Medical Mistakes Happen

You may have seen headlines in the past few weeks, “Medical mistakes cause 250,000 deaths annually,” “440,000 people in the US die annually from medical mistakes,” “Medical mistakes are the third highest cause of death in the USA.”

These headlines are scary but rather impersonal. I’d like to tell you about my first-hand experience with medical mistakes.

Almost three years ago, my favorite gastroenterologist retired. Finally, about a year ago, I went to see a new specialist in the field.

After introductions, he asked why I was there and I told him I was following up on GERD problems but with an eye toward reducing and eventually eliminating my use of Omeprazole. It was my goal because of the adverse publicity associated with the use of Proton Pump Inhibitors (PPI’s).

He said that before we could discuss Omeprazole usage he needed to do an upper endoscopy to look at the area. He said he was going to schedule one and wanted to know when I last had a colonoscopy. Told him a couple years previously and in response to his question about polyps, told him I didn’t remember but they may have found one or two. “Well,” he said, “we’ll do a colonoscopy at the same time.”

My HMO has digitized our medical records so a patient’s records are readily available. A provider can turn on the computer using his coded pass key, but this doctor never turned it on during the thirty minutes I was in the office, even though he easily could have checked the results of my previous colonoscopy.

When I got home, I looked through my paper records and found a record of the previous (25 months prior) colonoscopy with no polyps found and a follow-up recommended in ten years.

I called his office and cancelled the colonoscopy.

So far, no harm done. “But wait, there’s more,” as the TV pitchman says.

About six weeks later, I received a 90-day supply of a drug to treat gout, prescribed by this same doctor. I immediately called the pharmacy worried that this prescription was intended for someone else and they had shipped it to me in error. After checking, the clerk assured me that my doctor had ordered the drug for me. I called his office only to be told not to worry about it and to dispose of it.

This worried me. I didn’t remember any discussion about gout, I've never had gout, and why would a consultation about GERD result in a prescription for gout. Finally, if he prescribed for my nonexistent gout, I wondered what else this doctor might be doing.

I ordered a copy of my medical records including all entries by this doctor. In review, the record was innocuous. There was a brief review of my physical appearance and apparent health, and an order for an upper endoscopy and colonoscopy. He justified the order for colonoscopy by citing polyps. "The patient's colon cancer screening history is remarkable for a history of colonic polyps on previous colonoscopy. He has not had a colonoscopy for 2 to 3 years with the last colonoscopy showing the presence of adenomatous polyps with no atypia. He clearly will also need a colonoscopy." He may have been confused by my poor recall, but if he had simply checked my record he would have known the facts.

If that weren’t bad enough, on June 16, 2016, a prescription for Ursodiol written by the same doctor was filled and sent to me with instructions to take one 500 mg tablet three times per day.

I checked the internet drug sources and found that this drug is used mostly to dissolve gallstones or prevent them from building up. It should be prescribed and used with caution as it may cause liver problems.

Now worry turned to anger. I’ve never had gallstones and, again, there had been absolutely no discussion about gallstones with the doctor nor was there mention of that in my record.

Of course, there is a possibility that he wrote the prescription for a different patient and his staff confused that person with me. There may be other reasons for these mix-ups but the basic facts are clear. The drugs went to a person who didn't need them, with potential serious harm. 

I wondered about other patients who might receive such a prescription and take it thinking that it had been ordered by their doctor. Even if they checked the pharmacy, they’d find that the doctor did order it and so some of them might risk problems thinking they were doing the right thing. Perhaps the blame is mostly on the doctor but the patient who unquestioningly takes a drug in such circumstances is also partly to blame.

Of course, I didn’t take the drug. I also didn’t call either the pharmacy or the doctor’s office. This time I wrote a letter of complaint to my HMO.

