You're more likely to die as the result of a medical error than to be killed in a car crash, or die of breast cancer or AIDS. Here's how to protect yourself from mistakes made in the name of medical treatment.
In 1997, Karl Shipman, MD, a 64-year-old Colorado internist, fractured his wrist in a fall. He had surgery to set the wrist, but it got infected, and the infection spread to his spine, leaving him in incapacitating pain, recalls his daughter, Debra Malone.
The infection should have been easy enough to treat, but Dr. Shipman's physicians misdiagnosed the problem and prescribed only pain relievers and physical therapy, says Malone, a registered nurse. The infection worsened, and he was hospitalized in septic shock.
"When he reached the hospital, he still didn't get an appropriate diagnosis or care," Malone says. By the time hospital staff made the right diagnosis, Dr. Shipman was in the intensive care unit. He died there, 18 days later, from complications.
"That just shouldn't have happened," says Malone, who now heads the Colorado chapter of the patient safety group, Persons United Limiting Substandards and Errors in Healthcare.
"These days, people should not die of things such as broken wrists," she says.
Hospitals: 8th Leading Cause of Death
But they do, thanks in no small part to medical mix-ups that occur with alarming frequency. According to a recent, headline grabbing Institute of Medicine (IOM) report, a staggering 44,000 Americans die each year as a result of medical errors - misdiagnosis, inappropriate treatments, preventable infections, technical goods, and the like - in hospitals alone. That's more people than die in car accidents, of breast cancer, or of AIDS.
In the wage of the IOM report, the White House and Congress have proposed an array of measures to improve patient safety. But that alone is not enough, the experts say.
"Patients have a role to play in error prevention as well," insists Kenneth W. Kizer, MD, president of the Washington, DC-based health care improvement organization, National Quality Forum.
Here's what you have to do to protect yourself:
Find a Good Doctor
Remember the old joke, What do you call the guy who graduated last in his class in medical school? Answer: Doctor. Even if you belong to an HMO you probably have a choice among at least a couple of doctors in your area. Take some time to find the best by following these tips:
- Trade insider information. "If you know anyone on staff at your local hospital, ask them for a recommendation, says Arthur Levin, MPH, director of the New York City-based Center for Medical Consumers. "They see everyone in action and may steer you to, or away from, certain people."
- Do a record check. Call your state health department, and ask what agency in your state keeps records of doctors who have been disciplined or had their licenses revoked, says Levin. Then contact that agency, and ask whether the doctors you're considering have clean records.
- Go for volume. If you need a particular surgical procedure, find a surgeon who does it often. Frequent practice often makes for fewer mistakes, if not perfection, Dr. Kizer says. Call your state health department to find out whether it or a medical society in your area collects this information. If this information isn't available, ask the surgeons you're considering how often they perform the procedure each year and how many times they're done it in their career.
- Interview contenders. Once you've come up with a working list of potential doctors, it's a good idea to interview them. (Some physicians charge for this, so you may want to whittle down your list.) "Look for a willingness to listen and answer your questions," advises Joanne Turnbull, PhD, executive director of the Chicago-based National Patient Safety Foundation.
Be Your Own Best Friend
- Play it safe at the office, the pharmacy, and at home. To make sure you get consistently good care, you have to make an effort too. Here's what you should do:
- Remind your doctor. Whenever your MD pulls out a prescription pad, remind her of the other drugs, over-the-counter medications, vitamins, and supplements you're taking. Also bring up any drug allergies you have. You'll lower your odds of a drug interaction or allergic reaction.
- Read the writing on the pad. When you get a prescription, ask your doctor to spell our the name of the drug and specify the dose. Write that down on a piece of paper, and take it with you to the pharmacy, suggests John M. Eisenberg, MD, director of the Agency for Healthcare Research and Quality in Rockville, MD. That way, you can check the label against your notes when the pharmacist hands you your medication. A recent study found that 88% of medical errors involved the wrong drug or wrong dose. A 5-year-old Virginia boy died last year after taking a drug for bed-wetting. The prescription had inadvertently been filled at five times the appropriate dose. "That kind of thing happens too often," say Dr. Kizer.
