10 Medical Errors That Changed the Standard of Care

We learn most from our painful mistakes. Mistakes can injure patients and land physicians in legal and professional trouble. Studying these mistakes and learning how to prevent, monitor, and respond to them, however, has changed the standards of care. By working to eliminate common medical errors, physicians can protect patients, protect themselves from lawsuits, and help lower the cost of their professional liability insurance premiums.

In 1910, when Abraham Flexner researched the state of US medical education, only 16 of the existing 155 medical schools required more than a high school education for admission. Germ theory was still disputed.

The practice of medicine in the United States is now much more standardized, thanks in large part to changes to standardization of the qualifying examinations for US-trained physicians and to medical malpractice law.

Today's standards of care are now mostly based on scientific evidence. In the past 20 years, courts have held physicians and hospitals to national standards of care rather than accepting local variations in the practice of medicine.

In 1976, Dr. Jim Styner, an orthopedic surgeon, crashed his small plane into a cornfield in Nebraska, sustaining serious injuries. His wife was killed, and 3 of their 4 children were critically injured. At the local hospital, the care that he and his children received was inadequate, even by standards in those days. "When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system, and the system has to be changed,"  Dr. Styner said.

His family's tragedy and the medical mistakes that followed gave birth to Advanced Trauma Life Support (ATLS) and changed the standard of care in the first hour after trauma.

Dr. Styner helped produce the initial ATLS course. In 1980, the American College of Surgeons Committee on Trauma adopted ATLS and began disseminating the course worldwide. It has become the standard for trauma care in US emergency departments and advanced paramedical services. The Society of Trauma Nurses and National Association of Emergency Medical Technicians have developed similar programs based on ATLS.

Judy was 39 years old when she went to the hospital for a hysterectomy. After she died on the operating table, autopsy revealed that the anesthesiologist had placed the endotracheal tube in her esophagus, not her trachea.

Today, anesthesiologists measure a patient's carbon dioxide levels -- which are much higher from the trachea than from the esophagus -- through use of an end-tidal carbon dioxide monitor.

In 1982, ABC's 20/20 ran a segment titled "The Deep Sleep: 6000 Will Die or Suffer Brain Damage." This program highlighted several cases of medical mishaps that resulted in serious injury or death. The American Society of Anesthesiologists responded with a program to standardize anesthesia care and patient monitoring and in 1985 created the Anesthesia Patient Safety Foundation.

Standard practices now include the use of pulse oximetry and end-tidal carbon dioxide monitoring for anesthetized patients. The new standards have markedly reduced the frequency of anoxic brain injury and other major complications. The push for electronic monitoring systems for patients under anesthesia caused anesthesia-related deaths to plummet from about 1 in 10,000 to 1 in 200,000 in less than 2 years.

Sally and Ed looked forward to the birth of their first child. Sally's labor was long, so her obstetrician added oxytocin to speed things up. Unfortunately, administration of oxytocin led to unrecognized fetal distress, and their newborn daughter suffered severe brain injury and cerebral palsy.

Fetal monitoring to test both uterine contractions and fetal heart rate (FHR) is now the standard of care, with a 30-minute response time from recognition of fetal distress to delivery. The purpose of FHR monitoring is to follow the status of the fetus during labor so that clinicians can intervene if there is evidence of fetal distress, as reflected by an FHR above or below the normal range of 110-160 beats/min or an FHR that does not change in response to uterine contractions.

Electronic fetal monitoring (EFM), also called FHR monitoring, was first developed in the 1960s. Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002, according to the American Congress of Obstetricians and Gynecologists (ACOG). "When EFM is used during labor, the nurse or physicians should review it frequently," state ACOG guidelines.

Bill had a seizure and crashed his car into a tree, crushing both legs. Arteriography revealed that his right leg was salvageable but his left leg was not. Unfortunately, the x-ray technician mislabeled the films, mixing left for right, and the orthopedic surgeon first amputated Bill's right leg.

Preventing wrong-site surgery became one of the main safety goals of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO). Establishing protocols became an accreditation requirement for hospitals, ambulatory surgery centers, and office-based surgery sites.

JCAHO mandates standardization of preoperative procedures to verify that the correct surgery is performed on the correct patient and at the correct site. Guidelines include marking the surgical site, involving the patient in the marking process, and having all members of the surgical team double-check information in the operating room.

Despite these efforts, wrong-site surgery occurs about 40 times a week nationwide, a JCAHO survey found. The biggest pitfall is inadequate information about the patient. The solution is a carefully standardized method of collecting information.

Tom was 12 years old when his appendix burst and he was taken to the local pediatric hospital. Three days after the appendectomy, he developed another high fever. One week later, the surgeon performed a second procedure and found that a surgical sponge had been left inside.

Postoperative sponge and instrument counts have been routine for decades. There is no single standard, although nursing and surgical organizations have developed best practices for sponge, needle, and instrument counts.

Different ways of counting sponges may be used in the same operating room even during the same case, says the Association of Operating Room Nurses. This lack of standardized practice creates opportunities for errors.

