Medical Errors: My Child's Story
Early on Saturday, Sept. 12, 1998, my wife, Kim, in just the 24th week of her pregnancy, gave birth to our daughter, Katelyn Mary.
Katie weighed in at just 1 pound 4 ounces. She didn't cry when she was born. Babies who arrive that early don't have the lung capacity to make sounds.
Immediately upon birth, Katie was whisked to the neonatal intensive care unit, where she would stay for four months as doctors and nurses fought to save her life. From the delivery room, my wife was wheeled back to her bed, where it was soon discovered that the area around her cesarean section had been infected with E. coli bacteria, preventing the wound from healing. She would stay in the hospital, undergoing various treatments including painful skin debreeding, in which dead and infected skin around her wound was scrubbed off, for another three weeks.
Kim and I have often said that Katie probably would not have survived without the skill and dedication of the doctors and nurses who took care of our daughter. But as good as these doctors and nurses were, over the course of the months that followed when Kim and Katie went in and out of the hospital and their doctors' offices, mistakes were made by these well-intentioned health-care professionals.
In the neonatal ICU, the nurses missed a feeding the doctor ordered for Katie; since she weighed just 20 ounces, a missed meal could have dropped her blood sugar level low enough to send her into a coma. And then there was the pharmacist who incorrectly filled Katie's prescription for an antibiotic with a bottle of phenobarbital, a sedative that can harm respiration.
Kim also ran into problems. A failure to pass along a verbal order for a special painkiller resulted in a skin removal procedure being done without any anesthetic.
Many of the errors stemmed from poor order processing and record-keeping, tasks usually considered mind-numbingly mundane. Paperwork may be the bane of office life, but in medicine, it is the staff of life. Patients' lives depend on the accuracy of the information collected, stored and processed, whether on paper or electronically.
The Institute of Medicine, an arm of the National Academy of Sciences, said in a now-famous 1999 report that medical treatment errors were killing about 98,000 people per year. The report said that up to 7,000 deaths were attributable to medication errors, many of which result when a pharmacist misreads a doctor's order.
What's even more shocking is that in the five years since the institute issued its report, little has been done.
For instance, hospital patient safety committees, in the wake of the report, embraced the concept of computerized drug orders. If doctors typed their orders on screen, it would virtually eliminate mistakes due to illegible handwriting. To date, only 2.7% of U.S. hospitals have order entry systems that doctors use, according to KLAS Enterprises, a research company specializing in health-care information technology.
Part of the reason may be the fact that, according to a Henry J. Kaiser Family Foundation briefing on medical errors, only 5% of doctors think medical errors are a top health-care concern. (The non-profit Kaiser Family Foundation is not associated with Kaiser Permanente or Kaiser Industries.)
And it's just as shocking to find that in most hospitals, error-tracking is voluntary.
The Kaiser report went on to pose questions such as:
I would like to add my own question: Why are we asking these questions?
Yes, there should be mandatory medical error reporting. Yes, Congress should mandate clear targets for medical error reductions. Yes, there should be incentives for medical error reductions and penalties for institutions in which those errors arise. And, without question, Congress should mandate the installation of electronic drug ordering systems.
Baseline's study of the efforts by Cincinnati Children's Hospital Medical Center found that useful systems can cost millions of dollars—as much as $15 million just to install a drug order entry system, according to Nir Menachemi, an assistant professor and director of the Patient Safety Institute at Florida State University.
Not only are these systems expensive, but it's difficult to get new software packages to work with existing patient care information systems. And it's a headache to get doctors, long accustomed to barking orders at nurses, to sit down at a computer terminal to place pharmacy orders.
But as Cincinnati Children's Hospital has demonstrated, the effort is worth it. The organization's patient care information system has led to a reduction in medication-order and dispensing errors from almost 120 a month in February 2003 to about 90 a month in February 2004. And the system cut the time it takes to deliver drugs from the pharmacy from close to 2 hours in 2002 to less than 1 hour in 2003.
My daughter is now a healthy, vibrant, smart 5-year-old. My wife, who was still feeling the effects of her injuries more than a year after she left the hospital, has fully recovered.
Kim and I recently read a journal she started keeping after Katie was born. It's filled with details of heroic deeds by doctors and nurses to save our child. And it lists the mistakes that were made during that year. It jogged many memories—including the fact that Katie's prescription error was caught by Kim, a registered nurse, who eyeballs the labels of all the family's medications. We confronted the pharmacist in this case, who was shocked at his own mistake. But I'm pretty sure he didn't report the incident.
In fact, probably the only complete record of the medical errors made during my daughter's first year is my wife's journal. It's time for hospitals and doctors to take record-keeping just as seriously as proper diagnosis.