Patient Beware: How to Avoid Medical Mistakes

Patient Beware: How to Avoid Medical Mistakes
(Monkey Business Images/Shutterstock)
Joe D. Haines Jr
12/3/2022
Updated:
3/21/2023

Most people wouldn’t have any difficulty recognizing heart disease and cancer as the top causes of death in the United States. However, most folks are shocked to learn that the No. 3 cause of death in America is medical mistakes.

In a famous paper published by the Institute of Medicine in 1999 titled “To Err Is Human,” it was estimated that 98,000 people per year died due to medical errors. The concluding recommendation was that we should work more on making safer systems and less on individual blame.

According to a 2016 Johns Hopkins University study, approximately 250,000 people die per year due to errors committed by our health care system. The metaphor often used is that of two fully loaded 747 jets crashing with no survivors every day of the year.

Such a catastrophe would result in enormous public outcry, yet most Americans seemingly accept the same number or more of medical mistake casualty victims.

Incredibly, the 250,000 figure is very likely conservative. When causes of death, such as outpatient fatal drug reactions (198,000), deaths due to misdiagnosis (132,000), hospital-acquired infections (100,000), and deep venous thrombosis/pulmonary embolism (119,000) to name some of the worst offenders, the overall number approaches 800,000 deaths per year.

There are many causes for these preventable deaths.

While some efforts have been made in an attempt to change the systemic causes of these problems, Americans receiving health care today would be well-advised to take some basic precautions.

Patients literally trust their doctors with their lives. And there is much in our health care system to be proud of, including the best medical schools, the finest hospitals, superior technology, and everything that makes us believe what we’ve been told—that we have the finest, most advanced health care system in the world.

But there are also major shortcomings, including doctors that are too busy to really diagnose patients and an inclination by both patients and doctors to treat chronic conditions with drugs instead of lifestyle changes that can truly cure them.

Misdiagnosis is also common, and a good place to start when it comes to avoiding medical errors.

A study published in BMJ Quality and Safety in 2014 estimated that approximately 12 million Americans are the victims of misdiagnosis each year. The following conditions are most often misdiagnosed:
  1. Stroke
  2. Heart attack
  3. Spinal epidural abscess
  4. Pulmonary embolism
  5. Necrotizing fasciitis
  6. Meningitis
  7. Testicular torsion
  8. Subarachnoid hemorrhage
  9. Septicemia
  10. Lung cancer
  11. Fracture
  12. Appendicitis
With the possible exception of spinal epidural abscess, most of the other conditions listed above are straightforward problems that most experienced providers should be able to easily diagnose.

The question, then, is what can the average patient do to avoid becoming another statistic?

Perhaps the most important thing is to choose your provider wisely. Settling for whoever is on duty at the local “doc in a box” down the street may not be the best choice. A little research, including searching a prospective provider on the state medical association website, can be a good start.

Disciplinary actions, malpractice lawsuits, and license suspensions are some of the pertinent details that should be available. Also, while simply checking out providers with friends and neighbors is far from foolproof, some worthwhile opinions may be of interest.

A growing option, especially in primary care and urgent care settings, are so-called mid-level providers. Many of these mid-levels are competent in caring for 90 percent of patients who walk through the door. It’s the other 10 percent that can challenge even the most highly trained and experienced physicians.

Once you have hopefully selected a competent practitioner, you must become your own advocate. A great resource is the book “Top Screwups Doctors Make and How to Avoid Them” by Graedon and Graedon.

Their suggested strategies for safer health care are as follows:
  1. Take a prioritized list of top health concerns/symptoms to your visit.
  2. Take notes during your visit.
  3. Take a friend or family member with you (especially if you are hospitalized).
  4. Bring a list of medications and supplements so drug interactions can be detected.
  5. Know the side effects of medications that you are prescribed.
  6. Ask if the provider formulated a differential diagnosis and considered all likely possibilities.
  7. Consider a second opinion if doubtful of the provider’s diagnosis.
  8. Keep a copy of your medical records.
  9. Maintain a diary of vital signs, symptoms, blood sugar, etc.
  10. Find out the provider’s after-hours routine.
Graedon and Graedon list some of the most common errors. I’ll discuss a few of them and some examples I have witnessed.

Not listening to patients is a big one, and there’s blame enough to go around for both the provider and the system.