A US Department of Health and Human Services study says that this type of mistake occurs in 1 in 100 to 1 in 5000 persons. A 2008 study published in Annals of Surgery found that mistakes in tool and sponge counts happened in 12.5% of surgeries.

Nursing and surgical groups recommend that each member of the surgical team play an equal role in assuring accuracy of the counts. Recently, manufacturers have made sponges with threads visible on x-rays, radiofrequency identification systems, and bar coding to alert staff about missing sponges.

As a young child, Betty had been given penicillin, turned blue, and was rushed to the hospital. She was 15 when she got strep throat, was given penicillin, and died. No one had asked her about medication allergies.

Medical questionnaire forms have always included a space for allergies, although this became much more prominent after the Institute of Medicine report on patient safety in 1999.

In 2008, the Pennsylvania Patient Safety Advisory cited more than 3800 cases in which patients received medications to which they had documented allergies. Breakdowns in communication of allergy information include "documentation of patients' allergies on paper but not entered into the organization's computerized order-entry systems, and allergies arising during episodes of care but not documented in the medical record or communicated to appropriate staff."

Strategies to address the problem include adding visible prompts in consistent and prominent locations listing patient allergies, eliminating the practice of writing drug allergens on allergy arm bracelets, and making the allergy reaction selection a mandatory entry in the organization's order-entry systems.

Linda wasn't doing well in her first trimester. The nausea and vomiting left her severely dehydrated and with a low potassium level. In the emergency department, her nurse made a mathematical error and administered too much intravenous potassium. Within an hour, Linda was dead.

In the 1980s and 1990s, patient safety groups, including JCAHO, drew attention to the need for removal of concentrated potassium chloride vials from patient care areas. Now, almost all US hospitals have removed the drug from floor stock on patient care units. Potassium is now added to IVs by the manufacturer and is labeled.

The tragic errors that gave rise to this system change were caused by deficits in knowledge about the dangers of rapid intravenous administration of concentrated potassium or, more often, mental slips or selection errors when grabbing a vial of medication. Limiting access to this drug has reduced fatal errors.

Additional safety strategies include using premixed solutions, segregating potassium from other drugs and using warning labels, prohibiting the dispensing of vials for individual patients, and performing double-checks with a pharmacist.

Frank was 72 years old when he broke his right leg in a car accident and had to recover for a few weeks in a rehabilitation facility. The nurses didn't know that patients needed to move regularly, and Frank developed deep decubitus (pressure) ulcers. When these became infected, Frank's leg had to be amputated.

Each year, more than 2.5 million people in the United States develop pressure ulcers, notes the Agency for Healthcare Research and Quality. Bedsores can be fatal. The Centers for Medicare & Medicaid Services no longer provide additional reimbursement to hospitals to care for a patient who acquires a pressure ulcer while under the hospital's care.

The primary way to prevent decubitus ulcers is by turning the patient regularly, usually at least every 2 hours. Efforts to relieve pressure to avoid additional sores by moving the patient have been documented since at least the 19th century.

Nursing homes and hospitals now have programs to avoid development of bedsores by using a set timeframe to reduce pressure and having dry sheets by using catheters or impermeable dressing. Pressure shifting on a regular basis and the use of pressure-distributive mattresses are now common practices.

Lillian was 68 years old and weighed 250 lb when she underwent surgery to remove her gallbladder. The second day after surgery, she needed help to walk to the bathroom. Lillian's nurse, Millie, wasn't strong enough to support her and they both fell, breaking Millie's right arm and Lillian's left leg.

Historically, schools of nursing have taught students to manually lift patients using proper body mechanics, such as lifting with the legs and using correct posture. However, body mechanics are not sufficient to protect nurses from heavy weights, awkward postures, and the repetition involved in manually lifting patients, according to a position paper from the American Nurses Association (ANA).

The ANA supports policies that eliminate manual patient lifting. Safe patient-handling techniques involve the use of such equipment as full-body slings, stand-assist lifts, lateral transfer devices, and friction-reducing devices.

There is no federal legislation or regulation on safe patient handling, although several states have enacted such legislation, ANA says.

When Christy was 42 years old, her doctor discovered a large lump in her left breast. The lump should have been evident during Christy's 2 previous annual examinations if they had been complete. By the time it was diagnosed, the cancer had progressed beyond cure.

Breast examinations by the physician, teaching of techniques for breast self-examination, and recommendation of mammograms are now the standard of care.

Mammography was developed in the 1950s and became a common diagnostic tool in the 1960s. It is a key method for detecting breast cancer early, when it is easier to treat. In 2005, about 68% of all US women between 40 and 64 years of age had had mammography in the past 2 years, according to insurance studies. All US states except Utah require private health insurance plans and Medicaid to pay for breast cancer screening.

Standards for the timing of mammography vary by organization and by patient history. The US Preventive Services Task Force currently recommends that low-risk women older than 50 years receive mammography once every 2 years. ACOG currently recommends annual mammograms for all women 40 and older.

These are but a few examples of medical mistakes that have led to patient injuries or death -- and have led further to changes in the way physicians in the United States practice medicine. Recognizing that all of these mistakes could have been prevented, the federal government and various medical academies have developed guidelines for prevention and treatment of many diseases.