elizabeth grimball
Photo: Nigel Parry
In September 2000, Richard Flagg, a rugged Vietnam vet, checked into Meadowlands Hospital in Secaucus, New Jersey, to have a small benign tumor removed from his left lung. His surgery was the first on the schedule the morning after the Labor Day holiday, and the staff seemed rushed and running behind. But Flagg was optimistic; a CAT scan had indicated only a small portion of the lung would have to be removed, and in a few weeks the 60-year-old could return to his physically demanding job as a barge captain and a fully active life.

In the operating room, the table and instruments were set up for left-side surgery, the anesthesia was administered, and Flagg drifted into unconsciousness.

The next day when he regained clarity, he was stunned at the sight of tubes extending from the right side of his body. There must be some mistake, Flagg told the surgeon. But the doctor explained he had found a hemorrhaging tumor in the right lung and thus had saved his life.

Over the next several months, however, Flagg's health deteriorated. He never returned to work, had trouble walking, and was eventually tethered to an oxygen tank 24 hours a day. Still believing what the surgeon had told him about his right lung, Flagg happened to receive a copy of his medical records when his primary group of doctors filed for bankruptcy. After reviewing the records, he called his girlfriend, sobbing. On top of the stack was the pathologist's report that showed no evidence of a tumor in his right lung.

Flagg hired an attorney and sued. Desperate to regain his health, he consulted a cancer specialist, who delivered more bad news: His diseased left lung could no longer be operated on. Flagg didn't have enough lung capacity and wouldn't survive the surgery, the doctor said.

In September 2003, the tumor in his left lung ruptured and Flagg died.

Richard Flagg's story is horrific and difficult to fathom but hardly an isolated case. Incredible as it sounds, wrong-site surgeries account for an estimated one in every 15,000 operations. Meadowlands Hospital settled Flagg's case last May for more than $1 million (a spokesperson called the incident "regrettable" and says they have since upgraded their safety standards). As to what happened, it appears that a string of medical errors led to the devastating outcome, with something surprisingly simple leading the list. Flagg's attorney, Charles Rock, believes "the surgeon simply misread the CAT scan film by flipping it around, so that left became right." When the doctor entered the operating room, the incision site had not been marked on Flagg's chest, and no one on the surgical team verified with one another, or with Flagg, the procedure to be performed. So the surgeon ordered his patient repositioned and proceeded to cut out a portion of his healthy right lung.

Newspapers are full of stories about other terrible medical mistakes. In 2003, at Duke University Medical Center, 17-year-old Jesica Santillan died after the heart and lungs from a donor with the wrong blood type were implanted in her chest. In January 2004, sedation complications were to blame in the death of best-selling novelist Olivia Goldsmith (The First Wives Club), who died while undergoing routine cosmetic surgery at the prestigious Manhattan Eye, Ear & Throat Hospital. Not long after, at the same hospital a second woman was killed by an excessive dose of lidocaine, a common local anesthetic.

Without disclosing the hospital or patient names, in 2002, Robert Wachter, MD, chief of the medical service at the University of California, San Francisco Medical Center, reported an astonishing patient-mix-up case in the journal Annals of Internal Medicine. At a "teaching hospital," a 67-year-old woman identified as Joan Morris was recuperating in her room after a brain aneurysm procedure when nurses wheeled her into the catheterization lab. Mistaking her for "Jane Morrison," a 77-year-old patient who was scheduled to have an invasive cardiac test, doctors proceeded to stop and start Joan Morris's heart several times, only to discover their blunder an hour later. Luckily for Morris, she emerged from the ordeal undamaged.

Each year more than 33 million Americans walk into the forbidding and unfamiliar world of a hospital and put their lives in the hands of doctors, nurses, technicians, and administrators. And each year, according to a 1999 landmark report issued by the Institute of Medicine (IOM), an independent organization that advises the government on health policy, these medical professionals kill as many as 100,000 patients because of mistakes, most of which are clearly preventable. That's more deaths than from breast cancer or AIDS or even automobile accidents. Doctors operate on the wrong patients, amputate the wrong limbs, take out organs from the wrong side of the body, fail to monitor life-threatening conditions, misdiagnose, and administer fatal drug overdoses. The startling IOM report, titled To Err Is Human, was a wake-up call on the deadly extent of medical errors; it also noted that they cause serious and permanent injuries for thousands more patients. In a system designed to protect people, with the specific mandate to do them no harm, how have things gone so wrong?