Health care providers are sometimes simply in too big of a hurry, interrupting patients, peppering them with a narrow list of questions, and just not listening.

Patients can contribute to this with unreasonable expectations of the provider to solve a dozen different complaints in a 15-minute appointment. Over the years, I have found that if you give the patient an adequate amount of time to explain their problem, they will often make their own diagnosis.

Providing an adequate amount of listening can ultimately save a great deal of time. The provider must also focus completely on the patient at hand and avoid distractions such as typing on a keyboard and thinking about his schedule.

Misdiagnosis, usually due to failure to perform a proper differential diagnosis, is another major source of error.

Over my 25 years as a medical expert witness, I have seen hundreds of cases of misdiagnosis resulting in death or serious injury. Since heart disease is our No. 1 killer, I have seen many missed heart attacks because basic protocols were not followed.

For example, a case I just reviewed involved a 45-year-old man with high blood pressure, mild obesity, and a family history of heart disease. He was awakened at night with central chest pain that spread to his neck and lasted approximately 10 minutes. He had also recently worked out on his home treadmill and was forced to stop due to chest pain. The patient’s wife became concerned and took him to a nearby emergency room, where the patient tried to minimize his symptoms by presuming he had gastrointestinal reflux from eating some jalapeno peppers the night before.

The electrocardiogram and preliminary blood work didn’t confirm a cardiac problem, so the physician assistant seeing the patient accepted the patient’s wishful thinking of reflux. He reassured the patient and sent him home. Three days later, the patient died of a cardiac arrest. The autopsy showed a more than 95 percent blockage in the left anterior descending artery, commonly known as the “widow maker.”

One pearl of wisdom I have learned over the years with male patients is to always listen to the wife. Women seem to have an innate sense of when something bad is going on. While I can’t quantify this input, I certainly don’t deny its significance. This man should of course have been admitted to the hospital and had a consultation with a cardiologist, who would have recommended cardiac catheterization and likely the placement of a lifesaving stent in the blocked artery. He likely would be alive today if that had happened.

A similar case involved a 57-year-old man with two weeks of suspicious chest pain. He had a physical scheduled with his family doctor and decided to wait and discuss his problem at the next scheduled appointment. When the appointment came, the patient tried to bring up his symptom of chest pain with his doctor, who responded several times that the patient was at the office that day for a physical, not any new complaints. New complaints, the doctor repeated, would have to be addressed at a future appointment, which was made for several weeks down the road. Unfortunately, the patient followed his doctor’s instructions and died of a heart attack before his appointment occurred.

Close behind cardiovascular causes of death is cancer. Medical students are taught that cancer encompasses some 100 different diseases. And while some impressive gains have been made in the treatment of some cancers, other cancers, such as pancreatic cancer, are difficult to treat.

The rule has always been in general that the earlier the diagnosis, the better the outcome. A delay in diagnosis allows the cancer to progress from an early stage to a late stage with a uniformly poor outcome. Many malpractice claims result from delays in the diagnosis of cancer.

Pat was a 42-year-old mother of two children under the age of 10. She had a persistent cough complicated by worsening wheezing. Her family doctor assumed she had bronchitis, which was causing the wheezing. He prescribed antibiotics and bronchodilators for her symptoms. He evidently discounted her history of smoking three to four packs of cigarettes a day for the prior 20 years.

She returned several times to her provider, who never considered a chest X-ray. Seven months into her problem, she sought a second opinion. When the doctor walked into the exam room, he heard a “wheeze” that was characteristic of an airway obstruction. A quick chest X-ray confirmed his suspicion of a lung mass, which was encroaching on the right main stem bronchus. Unfortunately, Pat died a few months later of stage IV bronchogenic carcinoma.

A “pearl” of wisdom that young doctors should learn is that when a patient returns with the same symptoms or no improvement, this is a golden opportunity to step back and reassess the patient. No one is perfect, and mistakes will occur, but sometimes the correct diagnosis can be rescued before a disaster ensues.

Another classic mistake is accepting someone else’s diagnosis. This is actually a type of intellectual laziness and can result in catastrophe. Overlooking lab results can also be a fatal error.

Ed was a 54-year-old man with several weeks of abdominal discomfort whose physician decided to evaluate him with a CT scan of his abdomen and pelvis.

The scan was reported back as normal by the radiologist with one exception. There was a suspicious small mass in the left kidney. The radiologist recommended further studies to help determine the cause of the mass. Unfortunately, Ed’s physician overlooked the CT scan results and almost 18 months passed.

