The impact of errors in medicine

Not all errors have negative consequences. Many go unnoticed. Occasionally they save lives.

I was a fourth year medical student finishing a pediatrics rotation in Rochester, New York. The intern supervising had retreated to his call room with a flu-like illness and asked me to call him only in the event of major issue. I managed what seemed like two straight-forward admissions without any difficulty: a 7 year old with a flare of her asthma and a 16 month old with fever, vomiting, diarrhea and mild dehydration. The asthmatic quickly improved with epinephrine and IV aminophylline. (How many readers remember that era?)  

Then the lab came back on the 16 month old: his WBC (white blood cell count) was 28,000 (normal 5-12,000) with a ‘left shift’ (lots of immature white cells released in response to acute stress and called ‘bands’ because of the appearance of their incompletely formed band-like nuclei under the microscope). I debated awakening my intern, but decided to let him sleep and call my attending instead. He was easy to work with and had trusted me with issues like this in the past. I re-examined the toddler, who looked pretty good in terms of hydration, vital signs and exam/activity. He was certainly not toxic appearing and gave no signs of either sepsis or meningitis, I discussed my findings and the options on the phone and the attending felt an LP (lumbar puncture or spinal tap, to obtain CSF - cerebrospinal fluid) was necessary to avoid missing meningitis. He didn’t specifically tell me to awaken my intern, and I had done enough LPs to feel comfortable, so I told the nursing staff I needed to do an LP on the 16 month old in 294-A. The nurses were out straight and I decided to help out (and speed my return to bed) by setting up the equipment for the tap and bringing the child down to the procedure room myself.

When the nurse arrived, I had the tray out, the betadine poured, and the tubes labeled and ready to go, and the child on the procedure room table ready to be bundled into a restraint. She gave me an appreciative nod for helping with the prep and we went ahead with the tap. Taps in that age tend to be fairly easy - the anatomy is conducive and the landmarks easy to find - and this was no exception. Five minutes later 3 tubes of fluid were on their way to the lab. They were bloodless, a tribute to the smoothness of the tap, but disquietingly cloudy rather than clear. The results came back positive for white cells and gram positive bacteria, with a low sugar and high protein. (The culture subsequently grew out D. Pneumoniae, a kind of meningitis fairly common then but rarely seen in children now because of the pneumococcal vaccine.)

This didn’t fit well with the clinical picture of the child I had examined earlier and an uneasiness began to infect me. I went back to see the child in 294-A, and he was sitting up and looked great. I undressed him for a more complete exam and noticed to my great distress that there was neither betadine nor a bandaid on his low back. How could that be? I looked around the three bed room with a nagging suspicion and a growing distress. All three cribs were occupied, and the child in 294-C looked alarmingly familiar. I walked over and lifted up his johnny. There it was: dried Betadine and a bandaid covering a puncture mark. 

I had ‘tapped’ the wrong child. I made haste to the nursing station and pulled his chart. He was not on the pediatric teaching service, but had been admitted earlier in the day by one of the private docs in the community, with a diagnosis of irritability and fever. His WBC had been 12,000 without much left shift and he was being watched overnight with a plan to repeat his lab in the morning and send him home if his labs were stable and he was clinically doing well. I alerted the nurses, both to get fresh VS done (his temp was now 40.1) and to ask for advice about next steps. 

His attending was notoriously cranky when called at night, known to yell at staff and patients and hang up in the middle of a conversation. I called and explained that I was a medical student on the pediatric service, that I had inadvertently done a spinal tap on the child he had admitted rather than the child I had admitted, and that it was very positive, consistent with bacterial meningitis. I got the response I expected: “What the god damn right do you have interfering with my patients? You must be one dumb-ass medical student.”  I apologized again, and asked what he wanted me to do about the results, did he want me to start the antibiotics right away or did he want to come in and see the child first? There was silence. He asked if the parents knew. I said, no, I had not spoken to the parents. He told me to start the antibiotics (ampicillin and gentamycin) but NOT to talk to the parents (who were at home - it was uncommon for parents to stay with children in the hospital in those days). He came in shortly and examined the child, wrote a note and some orders, but said nothing to me. I overheard him on the phone with the parents telling them that their son had suddenly looked much sicker so he had gone ahead and done the tap urgently without calling them or getting a permit signed, and that it was a good thing, because the child had meningitis and any delay might have had dire consequences. Then he left, without even a glance in my direction.

A few moments later the nurse came by with a cup of coffee and a sweet roll, and apologized for not double checking the ID bracelet before we did the tap. I suddenly realized she thought it was her fault and was grateful that I had been willing to take the full blame.  “After you finish your coffee.” she said, “we still have to tap the right baby.” I had no appetite for coffee or a roll, so we went ahead with tap #2, which also went smoothly - and produced the totally normal results expected. 

I went back to bed but did not sleep, upset with myself for making such a stupid mistake (modern checklists and safety procedures largely prevent errors like that), very upset with the attending who had castigated me and taken credit for something he had not done, but overwhelmingly, I was distressed by the role serendipity had played in saving the life of a 16 month old whose parents had entrusted him to the system. That was one lesson I learned: do the very best you can, but accept that luck can instantly and unpredictably knock down your carefully constructed house of cards, or provide a life boat in the midst of chaos. Accept it with grace.

I also learned (neither for the first nor last time) the value to adhering to every step in a process and never taking shortcuts. I knew the drill. I should have checked the ID bracelet when getting the child, and then when setting up, and then when labeling the specimens. The nurse should have checked the ID bracelet before letting me start the LP and again before we sent the specimens. Five chances we missed to learn our error.

I learned something else, as well. The attending physician for the child with meningitis wrote a nasty letter about me detailing my carelessness and incompetence (but not mentioning his own dishonesty with the parents) and sent it to the medical school dean, who called me in to show me the letter and talk about what had happened. After I read the letter (the attending had not had the courtesy to send me a copy or talk to me about it), he asked me to explain what had happened. I told him that I had screwed up and done an invasive test on the wrong child, but that I had been lucky and no harm had been done and an unsuspected meningitis had been found and treated, which I hoped would be considered in my favor.  He smiled (the only time I ever saw Dean Orbison smile in five years) and said that was the correct answer, and that I was going to be a fine physician. Then he showed me the letters from the nurse and the attending on the teaching service, each of whom had spontaneously written a letter about the incident and attached it to my evaluation. They were both matter of fact but quite positive about the fact that I had made a serious error, but had recognized it on my own and had not hesitated to get help and make things right with no attempt to cover it up or deflect blame. 

And that was the third lesson I learned. Errors are inevitable. We all make mistakes. Some will be small and of little consequence, but some will be major. The only acceptable response is to be open to our fallibility, to be willing to recognize and admit one’s errors, and then honestly and openly do what has to be done to fix it. 


 

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