Jennifer Daley, MD, senior vice president of clinical quality and chief medical officer for Tenet Heathcare's 78 hospitals, can tell you how easy it is for a situation like Richard Flagg's to occur, because it happened to her. Twenty-five years ago, when she was a first-year resident at Boston's New England Medical Center, a patient with breast cancer was having trouble breathing. Another doctor had left instructions on the sign-out sheet to drain the left side of her chest. "I had been on duty 22 hours straight and caring for 60 patients. I was tired and had too much responsibility," Daley recalls. "It was the perfect recipe for disaster."

Daley picked the left side of the patient's chest looking at her face-on, "but when I turned her around, because I was so tired, I didn't accommodate for that and so, in my mind, left became right." As soon as Daley put the needle in, she says, "I knew I'd done it wrong and withdrew it. Fortunately, the woman didn't sustain any significant damage. I took it incredibly personally, as most physicians do. I was very upset and felt terribly responsible. The patient didn't know because, back then, we never told them."

Wachter attributes the Morris-Morrison mix-up to a scenario that should scare us all. "It was one of those crazy, overflow days," he explains. "It's tricky to keep track of who is where at any given time, especially given the rapid turnover of patients and hospitals' ever-increasing propensity to run fast and full in their desperation to meet the bottom line."

By and large, notes Donald Berwick, MD, president and CEO of the nonprofit Institute for Healthcare Improvement in Cambridge, Massachusetts, and a member of the committee that compiled the IOM report, "errors are not due to bad or careless doctors and nurses. Most problems are wired into the system."

The death of young Jesica Santillan underscores the point. "The surgeon in her case was considered one of the best," says Wachter, "but he screwed up, assuming the donor's blood type had been verified. If all you do is focus the blame on him, however, you have not peeled back the layer of the onion that made the mistake possible. You have to take on the system that had no double checks built in for this incredibly crucial piece of information."

Beyond all the technical and logistical glitches, many believe that the most pernicious problem is lack of communication-between doctors, nurses, administrators, and patients. This breakdown is responsible not only for many fatalities and injuries but also for a profession that is, at its core, emotionally dysfunctional. When something goes wrong, the medical team involved too often remains entrenched behind a wall of silence, which makes tragic situations even more painful and perpetuates the occurrence of mistakes. In a few progressive hospitals, a true revolution is taking place as doctors are acknowledging their errors and saying they're sorry. By and large, however, most continue to adopt a defend-and-deny position, which inherently contains a sad irony: Only by acknowledging errors can they ever be prevented.

Months before Richard Flagg finally saw the pathology report that showed no evidence of a tumor in his right lung, "five doctors, including the surgeon, had also seen the report, but none of them ever bothered to call and tell Richard," says Charles Rock, his attorney. "They wanted to protect their profession's image."

Another common communication error led to tragedy in the case of Lewis Blackman. In November 2000, Lewis and his parents believed they had little to worry about when he checked into the respected Medical University of South Carolina Children's Hospital in Charleston. A healthy 15-year-old, he was having elective surgery for a condition-a sunken chest-that was basically cosmetic.

After the operation, Lewis received large doses of Toradol, a powerful pain medication that carried clear warnings about its risks of causing perforated ulcers and kidney failure. On his third day in the hospital, Lewis was suddenly stricken with excruciating pain in his upper abdomen. A nurse told the boy's mother, Helen Haskell, that gas was to blame and did nothing. Over the next 30 hours Lewis's belly grew hard and distended, his skin became pale, his temperature and blood pressure dropped while his heart rate soared. The staff caring for him, however, missed that he was suffering from side effects of the Toradol and was in grave peril.


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