To err is human.
Well, not if you’re a doctor.
Even a small mistake can prove to be the biggest mistake of your life if you’re a doctor!
I’m a nurse, but I was working in the ER when a guy came in for a scratch on his neck and “feeling drowsy”. We start the usual workups and this dude’s blood pressure TANKED. We scrambled, but he was dead within 10 minutes of walking through the door.
Turns out the “scratch” was an exit wound of a .22 caliber rifle round. The guy didn’t even know he’d been shot. When the coroner’s report came back, we found that he’d been shot in the leg and the bullet tracked through his torso shredding everything in between. There was really nothing we could’ve done, but that was a serious “what the hell just happened” moment.
Once as a tired medical resident I was called to the ER to admit someone at like 3am. This bonehead had gall bladder removal a week ago and now had a surgical-site wound infection. I asked if they’d taken their post-op antibiotics they were prescribed, and they weren’t sure.
I was getting more and more frustrated with this bonehead preventing my sleep so I decided to use a “pregnant pause” interview technique, and just shut up. This usually results in either awkward silence and the patient saying “uhh what happened doctor” or awkward silence followed by some useful deep revelation.
In this case the guy hung his head low, looked at his feet through unfocused eyes, started to sniffle while his halting voice cracked “I can’t read. Never could. Didn’t know the instructions they wrote down for me and didn’t know I had medicine to buy. I didn’t ask them because I was embarrassed.”
Illiteracy haunts rural and urban places in most countries. Those folks aren’t reading this, they depend on our patience and understanding to detect and bridge that vast communication gap.
This incident has always stuck with me.
I am a pathologist.
Now there is not an exact answer for how long the HIV virus can survive inside a dead body. Probably a matter of days. But at any rate, the patient should of course always be considered infectious at the time of autopsy.
The biggest mistake I ever made was cutting myself while performing a postmortem examination of an HIV infected body.
Lucky for me I did not acquire the virus even though I easily could have.
I am doctor myself, but I am speaking here for a fellow doctor who messed up a coronary bypass.
The average non-medical person just doesn’t understand how certain things happen, and it seems unbelievable that a doctor could do a coronary bypass to the wrong artery unintentionally, by mistake. Like what happened in Dana Carvey’s case. It’s beyond a non-medical person to understand that it’s pretty hard to find a specific vessel at a specific location on the heart with the given time constrains.
I’m impressed this isn’t a more common situation.
Then, after an incident like that, people just think that the doctor should “lose their license for that!” Who cares if that physician has spent 15 years in extremely rigorous training, went hundreds of thousands into debt, and has committed his life to the profession.
My entire identity is partly wrapped into being a physician. That’s like saying a parent who makes a serious parenting mistake should simply lose their children forever (and yes, I am a parent as well). Plus, there are patient privacy laws, non-disclosure arrangements from lawsuits, and a lot of other things. I think malpractice is a wholly flawed concept. A surgeon in the following specialties has a 99% chance of being sued in his career.
My mom just retired from obstetrics and gynaecology, and told me about a time early on in her career when, while not a real medical mistake, she still almost ruined the operation.
She was performing a c-section I think, and she dropped her scalpel on the floor. Before she could think, she blurted out “oh shit” as a reaction. The mother being operated, thinking something was wrong with the baby, started panicking out of her mind.
It took a team of nurses, the husband, and the mother of the patient to calm her down. Even small mistakes like this can prove punishable for a doctor.
I know of a case on a special ward for immunosuppressed people. In this case, it was someone who had a bone marrow replacement for a rare hematological disease. She was recovering quite well. The ward had positive pressure, airlocks and other safety measures. However, that did not prevent family from sneaking in a pizza from the hospital restaurant without staff knowledge. Now pizza is not the cleanest food there is.
The patient eventually died from an opportunistic infection, because she at that time had no immune system to speak of.
Safety protocols have been updated since.
