctors, like mechanics, make mistakes when they diagnose an illness or injury. If, after following the doctor’s advice you get worse, it is time to raise a bit if hell and insist upon a reevaluation of the diagnosis.

Lastly, as doctors age, they should be required to prove that they are still mentally qualified to make medical decisions with at least a certification every few years.

My father’s death was absolutely preventable.

Liz

My husband had to have a feeding tube replaced. The doctor doing the surgery punctured his intestines in doing so; my husband suffered greatly in recovery until someone finally decided something was wrong. The original doctor never apologized to us: however the surgeon who did the repair job told us or implied that he would address the error with him. My husband’s children did not want me to file a complaint with the hospital and I did not do it…I have regretted never complaining to the hospital and to the doctor who caused great pain and suffering.

How do these errors happen? Our audience says that the health care system needs to allow their doctors and nurses to speak up and that patients need to stay on their toes.

From A NP:

We need a system that respects each member of the health care team and treats them as equals. It’s the hierarchical set-up — with the physician as the boss — that often leads to a fear of speaking up when an error is about to occur. We can learn a lot from the aviation industry with respect o this.

From Annah B:

I have been a Contracted employee for years working in the Twin Cities medical institutions. Across the board I have noticed that provider-to-patient ratio is a constant problem. How can you expect a provider not to make mistakes when they may only have 5 minutes with each patient?

From Barb:

We the people need to take a role in our visits. Ask questions. If the medicine seems wrong, ask. Find out what meds you are to take and when you are to take them, so if someone comes in to give you something at the wrong time, ask about it. Don’t be afraid to question in a nice way. Doctors and nurses have a lot on their plates and sometimes things happen.

And two people gave examples of how other industries deal with errors:

Dave

In software development, mistakes are expected (we call them “bugs”, or, more correctly, “defects.”) We develop testing procedures and have independent testers look at applications to identify and classify defects, sending a resolution request back to the original developers.

We need a culture change in health care, and I think the only way to accomplish this is to change the economic model from rewarding quantity to rewarding quality.

Seph

In aviation, they’ve been encouraging safety reporting, including honest mistakes – in exchange, the reporter is granted a degree of immunity. This system has helped make aviation, especially commercial flying, an extremely safe form of travel. Why wouldn’t that approach work in medicine?

What do you think we can do to prevent medical errors? And I’d love to hear your stories about how you’ve worked with your doctors or nurses to better control your health care.