10 Medical Errors that Shaped the Standard of Care, Part 1
Much like you and me, doctors aren’t perfect. We love to believe that the people operating on our bodies never make mistakes, but that’s not the case. Although mistakes are made, sometimes they shift the medical landscape and save countless lives down the road. Below we examine five medical mishaps that changed the standard of care for medical professionals, and we’ll reveal the next five in a later post.
1. Trauma care – In 1976, orthopedic surgeon Dr. Jim Styner crashed his small plane that was carrying his wife and four children. His wife was killed in the crash, and three of his four children were critically injured. They were taken to a local hospital, but received inadequate care as the hospital was ill equipped to deal with multiple severe trauma cases. “When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system, and the system has to be changed,” Styner said. His tragedy led to the development of the Advanced Trauma Life Support (ATLS) and implemented a system of care for patients in the first hour after trauma. Four years later, ATLS was adopted by the American College of Surgeons Committee on Trauma and disseminated worldwide.
2. Anesthesia – Anesthesia procedures came under review in the 1980’s because some patients were dying or suffering brain damage because of unmonitored anesthesia techniques. In 1982, 20/20 ran a segment called “The Deep Sleep: 6000 Will Die or Suffer Brain Damage”, highlighting the dangers of anesthesia. The American Society of Anesthesiologists responded with a program to standardize anesthesia care and patient monitoring. They also created the Anesthesia Patient Safety Foundation in 1985. The new standards have resulted in a significant drop in anesthesia deaths, as they fell from 1:10,000 to 1 in 200,000 in two years.
3. Fetal Heart Monitoring – Fetal monitoring came under review after a newborn suffered severe brain damage and cerebral palsy as a result of an injection to speed up the birthing process. Fetal monitoring to test the uterine contractions and fetal heart rate (FHR) is now the norm. The purpose of FHR monitoring is so doctors can intervene during the delivery process if the baby becomes distressed. They also added a 30-minute response time from recognition of distress to delivery, to ensure the baby is given the best chance to survive.
4. Wrong Site Amputation – Wrong site amputation sounds like something out of a bad horror movie, but it does happen. There was a case where a man named Bill severely injured both of his legs in a car accident. X-rays revealed that his right leg was salvageable but his left leg was not. The X-ray technician accidently mislabeled the images, and the surgeon amputated the wrong leg. Preventing wrong site amputation is one of the main goals of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), and they implemented guidelines to make sure the correct operation is preformed. This includes marking the site, involving the patient in the marking process, and having each member of an operating team double-check the information provided to them.
5. Sponge counts – Sponge counts came to the forefront of the medical world after a 12-year-old boy had a sponge left inside him following an operation to address his burst appendix. Doctors removed the sponge three days later, but it called for a review of sponge and instrument counts during surgery. There is no defined way to count medical equipment, but nurses and surgeons are advised that each member of the operating team individually count the number of instruments being used in a procedure. They are also asked to count again before the wound is closed. Operating equipment has also made advances, as manufacturers have made sponges with threads visible on X-rays.
Dr. Silverman comments
This is some sobering information. It’s an honor to think that the ATLS protocol was developed by an orthopedic surgeon.
Also, signing off on a person’s amputation site is a policy developed by the American Academy of Orthopedic Surgeons. They also developed a type of instrument checklist that myself and my assistants follow during every procedure.