- Know your drugs. Before leaving the doctor's office with that prescription, ask your doctor what it's for, whether you should take it on an empty for full stomach, whether you should avoid certain foods, beverages, or activities while taking it, and what common and uncommon side effects are. Also ask your pharmacist for written side effect information. According to another study, patients who got side effect information in writing were better able to recognize when they were having a bad reaction.
- Become an expert. Read up on whatever ails you, and find out what treatment gets the best results. For a rundown on treatments that have proven themselves in clinical trials, visit www.guidelines.gov.
- Get a second opinion Before you have surgery or undergo any major procedure, ask another doctor to review your case.
- Call for your test results. "One of the big things that contributes to error is lost diagnostic test results," says Dr. Turnbull. Call your doctor's office for the results of any test you get. If the results were lost, you'll have sounded the alarm. "Don't accept the answer, 'If you don't hear from us, it's okay," she says.
- Keep a copy of your records. Ask your doctor to give you a copy of your complete medical file, including any diagnostic test results. That way, if you change docs or go to a specialist, you can be sure that your new MD gets your complete dossier so she has your full history. Previous health problems can shed light on new ones, says Dr. Turnbull.
Find a Good Hospital
Before you need one, investigate the hospitals in your area. (Check first to find out which are covered by your insurance plan.) Be sure to check the following:
- Do an accreditation check. Find out whether each had met the standards for accreditation set by the Joint Commission on Accreditation of Healthcare Organizations. Visit www.jcaho.org or call (630) 792-5800.
- Go for volume - again. "Some data suggests that hospitals that do a lot of a certain type of procedure are better places to get that procedure than those that do it only once in a while," says Dr. Turnbull. If you need a particular procedure, call each hospital's community relations department, and ask how often the hospital performs that procedure. If the hospitals in your area don't keep track, call the state health department, and ask if the department or any other agency has this information.
- Ask about safety. While some states required hospitals to report certain errors, reporting requirements tend to be scattershot, making error data an unreliable indicator of safety, says Dr. Kizer. So what's the best way to find out how safe a hospital is? Before you pick one, call the hospitals in your area, and size up their commitment to patient safety by asking their community relations staff these pointed questions:
- Do you have concentrated potassium chloride in the wards? The concentrated form of this solution (used to restore potassium levels in patients who are dehydrated) has to be diluted with saline before use. If someone slips up and forgets to dilute the stuff, it can be fatal. If a hospital has banned the concentrated solution, that's a point for safety, says John M. Eisenberg, MD, director of the Agency for Healthcare Research and Quality in Rockville, MD.
- Does a pharmacist participate in daily rounds? When a pharmacist does, medication error rates are usually lower.
- Do you have a computerized physician order entry system? In hospitals with this system - a minority at the moment, unfortunately - doctors type prescriptions right into a computer, preventing illegible handwriting-related errors. The computer then checks to ensure that the dose is right, and that the drug won't interact with other medications the patient is taking.
- What's your ratio of patients to registered nurses? There's no ideal ratio. In general, though, the fewer patients per nurse, the better.
- Do you have house staff? Doctors employed by the hospital - those who work in-house full time, rather than shuttle between the hospital and their private offices - are a plus, providing continuity of care and oversight.
- Does an intensivist oversee the intensive care unit? An intensivist is a physician who specializes in intensive care. Having one overseeing the ICU wins safety points, says Debra Malone, who heads the Colorado chapter of the patient safety group, Persons Limiting Substandards and Errors in Healthcare.
