Medical Mistakes Occur At All Levels Of Care
Medical and surgical errors are very common in the hospital setting. They increase malpractice lawsuits, the cost of medical care, patients’ hospital stays, and morbidity and mortality. As an infectious diseases specialist for over forty years, I was not aware how common these errors are until I became a patient myself after being diagnosed with hypopharyngeal carcinoma. My initial cancer was successfully removed, but a local recurrence occurred twenty months later. I underwent pharyngo-laryngectomy with flap reconstruction after attempts to remove the cancer by laser failed.
Although the care I received was generally very good, I realized that mistakes occurred at all levels of my care. I am sharing my personal experiences about the medical and surgical errors that occurred during my hospitalizations at three different hospitals. My inability to speak after surgery made it difficult for me to prevent all of these mistakes. Fortunately, I was able to abort many of them.
I realized that my surgeons had failed to diagnose the recurrence of my cancer in a timely fashion although they examined me periodically after my initial surgery. I had been complaining of sharp and persistent pain in the right side of my throat for seven months. The recurrence was finally observed by an astute resident who was the first to ask me to perform a valsalva maneuver (exhale while closing my mouth) during the endoscopic examination. This allowed visualization of the pyriform sinus where the tumor was located. I had wondered why my experienced surgeons never performed such a basic procedure. If they had done so earlier, my tumor (4×2 centimeters) would have most likely been observed and removed much earlier.
Subsequently, my surgeons, using laser equipment, mistakenly removed scar tissue instead of the cancerous lesion. A week after the surgery pathological studies revealed that the tumor was actually farther down in the pyriform sinus. This error could have been avoided if frozen sections of the lesion itself, not just its margins, had been analyzed in the operating room. Accordingly, I had to undergo an additional surgery to remove the tumor. The prior surgery made the repeated attempt more difficult because of swelling and post surgical changes at the surgical site.
I also experienced hazardous situations because of nursing errors. One day after my laryngectomy, while still in the surgical intensive care unit, I experienced airway obstruction and reached for the call button. It was not to be found as it had fallen to the floor. I tried to call the attention of the staff and, even though I was a few feet away from the nurses’ station, I was ignored until my wife luckily arrived ten minutes later. Without a voice, I was helpless in asking for assistance and was in need of air while medical personal passed me by.
A similar incident took place on the otolaryngology floor a week later when the nurse did not respond to my call to suction my airways. I had difficulty in breathing, as mucus in my trachea obstructed my airway. The nurse came to assist me only after fifteen minutes. I learned that she was on the phone ordering supplies during all that time. There were two physicians and several nursing assistants on the floor, yet no one responded. Incredibly, even on a ward dedicated to people with airway issues, there were many distractions that prevented physicians and nurses from paying attention to their patients’ immediate needs.