"The short answer is, over the past 50 years, medicine has become increasingly complex, and this progress has created far more opportunities for error," explains Wachter, coauthor, with Kaveh Shojania, MD, of the 2004 book Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. The once simple fee-for-service doctor-patient relationship has been eroded by burdensome paperwork, managed-care hassles, advances in complicated technology, more handoffs of patients from one set of doctors to another, and the long-standing problem of fatigue among residents and interns. A large number of unnecessary deaths-more than 7,000-are due to medication errors, mostly from illegible handwritten notes and prescriptions, confusion over drugs with similar names, and doctors' lack of knowledge about the appropriate use of a drug.

Above: Elizabeth Grimball, 15, is paralyzed because doctors dismissed her complaints as "psychological."
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.
The experience had such a profound effect on both of them that they cofounded Medically Induced Trauma Support Services, a support group for patients, their families, and the healthcare professionals involved in adverse medical events. The correlation between disclosing errors and patients' decision not to sue has been borne out in some hospitals. The Veterans Affairs Medical Center in Lexington, Kentucky, for instance, adopted a policy of "extreme honesty" in 1987, and instead of their malpractice costs soaring, according to a study, the facility had one of the lowest payout rates compared to similar facilities. "Until we can establish openness and honesty in healthcare," says Van Pelt, "it will be hard to make progress. Without openness, you can't identify problems and fix them."

Although most doctors aren't willing to come clean, some are anxious to unload. When Dan Shapiro, PhD, a clinical psychologist at the University of Arizona College of Medicine, first invited physicians to participate in group seminars, he says, "I expected them to talk about patients who had taken advantage of them or made them angry by challenging their authority. But I was wrong. They came instead to talk about the medical mistakes that continued to haunt them."

Over the past four years, Shapiro has conducted seminars with more than 400 doctors, who, assured of anonymity, write heartfelt letters to patients they have wronged or harmed but, unlike Van Pelt, don't send them. "For many of these doctors, the pain and regret never goes away," says Shapiro. One physician, who had missed a cancerous tumor in the lung of a patient, wrote to the man's widow: "I'm so sorry we killed your husband. I want to cry with you, but I can't. But I'm crying in my soul, in a place where no one else can see. I was trained to do that, you know. Always, where no one else can see."

Remorse, however, does not constitute an apology; nor does an unsigned, unsent note. If the letter-writing exercise helps relieve some of the doctors' guilt, it does nothing for the patients they've hurt, or those who mourn the ones they've killed.

It's been five years since the Institute of Medicine brought the dark side of America's healthcare system into the spotlight. Since then no definitive data has come out to determine whether the number of medical errors has gone up or down. One study published in 2004 found an average of 195,000 hospital deaths a year resulting from medical errors, but many experts don't consider the findings scientific because it was done by a commercial company—Health Grades, which gives quality ratings for hospitals and nursing homes. An independent survey of more than 2,000 adults last year, however, did carry some weight. Conducted by the Harvard School of Public Health, the U.S. Agency for Healthcare Research and Quality, and the Henry J. Kaiser Family Foundation, this survey suggests that one out of three Americans is the victim of a medical error—personally or via a family member. For 8 percent of the population, the mistake proves fatal.

Still, the IOM report has stimulated some improvements in patient safety, and a few of them are coming from surprising sources. Last year UCSF Medical Center and a few other top teaching hospitals invited groups of commercial airline pilots to train doctors and nurses in teamwork and communication principles. "The pilots were flabbergasted by the lack of standardization within hospitals," notes UCSF's Wachter. "For example, they found that OR rooms are all set up differently, even in the same hospital. Pilots can walk into any of United's 737s, and they're all set up the same way—why would you want it otherwise?"

Increasingly, aviation parallels are serving as a model for patient safety for a simple reason. "If pilots make mistakes, they go down with the plane," Wachter points out. "In medicine we don't have that kind of personal incentive."

Nurses in many hospitals now routinely ask patients their first and last names before administering a medication or wheeling them into an OR. Doctors, for the most part, have stopped using confusing abbreviations on prescriptions, and the new so-called Universal Protocol means there are detailed guidelines for confirming patients' identities, clearly marking surgical sites, and verifying the procedures to be performed. Whether doctors will actually follow such recommendations, however, is another matter. "Many physicians don't like to be told what to do, and they perceive these requirements as slowing them down," Wall of Silence's Gibson points out. "They don't want to take the two minutes for pre-op verification. It's a change that is costless, and yet the value is priceless."

To counteract the fatigue factor, new regulations have reduced the number of hours residents can work each week from more than 100 to 80. But according to a recent study in The New England Journal of Medicine, critical care interns putting in more than 80 hours a week have double the rate of attention failures during night shifts than those working an average of 65 hours.

Gibson, who is also a senior program officer at the Robert Wood Johnson Foundation, worries that "no meaningful change will come until there is accountability in medicine and the culture of silence is dismantled."

