the worst Medical Errors and how to mange them.pptx

The worst
medical error
death
sentinel event
adverse event
medication error
wrong surgery

1. Title of the presentation Speaker’s info and title The worst Medical Errors and how to ma nage them Dr Ihab Suliman . دكتور ايهاب فتحي سليمان @ IhabFathiSulima

2. What is a Medical Error? “An act or omission that would have been judged wrong by knowledgeable peers at the time it occurred” Institute of Medicine

3. Non-Preventable adverse events Potential adverse events Near Misses Medical Error Adverse Events (complications) Errors and Adverse Events Negligent adverse events

4. Burden

5. Top Health Statistics  Medical billing errors cost Americans $210,000,000,000 annually. Roughly 12,000,000 Americans are misdiagnosed each year. Medical errors cause an estimated 250,000 deaths in the United States annually.  As many as 80 percent of medical bills contain at least one error. A little more than 4,000 surgical errors occur each year. It’s estimated that 7,000 to 9,000 patients die every year from medication errors.

6. Locations of Errors Emergency Rooms, Intensive Care Units, Oncology. Elderly, Children Very sick patients Epidemics or Pandemics

7. Case 1 Katherine Wood, 37, of Stow, Massachusetts, was bitten on a tick while on a nature walk in November 2016 She started experiencing symptoms including shortness of breath, chest pain, neck stiffness and numbness in the hands Several doctors misdiagnosed her and one doctors told her to 'try meditation' and that she 'didn't look unwell' Wood was finally diagnosed with Lyme disease, a tick-borne illness, in July 2017 and was given a three-week antibiotic regimen Her infection was only cleared up partially, so another doctor gave her both oral and injectable antibiotics Wood is 18 months into treatment and said she wants to encourage others to be their own advocate 

8. Untreated Lyme has stolen two and a half years from me so far,' she wrote. 'My goal is to reach remission and live a symptom-free life. I now find comfort in taking the proper precautions to protect myself and my family.    In a first-person account written for  Health , Wood says she feels better than she did months ago, and encourage others to trust their gut and advocate for themselves if they feel like something is wrong.

9. 20 y.o. woman with abd pain, n/v, given antacids Continued sx with decreased appetite, forced self to eat, felt worse and would then regurgitate PMD suspected bulimia. Referred to psych, dx w/ anorexia w/ bulimia Over next few years seen by several physicians and continued wth PMD devoted to pts with eating disorders Also intermittently seen by endocrinology, orthopedics, hematology, ID, psychiatry and psychology. Tried four different antidepressants and talk therapy Registered dietician monitored pt’s diet and calorie counts. Reported consuming adequate calories but had persistent wt loss. ? if patient was correctly reporting, falsifying reports? Eventually seen by a GI physician years later and diagnosed with celiac sprue.

10. William Osler “If you listen to the patient, he is telling you the diagnosis”

11. Case Study A 38-year-old woman comes to the hospital with 20 minutes of itchy red rash and facial swelling; she has a history of serious allergic reactions A nurse draws up 10 mls of 1:10,000 adrenaline (epinephrine ) into a 10 ml syringe and leaves it at the bedside ready to use (1 mg in total) just in case the doctor requests it Meanwhile the doctor inserts an intravenous cannula The doctor sees the 10 ml syringe of clear fluid that the nurse has drawn up and assumes it is normal saline

12. Continue case study There is no communication between the doctor and the nurse at this time The doctor gives all 10 mls of adrenaline (epinephrine)through the intravenous cannula thinking he is using saline to flush the line. The patient suddenly feels terrible, anxious, becomes tachycardia and then becomes unconscious with no pulse She is discovered to be in ventricular tachycardia, is resuscitated and fortunately makes a good recovery Recommended dose of adrenaline (epinephrine) in anaphylaxis is 0.3 - 0.5 mg IM, this patient received 1mg IV

13. Wrong Leg A diabetic  Florida man  received $1.15 million in settlements after he entered a hospital to have his right leg cut off below the knee due to a diabetes-related circulatory disease. After a series of mistakes, though, the man’s left leg was removed. He had the proper leg removed at another hospital and he ultimately learned to walk using prosthetics. The case led investigators to put a temporary ban on elective surgeries at the hospital.

14. A man lost his  $3 million lawsuit  against a Virginia doctor who followed his patient’s instructions. The 33-year-old construction worker, who had stopped taking his anti-psychotic medicine a year prior, was working when he became convinced the number 666 was on his right hand. Believing the hallucination was evidence he was evil, the man removed the hand with a table saw on the job site. The man’s coworkers preserved the hand in a cooler and he was rushed to the hospital where he initially agreed to have the hand reconnected, but later changed his mind. The doctor consulted a judge who said the man appeared competent and advised the doctor the man could sue if he reattached the hand against the man’s wishes. Under state law, the consultation with the judge shielded the doctor and hospital from liability.

