Sometimes it takes a specific instance of medical malpractice to illustrate how far we still have to go before all medical patients receive care free of errors.
Take a report in the Times last week which seems like it is out of a horror movie. According to the tale, doctors at one facility pronounced a patient dead following an adverse reaction to drugs. The female patient was an organ donor, and a medical team brought her body to the operating room to extract the organs for donations. Shockingly, while prepping the body–moments before cutting her open–the patient opened her eyes. She was not dead.
How on earth could such a mistake be made in a modern hospital today?
As with most instances of malpractice, the answer is complex. A review of the situation by a patient safety group points out that many different errors were made which led to the situation. For example, a nurse performed a required reflex test on the 41-year old patient and noticed that the toes were curled. In addition, at the time the nurse noted that the nostrils appeared to be moving in an out. On top of that, the article suggests that the patient was “fighting” the respirator and wanting to breathe on her own.
Those nostrils motions were actually recorded in medical records, but, amazingly, nothing was actually done in response. A sedative was given and the patient was wheeled into the operating room.
Expectedly, as news of this situation spread, all those in the patient safety world have expressed collective frustration. The facility has since been cited by state officials and was required to submit a plan of corrective action on top of being fined. An outside consultant was also hired to oversee changed protocols at the facility to literally re-teach the diagnosis of death.
Rare, But Not Uncommon
This bizarre and shocking tale is an important reminder of the reality of medical care today. Of course, most medical professionals do not make errors of this nature. But, these and similar mistakes do happen far more than the average resident would suspect. In some ways, the most unique the situation the more likely that a mistake will be made. That is because in these less common situations, all those who notice small signs which indicate a problem (like moving body parts) are more likely to ignore them or not counsel for more information. It is almost as if some medical providers assume that such an error couldn’t happen and so use the unlikelihood to cut corners, which actually leads to the mistake itself.
Local residents should also use this case as a testament to the fact that their suspicions about medical malpractice, no matter how unique, are not necessarily wrong. That does not mean that every adverse event is connected to a medical error. But it does mean that it is not appropriate to always assume that doctors, nurses, and aides acted appropriately. They often do not, and cause severe harm.
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