Some victims aren't waiting around. After her son died, Helen Haskell channeled her grief into activism and introduced a bill now under review in South Carolina's legislature. Called the Lewis Blackman Hospital Patient Safety Act, the bill would require hospitals to give patients the telephone number of the attending physician and inform them when they're being treated by residents. "Any one of these provisions could have saved our boy's life," Haskell says.

In the end, the correction of many medical errors will come down to patients themselves. "Patient empowerment is key," says Robert Wachter. Fifteen-year-old Elizabeth Grimball knows this all too well. "I would tell people to trust their instincts," she says, "because you know your body better than anyone."

That means, if you have a hunch that something is wrong or not being addressed, speak up, get a second opinion, and if necessary, change doctors. "Sparing a doctor's feelings is not worth the price if that physician is wrong," adds Elizabeth's mother, Leila Grimball. "Medical negligence is painful for everyone, but it is the patient and his or her family who bear the brunt of the tragedy. And the heartache never totally goes away."
Haskell pleaded for an experienced doctor, but the residents and nurses never summoned one. When her son's blood pressure became too faint to read, inexperienced first- and second-year residents concluded the monitoring devices were broken, and after a few hours, Lewis died. He had bled to death internally.

Haskell watched in agony as he "went from perfect health to death in a few days due to a basic lack of communication. I think everyone was reluctant to disturb the chief doctor at home because they were afraid he'd get angry."

In medicine "there's a pecking order and a sink-or-swim culture that creates a climate of fear," says Rosemary Gibson, a leading healthcare innovator and the coauthor of Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans. And that anxiety often prevents residents from seeking help when they are in over their heads.

Elizabeth Grimball has lifelong paralysis because of another insidious aspect of the medical culture-the arrogance of some doctors who don't listen to their patients. In 1997, when she was 8 years old, Elizabeth told her doctors, who were from the University of South Carolina School of Medicine, in Columbia, that her kidney cancer, which had been in remission, was back. They didn't believe her. Though the girl insisted the pain in her legs was severe, and an MRI was ordered, the doctors dismissed her complaints as psychological and canceled the test.

Over the next three months, Elizabeth's symptoms worsened and she lost 20 pounds. Frantic, her mother, Leila Grimball, continued to call the doctors. "Every time I told them she was getting worse, they kept saying it was psychological. I began to think my child was going crazy. I thought the doctors would rule out the chance of relapse with a child who had a history of cancer, so I accepted what they said."

Elizabeth was ultimately admitted to an outpatient psychiatric unit where, after she had seizures, an MRI proved she'd been right. The cancer had spread. A tumor in her brain was causing the seizures; another in her spine was putting pressure on nerves and creating the pain in her legs. A lawsuit against the medical school asserting that the delay in diagnosis resulted in permanent paralysis from the waist down was settled a year later. Elizabeth, now 15, is confined to a wheelchair for the rest of her life.

"And for what?" she asks rhetorically. "I'm having to suffer through no fault of my own. The doctors made me feel like I wasn't there. My body was telling me one thing, and the doctors were saying something else. If they had just listened to me, they would have found the cancer. They know they made a mistake, but they can't acknowledge or really accept it."

In Lewis Blackman's case, the surgeon in charge did take full responsibility, for which Helen Haskell is grateful. Still, none of the residents said they were sorry. "Where the anger comes in," she says, "is when doctors don't apologize, don't explain, and implicitly trivialize the life of the victim."

One doctor who dared to break the professional hush and speak the truth about a mistake he'd made found something remarkable and unexpected. In 1999, at Brigham and Women's Hospital in Boston, anesthesiologist Frederick van Pelt, MD, prepared to administer a combination of powerful drugs to his patient Linda Kenney. The 37-year-old mother of three was having ankle replacement surgery.

Inadvertently, Van Pelt put the anesthesia into a vein. Kenney had a seizure and went into full cardiac arrest. Doctors barely saved her life and worried she might have brain damage, but she eventually made a full recovery.

Van Pelt says, "I felt so terrible about what had happened that I wanted to be accountable and open about how it had affected me." Kenney's husband, furious at Van Pelt, kept him from speaking directly with his wife, as did hospital administrators. "They try to minimize communication between doctors and patients, not necessarily to hide an error but because of the fear of litigation," Van Pelt says.

So he wrote Linda Kenney a letter. "I said I was sorry and apologized for causing the outcome. I told her that the event had had a dramatic impact on me as well. It really shook me up." Van Pelt invited her to call him, giving her his home telephone number, but it took six months before she finally did. When they met at a coffee shop, Van Pelt recalls, "I basically asked for forgiveness, and she gave it to me." Kenney, who decided not to sue Van Pelt or the hospital, says, "That's when the true healing began."

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