As a very young doctor in training I misdiagnosed a woman with epilepsy.
Some years prior she had sustained a gunshot wound to the frontal area, damaging the underside of one of her frontal lobes (front area of the brain) and severing an optic nerve to one of her eyes, as well as some of the muscles that rotated that eyeball. Surgery saved her life but the frontal lobe was scarred and one eye was blinded and always pointed down and at an angle away from her nose.
A few years after that she began having spells of a bizarre sensation, altered awareness, a pounding in the chest, and she had to sit down, stop what she was doing, and couldn’t speak. These were odd spells and I assumed she had developed frontal lobe epilepsy from the scar on her brain. Increasing doses of anti-seizure drugs seemed to work initially, but then the spells came back.
A couple years after my diagnosis her endocrinologist, who treated her for diabetes mellitus, checked her thyroid.
It was super-high. The spells were manifestations of hyperthyroidism. She drank the radioactive iodine cocktail which ablated her thyroid, got on thyroid replacement therapy, and felt well thereafter. No permanent harm done and she was able to come off the anti epilepsy drugs.
She was obese – not the typical skinny hyperthyroid patient – and if she developed thyroid eye disease, I couldn’t tell because her one eye was already so messed up. I see how I screwed it up, but in retrospect I have never been sure what I could have done differently, except test her thyroid at the outset of treatment.
Hence, a lot of patients – thousands – have had their thyroid checked by me since then. Every so often I pick up an abnormality and it gets treated.
The lady was an employee of the hospital where I trained and I ran into her one day; she gave me a hug and let me know how this had all gone down.
She made a point of wanting me to know she didn’t blame me “because I always seemed to care about her and what happened to her.”
I think about her, and how I screwed up her diagnosis and set back her care, almost every day. I am a much better diagnostician now but I always remember this case and it reminds me not to get cocky or be too sure that my working diagnosis is correct.
My grandmother has had diabetes for about 20 years, and takes a handful of meds to help control it. About 10 years ago she developed a persistent cough. It wasn’t bad, she said it felt like a constant tickle in the back of her throat.
She went to her doctor to find out what was going on, and he ordered a battery of tests concerned that she was developing pneumonia, lung cancer, etc. All the tests came back negative, so he prescribed a cocktail of pills to help combat it. Over the span of 5 years, she had tried about 35 different meds and none helped.
One day when she went it for a routine check-up, her normal doc was out and she saw one of the on-call residents. He looked at the barrage of pills she was on and asked why. When she explained, he replied, “Oh, the cough is a side effect of this one particular drug you’re on to regulate your insulin. If we change you to this other one, it will go away.”
It did. Face-palm.
This wasn’t a big mistake but definitely the most awkward one for me.
I was gluing up a lac on a 14-year-old girl’s forehead. Anyone who has used derma-bond before knows that stuff can be runny and bonds very quickly. I glued my glove to her face. Her mum was in the room, and I had to turn to her and say “Im sorry, I’ve just glued my glove to her face.”
I was a nurse at a hospital where I gave anticoagulant (blood thinner) to the wrong patient. Over the the next day this patient’s red blood count dropped and he ended up in ICU.
Hi, a dentist here. I was performing a simple extraction and preparing for the case when I didn’t realize that I had the x-ray flipped the wrong way the whole time. I was viewing the film backwards, and pulled out the wrong tooth. When I realized my mistake I started freaking out, only to find out that by some dumb luck, the tooth I extracted had to go as well.
For the record, this happened in dental school, so safe to say it was a learning experience. It was my first and very last time to make that mistake.
I didn’t cause this one but kind of “saved the day” as a resident that was surgically assisting. We were doing a C-section and everything was going well until it was time to take the cord blood. I am to fill up the test tube with blood and the surgeon looks at it in shock, saying the tube has one very large chunk of glass broken off of the rim.