15. A  New York couple  sued a fertility clinic in 2007 for unspecified damages after their attempt to have a second child was successful. When the baby girl was born the pair suspected there may have been a mix up at the clinic as the child didn’t seem to resemble her white father. A series of DNA tests revealed the baby was the product of another man’s sperm. While the results of the cases have not been publicized, the New York Supreme Court did throw out the majority of the couple’s claims saying that “(t)he birth of an unwanted but otherwise healthy and normal child does not constitute an injury to the child's parents."

16. A  California woman  was seeking unspecified damages in a suit against a hospital she says left something behind during a surgery. The woman had a procedure to have a benign tumor removed from her abdomen and had been discharged for weeks before she was rushed to an emergency department complaining of severe pain in her back, kidney, and abdomen. ED doctors discovered an eight-inch pair of surgical forceps. Ultimately, the woman had 18 inches of her small intestine removed after it had looped through the handle of the forceps. It is unclear who prevailed in the suit.

17. A  Philadelphia woman  briefly received a nearly $1 million jury award after she sued a university hospital for ruining her psychic business. The woman claimed that an allergic reaction to a pre-CAT scan dye injection left her with severe, recurring headaches which left her unable to use the alleged psychic powers she harnessed to make a living. Before the procedure she claimed to be able to read auras, conduct seances , see both the future and the past, and help police solve crimes. Ultimately, the jury award was thrown out on appeal.

18. Switched Vials Cost a Renowned Photographer His Life One of the worst medical malpractice cases in history is that of the man who suffered a  huge  loss due to a teeny, tiny error.  Miami Herald photographer  Bob East  decided to donate his eye to science after he found out he had corneal cancer. So a doctor brought a tiny, unmarked vial of a formaldehyde-like substance into the operating room.  The surgery went smoothly at first. But then, an anesthesiologist grabbed the vial of preservative instead of the one he needed, and injected it into East’s spine. The damage was instant, and permanent: East was brain dead. He died five days later. 

19. Girl Gets Organ Transplant–With Wrong Blood Type  This medical malpractice story will blow your mind because of how preventable it was. Even more astounding is  where  it took place: in the prestigious Duke University Hospital.  17 year-old  Jesica Santilian  received a much-needed heart and lung transplant. But doctors made one huge mistake: they didn’t check her blood type first.  The new organs didn’t match Jesica’s blood type, so her body rejected them. She suffered severe brain damage, and died soon after. The  negligent hospital  covered up the mistake for 11 days before accepting responsibility. 

20. Woman Needlessly Loses Both Breasts  At 35 years old, Darrie Eason’s doctor told her she had breast cancer, and that she’d have to get both breasts removed. After the surgery, she discovered they made a mistake – she never had breast cancer. This case is extra horrifying due to the fact that she went out of her way to get a second opinion to make sure, but the doctor told her the same thing as the original – that she had breast cancer and she should get a double mastectomy. The one good thing is, she sued them and ultimately forced them into a settlement, winning $2.5 million of compensation.

21. Name Confusion Patient had been prescribed sulfasalazine 500 mg for rheumatoid arthritis. Her outpatient pharmacy began dispensing sulfadiazine 500 mg 6 times daily instead. She continued to fill sulfadiazine monthly. She presented to the ED with kidney stones. Recurrent reports on mix-ups between dexamethasone and dexmedetomidine; Methylphenidate 10 mg and Methadone 10 mg Tramadol was dispensed in place of Trazodone Continued mix-ups between hydralazine 50 mg and hydroxyzine 50 mg Wrong prescribing and dispensing errors with metolazone and methotrexate and methimazole (caused by entering “met” while ordering)

22. Fatal Methotrexate Errors Analysis of inadvertent daily methotrexate administration over 18 months between 2018 and 2019 1 ~50% involved older patients who were confused about the frequency of administration 50% were made by healthcare providers who inadvertently prescribed, labeled, or dispensed methotrexate daily when weekly was intended. FDA sponsored study suggests that up to 4 per 1,000 patients may mistakenly take the drug daily instead of weekly 2 Suggests the number of dose frequency errors could be far greater ISMP. QuarterWatch . 2019 Dec 4. www.ismp.org/resources/scope-injury-therapeutic-drugs Herrinton LJ, et al. Pharmacoepidemiol Drug Saf . 2019;28[10]:1361-8

23. Case Report Patient was prescribed, via telephone, metolazone 2.5 mg daily. Pharmacy technician accidentally selected methotrexate 2.5 mg daily by searching using the first three letters of the drug name and the strength. Patient took methotrexate daily and died less than a month later. No hard stop to verify an appropriate oncologic indication

24. Thank you Dr Ihab Suliman . دكتور ايهاب فتحي سليمان @ IhabFathiSulima