Ms. A was a sweet older lady with a bad heart who was transferred all the way from Montana in order to get expedited workup for cardiac (heart-related) surgery.

Her story of her symptoms and disease course was the story told by hundreds of patients seen at any given hospital every year.  It started with a few weeks of chest discomfort while walking, followed by a day of chest pain, nausea, vomiting and dizziness prompting an urgent 911 call.

Where she thought her symptoms were attributable to bad heartburn, the studies at her local hospital demonstrated otherwise: She was found to have severe disease in all of the major oxygen-carrying vessels that supplies her heart and was at a high risk for a fatal heart attack without surgical intervention.

While caring for Ms. A overnight, I made the incorrect decision to administer a cardiac medication to treat her disease that is known to increase the risk of bleeding during surgery.  Given her need for the operation, the benefit of providing this medication to safely temporize her heart condition in the short-term did not outweigh the risk of delaying the intervention that she ultimately needed.  Despite the standard of care regarding this clinical scenario, I made the wrong call.

The background

Making a medical error is the most feared consequence of practicing medicine.  From misreading lab values to doing surgery on the wrong site, any slip in clinical judgment can potentially cause serious injury or even death.  A landmark study conducted by the Institute of Medicine (IOM) demonstrated that medical errors in the U.S resulted in around 75,000 unnecessary deaths and over 1 million excess injuries each year. Despite this data, it is remarkable that medical errors are made every day and usually result in little to no negative patient outcomes.

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