The glass piece is nowhere to be seen. Now there is an open abdomen in front of us with blood clots everywhere, and we’re not sure but there is high probability that the glass piece is somewhere in there. So as safely as possible we are sticking our hands around to try and find this glass. If it is inside the abdomen the chance of even seeing it on Xray is minimal and the glass piece will soon dice up this patients bowels/blood vessels and God knows what else.
After around 3-4 minutes (felt like eternity) I feel an edge of something firm just inside the edge of the incision. I pull up a blood clot with the glass piece inside. It didn’t go into the cavity and all is well.
Surgeon said she’d buy me a drink but never did get it. But that’s okay.
On my first day as a camp nurse for people with intellectual disabilities I gave 9 pills to the wrong guest.
I didn’t know who I was looking for and asked my friend to send out the guest. This guest’s hypochondriac roommate walks out instead, and tells me he is the person I’m looking for. I ask my friend for confirmation. She THOUGHT the correct person had come to me and confirmed from afar that it was, and I administered the meds.
My stomach dropped when the actual person I was looking for came out 12 seconds later! On top of that the hypochondriac roommate had a LOT of drug allergies. Wrong pills are literally poison for such person.
We called poison control and luckily he everything was okay, apart from the fact that he still continued to ask for everyone else’s pills at all times.
I worked there two summers and thankfully had no other disasters like this one.
I had a 9 year old girl bought in one night with her parents complaining of fever and respiratory distress, presenting with coughing and wheezing. The kid was really out of it and the parents were very upset. I thought it was Bronchitis, but admitted her and at once ordered treatment for her fever, cough and even throat cultures.
I was with another patient when the kid started hallucinating, sobbing and spewing everywhere. I figured it had to do with the fever, so I packed her with ice, but she died maybe a half hour after that.
This wasn’t my first death, but it was one of the worst. A 9-year-old girl just died. I couldn’t tell the stiff neck since the kid was coughing and whizzing. She also couldn’t tell me anything that would point to simple or complex seizures.
She died of Neisseria meningitidis. About 10% of adults are carriers of the bacteria in their nasopharynx, the part of the throat that is behind the mouth and nasal cavity.
The worst case of wrong diagnosis. Now this bacteria is contagious. We called in all her school mates and anyone else we could wake up. To my horror we saw three other kids go and the rest got antibiotics quickly enough.
Probably my worst day in medicine.
My brother is a surgeon, and during part of his residency, he had to work in the paediatric unit. He was working with two newborns. One was getting much better and fighting for life. He was going to make it just fine. The other baby was hours from death. He wasn’t going to make it. My brother was in charge of informing the families.
My brother realized about 15 minutes later that he had mixed up the families. He told the family with the healthy baby that their baby wasn’t going to make it, and he told the family with the dying baby that their baby was going to be just fine.
He then had to go back out to the families and explain the situation to them. How devastating, I can’t even imagine what it would have been like to in any of the parent or even my brother’s shoes. Worst for the family who lost their baby – to be given a glimmer of hope and have it ripped away from you not even an hour later.
That was most upset I’ve heard my brother. He felt destroyed.
I was working in Yosemite as a camp counselor. There was no internet access there. I started to get a red rash on my chest, and then on the same place on my back, and it started to expand and crawl up towards my armpit. And it hurt, really, really, really bad. As if you had the worst sunburn ever and someone slapped it really hard every time you moved.
I went to see the nurse. In that place a new nurse gets cycled in every week. She looks at it and goes “Ohhh that’s poison oak!”. I was like, really? I haven’t really gone hiking anywhere…,
She assured me that it was poison oak and that I must have accidentally gotten the oils in my clothes or something. She then proceeds to rub in hydrocortisone cream into my chest and my back as hard as she can. I’m literally tearing up its so painful, and all she can say is, “I know dear, I’m sure it’s painful.” She gave me a bottle of the stuff and some anti-histamine pills and told me it’ll be gone in 2 days. It wasn’t.