Ed returned to his doctor with urinary tract symptoms (blood in the urine) and additional studies showed that his kidney had been replaced with a tumor, which had already spread to surrounding tissues. Ed died a few months later from what could have been a curable cancer when the initial abnormality was detected. The old adage, “No news is good news,” definitely does not apply in the case of test results.

The Graedons also mention the following screw-ups doctors make: providing too little information to patients, not dealing with side effects of treatment, under-treating or ignoring evidence, overreacting or being seduced by numbers (treating the lab report instead of the patient), overlooking drug interactions, failing to revise the plan, overlooking lab or X-ray results, and not addressing lifestyle issues, such as smoking.

Drug or medication mistakes are a special category.

Many people are unaware that Pen VK, amoxicillin, and Augmentin are all forms of penicillin. And if you’re allergic to penicillin, you should not take any of the above.

Drug interactions are a real problem, particularly in the elderly. Elderly patients can be prescribed 20 to 30 different medications. Geriatric patients should consult the Beers List, which lists drugs that older people should avoid. Few, if any, providers are smart enough to determine all the potential drug interactions with this many medications on board. Thank God for computers to help us keep track of the estimated 100,000 potential drug interactions.

But computers can be ignored, especially when prescribers routinely override red-flag warnings of drug interactions. A good rule of thumb is to eliminate as many drugs as possible. If an elderly patient is complaining of unusual symptoms, it’s usually prudent to discontinue all nonessential medications as a start.

Most of our medications used to be made domestically, making it easy for the FDA to ensure that standards were maintained. Today, approximately half of all drugs Americans take are manufactured in foreign countries. And up to 80 percent of pharmaceutical ingredients come from foreign sources, especially China.

Fentanyl, a potent opioid pain reliever, is a good example, since the ingredients are often made in communist China and shipped to Mexico, where the tablets are produced. The fentanyl is then smuggled across our porous southern border and distributed to unsuspecting Americans, resulting in more than 100,000 deaths each year in America due to fentanyl poisoning.

What can a patient do to prevent themselves from becoming a victim of medical errors? Robert Fox (a lawyer) and Chris Landon (a doctor) have written an entire book, “Avoiding Medical Errors: One Hundred Rules to Help You Survive Mistakes by Doctors and Hospitals,” to help.

Here are a few highlights:
  1. Use your state medical boards’ website to research your provider.
  2. Obtain an independent second opinion if your provider seems unsure of your diagnosis.
  3. Consider stopping medications if there is no improvement over time or your condition worsens.
  4. Do not go home if you don’t feel OK (there’s always the emergency room available for a second opinion.
  5. Before seeing a provider, prepare a short list of questions.
  6. Create and maintain your own medical file.
  7. Avoid traveling far away from home for surgery.
  8. Do not have surgery on a holiday or weekend.
  9. Use a black felt tip marker to indicate which body part is to have surgery (“surgery here”) so the proper limb is operated on.
  10. Before taking any medications, either you or your advocate should verify that the medications were prescribed for you and not another patient.
  11. Verify the meds from your pharmacy were prescribed by your provider.
  12. When tests are ordered, always follow up until you receive the results and understand what the results mean.
  13. Consult an attorney if you believe that you were the victim of a medical or hospital error (only if you received care that was below the standard of care and the substandard care resulted in injury).
Another reference that provides excellent advice on confronting medical error is “When We Do Harm,” by Dr. Danielle Ofri. Even though we live in a country with the greatest health care system in history, Ofri explains how the system is not immune to human error and probably never will be.

To best deal with human error—it must be anticipated and expected. Losing the equivalent of two jumbo jets per day due to medical mistakes isn’t acceptable. While some improvements have been made, American medicine is still falling woefully short. In the meantime, the patient must assume more responsibility to prevent errors and ensure that they don’t become another statistic.

Joe D. Haines, Jr, MD, MPH, FAAFP is a board-certified family practitioner. In addition to family medicine, he also completed an aerospace medicine residency and received an MPH while serving in the US Navy. Dr. Haines has practiced medicine for 40 years and remains active with medical expert witness work and writing. He is a veteran of the Afghanistan War, serving as the Wing Surgeon for the Marine Corps in 2011 He has over 200 publications in a wide variety of journals.
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