Prepare for Your Stay
Take these steps before you leave for the hospital, and you're more likely to spot potential errors before they happen:
- Think "advocate." During your stay, you'll need to be your own advocate, questioning the care you get. If you won't be in shape to do this yourself, line up family members or friends who can stay with and do it for you. Here is one family's story about a hospital mix-up and how they guarded against it happened again:
"My child was in three different hospitals: All were very good, and all three made potentially life threatening mistakes when treating her," says Kevin Roberg, a Minneapolis executive whose late daughter, Kelsey, was diagnosed with kidney cancer at 10 months and spent most of her 6 years in hospitals. In one hospital, a nurse accidentally allowed air to leak into Kelsey's IV line, sending the child into cardiac arrest. In another, the medical staff gave her 10 times the appropriate dose of a potent chemotherapy drug, nearly killing her.
After the medication mix-up, Roberg and his wife took turns staying by their daughter's bedside, monitoring every aspect of her care and asking for explanations of anything that seemed inappropriate. Their vigilance prevented at least one other major error. When a nurse at a third hospital tried to give Kelsey a drug the Robergs where unfamiliar with, they asked for an explanation. It turned out that the medication was meant for someone else.
"The thing is, these were smart people who were trying to do the right thing, but health care is now so complex, it's easy to make mistakes," says Roberg, who now sits on the board of Minneapolis-St. Paul Children's Hospital, which recently introduced a new patient safety campaign.
- Know what to expect. Ask your doctor what you should do prior to hospitalization = whether you should avoid certain drugs before surgery, for instance - and what tests, drugs, and procedures you're likely to get during your stay, Dr. Turnbull says. List this information, and bring your list to the hospital. There, you or your advocate should check it every time someone comes in to give you a pill, or a test, or a procedure.
When You're in the Hospital...
[Prevention, "Get Out of the Hospital Alive." Barbara Loecher with Pam Boyer, January 2001. 105-109 and 159-161.]
- Question authority. Throughout your stay, you'll need to monitor your care, and question anything that seems odd to you, either because your doctor never told you to expect it, or you never read about it while doing your research. (In the hospital suddenly? Have a friend or relative do some research for you.)
- Know your team. As soon as you're admitted, ask your nurse for the names of the doctors and other nurses who will be seeing you and their credentials. If you're in a teaching hospital, find out which physicians are interns and residents - physicians in training - and which are experienced attending and admitting docs. If you're not sure the intern or resident is doing the right thing, ask whether he's checked the protocol with an experienced physician. "If a nurse says she checked what she's doing with the doctor, ask which doctor, since she may have called the intern," Malone says. If you're in the intensive care unity, and there's an intensivist - intensive care specialist - overseeing it, insist that he see you at least once.
- Check your chart. You have a right to see it, says Malone. Make sure you're down for the medications and procedures your doctor told you to expect - and not for ones your doc didn't tell you about. Ask for an explanation, or request that the medical staff contact your personal physician.
- Get an autograph. Before surgery, ask your doctor to sign the site first, says Dr. Turnbull. You'll be less likely to make "Doctor Removes Wrong Kidney" headlines.
- Inspect their fingernails. According to the Centers for Disease Control and Prevention (CDC), inadequate hand washing in hospitals and other health care centers is a "significant contributor to disease transmission." The CDC estimates that 2 million patients come down with hospital-spread infections annually, and that a third of these infections could be prevented. One recent study found that health care workers are more likely to wash up between patients, and use more soap, when asked if they've done so. So ask, "Do it in a joking way, or wear a pin that says, 'Don't touch me until you wash your hands,'" says Dr. Turnbull.
- Get your walking papers. Before you leave the hospital, get written instructions on how to care for yourself after discharge, says Malone. Review what's in writing, and make sure you understand it. Studies find that docs think that patients understand more about posthospital care than they really do. If you're under sedation, make sure your advocate reviews your discharge instructions and understand them. Make sure your personal physician also gets a full report.
- Call for help. If you don't feel ready to be discharged - you're still in pain or have other symptoms that medication doesn't have under control - call your insurer or managed care company, and ask for authorization for a longer stay, Dr. Turnbull says.