I couldn’t move without being in terrible agonizing pain. I returned to the nurse and told her, “I don’t think it’s working.” She says to me, “Oh, my brother, who’s a doctor knows what it is and he doesn’t even need to see you.” He says its something called “Herpes Zoster”. For those of you who don’t know, Herpes Zoster is Shingles, a big brother of chicken pox. I had been living with undiagnosed shingles for like 5 days, and at this point the rash was the most disgusting collection of painful, puss-spewing pimples ever.
I ended up getting driven to the closest clinic which was 40 minutes away, and the doctor said it was one of the most severe cases of shingles she’d ever seen. Gave me some Vicodin to put me in “feel good” mode and told me everything would disappear in 3 weeks.
Since that time, I have a rare complication called Post-herpetic Neuralgia in the spot where my shingles was. This causes me to feel basically the same pain because my nerve endings are now too screwed in those places.
Turns out Hydrocortisone cream is the worst thing you could put on shingles.
In health care, at every level from the top to the bottom, mistakes get made, and you just try to keep them as infrequent and minimal as possible.
When I was a student rotating through OB/Gyn, I wrote an order for a woman’s post-partum continuation of magnesium sulphate, as she was pre-eclamptic ante-partum. I was super careful because I knew what could happen with magnesium toxicity, and double-checked the order with the resident afterwards.
The nurse, instead of hanging one bag of mag-sulfate and another of I forget what, hung two bags of mag-sulfate, one of which she slammed into the patient over a minute, instead of slow-infusing over 12 hours.
The woman told the nurse she didn’t feel right, but the nurse hushed her. I happened to be walking by, and randomly stopped in to see what was up. There they were, two bags hanging, both marked in a bright red warning label.
I called for the fast response team. They, and my team, got there in time and took over, but she still went into respiratory depression and ended up in the ICU.
I reamed the nurse when I overheard her laughing about the incident like she hadn’t just almost killed someone.
I am a pharmacy student here and was on rotations when this happened. We had a lady who was taking VERY high doses of Oxycontin (roughly 240mg a DAY) for pain. I don’t remember what it was related to, she had a laundry list for her PMH.
So she is admitted to the general floor with altered mental status which was major side effect of opiates. So no big deal actually, get the opioid out of there and the patient will probably come to normal state.
Under my care (with my preceptor), the nurses on the floor had to use Naloxone on the patient. Now Naloxone (or Narcan) is an opioid reversal agent. It wakes you up when you have too much but negatively affects your chances at living, as it can respiratory depression and other things.
Patient is taken off her 200mg+ Oxy to see where her pain is. She’s on 20mg a DAY now. She isn’t complaining about pain, but she’s still altered mental status. 24 hours pass, nurses Narcan her 6 times in 24 hours. SIX TIMES.
Unheard of at a small hospital. She hadn’t had her Oxy in almost 16 hours when she got her last Narcan shot.
Due to her altered mental status, patient was put as a “fall risk”. As the nurses are putting the mats next to the patients bed, they turn around to get the pads that go over the sensors and the patient falls out of bed. Off the side? Nope. OFF THE END. They think she’s fine, put her back in bed. They find her home med of Oxy that she had been taking in her bed. That explains why she is altered mental status, she’s over-medicated. Problem solved? Nope. We wait, the patient is now 20 hours post the dose of hospital given medication but is still in altered mental status!
I tell my pharmacist that we need to do a CT scan because she could have hit her head. ANYONE that falls should have a CT, especially if they are altered mental status. The nurse said she could have hit her head but the MD didn’t order a CT scan because they wanted to put in a pacemaker. The patient had a low heart rate too, so they thought that was the cause of the altered mental status. I beg my pharmacist to let me talk to the Doctor myself. I just had that feeling. That bad feeling of ‘there’s something wrong happening’. I’m good friends with an anesthesiologist that works at this site, so the pharmacist suggests we ask them first. I talk to them, they agree with me and go tell the MD to get a CT of the patients head. They do it.
2 hours later, patient is in ICU, crashing. Why? Cranial Hemorrhage as per CT scan. The patient had hit her head really bad.
Next day, doctor comes to thank me. They were going to put the patient under for the pacemaker right when they did the CT scan.
I’m in the military, and as I’ve gotten closer to 40, it seems I’ve begun to develop high blood pressure. The on-base doctor insisted I needed medication to control it, so he wrote a prescription. To be honest, I hadn’t seen this doctor before, and he seemed a bit off. Not sure how to describe it, but he just seemed a bit less than completely there.
Anyways, I walk down to the pharmacy area and wait my turn. I’m called forward and the pharmacy tech asks for my ID, looks up the order, and asks me some basic questions. “Name”, “Date of Birth”, and “Allergies”. I told her I was allergic to penicillin and sulfa.
The prescription was for Hyzaar. Any medical student can probably tell you how moronic this order was. Hyzaar specifically has side effects for those with allergies to penicillin or sulfa. I’m allergic to both.
The tech actually said out loud “What in the hell!”. She calls the doctor on the phone and starts chewing him up. Keep in mind she’s a civilian and he’s a commissioned officer. Neither of them “outrank” the other, so he’s arguing back with her, and then she says, “Your pill popping is over. Today you could have killed this patient because you’re always too high to know what’s going on around you. I’m going to the wing commander over this.”
To shorten the story a bit, the matter was brought before an ethics board and a court-martial. Seems he was “trading scripts” with other doctors in the area for pain pills, was high nearly every waking moment, and could have actually killed me. He received a sentence of over 1 year.
I worked in a digestive health clinic for a year or so to build up my med school application. I was a gastroenterology tech and obviously worked with many doctors. I got close to one of the doctors and he preceded to tell me about an incident with one of the other doctors that I worked with everyday.
Apparently he was performing a colonoscopy on a rather fluffy woman and accidentally went into the wrong orifice. These colonoscopes are hooked up to video screens and air/water supplies so the doctor can inflate the colon with air and have a better look at the lumen of the colon. Apparently this doctor mistook the cervix for cancer and preceded to take multiple biopsies, sample tissue, out of it. Also he also put so much air in her that both of her fallopian tubes ruptured and she had to have an exploratory laparotomy.
A doctor should always double check.
I am a nurse here and I was assisting a senior doctor during a vasectomy. The doctor found the testicular artery and thought it was the vas deferens (the sperm tract) and was about to tie it off and cut it.
In a very diplomatic way I told him to double check the anatomy. Phew!
We were doing a lower extremity bypass graft. Basically, there’s a section of the artery in the patient’s leg that’s too small to get enough blood past (usually due to cholesterol and smoking), so you strip a vein from the leg, the other veins can compensate well enough, turn it around so the valves in it are pointing in the right direction, and hook it up to the artery before the blockage and after it, effectively bypassing the blockage.
Well, the veins get their blood from little tributary vessels, and these have to be tied off because the vain they gave blood to is no more there.
Now, one of the ties slipped off after the operation. This theoretically seems to be a very tiny mistake, but in reality it can cost someone’s life within hours.
We see the guy has arterial-pressure blood spurting out of his vessel into his leg, which then caused massive blood loss and nearly caused compartment syndrome – compression of the tissues, vessels, and nerves in the leg, extremely dangerous even when you’re not actively bleeding out.
Twelve units of blood and two hours in the operating room at 3 AM later we saved the patient’s life and his leg. The guy did very well after that and was discharged on post-op day 4.
I think it’s almost a privilege in a morbid way to have seen it, because it showed me just how unbelievably important even the tiniest detail is in the surgeries we perform.
A new hospital opened in my city and one of the first surgeries preformed was a leg amputation. All went well, patient survived and then the mistake was realized: the doctor amputated the wrong leg!
I feel sorry for the chap.