In early December I received a call from an assistant in that same office saying that I needed to come in (“at absolutely no cost to you. Even parking will be paid”) for a repeat of the upper endoscopy because, “there had been discrepancies in the administration and interpretation of the original test.” Upon further questioning, he told me that the doctor in question, “No longer works here.”

I don't know if this was a bundle of medical mistakes or an example of a medical doctor on the take or with other problems, but the important lesson to remember, as I said in my last post is, MEDICAL PATIENT BEWARE.

I hope this doctor was the unwitting victim of mix-ups and incompetent staff. But even assuming the worst, that he was doing things in an unethical way for unethical purposes and got caught, it often results in only a hand slap. Assuming he was investigated and Washington State revoked his license in this state, he could move to another state and probably begin practice there.

An unnecessary colonoscopy or other invasive procedure can be dangerous. Erroneous drug prescriptions can be dangerous. No matter the reason, if I had taken those pills because he had prescribed them for me, I might be trying to post blog entries from the great beyond.

I like to think I'm savvy enough not to take questionable prescriptions like that, but what if I'd been overtired, or ill, or distracted, or what if it had been someone else similarly impaired? It's easy to see how death or severe illness from medical mistakes can happen.

As you can see from this example and as we’ve all heard from friends or family, doctors make mistakes. Just because a person has a piece of paper giving him authority to practice medicine, he is still a human being with human weaknesses.

Moreover, doctors are given (rightfully so) a lot of authority. They listen to a person’s symptoms, interpret tests, investigate the various drug (or surgery) options and devise a treatment plan. Typically, they don’t have a supervisor checking their decisions or reviewing their prescriptions or surgical procedures. They operate with a great deal of autonomy. BUT, they sometimes make mistakes! 

How do we protect ourselves from such mistakes?

First, take backup. Have another person with you to listen and watch but also to serve as your advocate. Another person's eyes and ears may catch things that you don't or ask questions that you don't think about. Take notes, your memory is never perfect and when stressed it's even less so.  Ask for a printed summary of the doctor's instructions. Since my HMO converted to computerized records a couple years ago, patients receive a printed summary of the visit. That's a great help but even if your provider doesn't use a computer, ask for a summary of the visit.

There is another reason for having another person present, especially if you are a patient in the hospital. If you are ill or tired or even unconscious, your advocate can influence the behavior of the doctors or other medical professionals simply by being there watching. They know that your friend or family member is on your side and that will influence them to take extra care they might not take without a dedicated observer.

If you can’t find backup, consider taking a recording device, ask for permission and make a recording of the doctor’s instructions, procedure review or other communications. This is especially important if you have been sedated. Even though you may appear normal, your memory is probably unreliable at that point. Also, the fact that you are recording will encourage medical personnel to be more accurate and cover all necessary facts and instructions.

Second, be vigilant. Always read the labels, make sure they know it's you. Check the name on any papers they hand you. Make sure you are taking the drugs specified on the label. There are several good sites on the internet that will help you identify the drug the doctor prescribed. Just because the label says it’s the right drug, doesn’t make it so. The color of the Omeprazole capsules I take has changed twice in the past two years. It only took me a couple minutes to double check to make sure I was taking what the label said.

Don't feel irritated when they ask your name and DOB again and again. Encourage them to ask more often by thanking them for asking. Medical professionals are human and they make mistakes. Try to help them make as few as possible.

Third, if he is prescribing drugs, check a doctor’s income from drug companies at this site: https://openpaymentsdata.cms.gov/ or this site: https://projects.propublica.org/docdollars  Some doctors make big bucks (some make over a million dollars a year) from drug company payola. I'm not saying it would make your doctor prescribe the wrong medicine, but it might influence his prescription decision.

Fourth, request copies of your records. As a patient, you are entitled to receive copies of your records, but you must ask. Review those records while the visit is fresh to make sure it agrees with what you and your backup remember. If there are mistakes, request correction.

Finally, remember it's your health and your body. Question a recommended course of treatment and ask why certain drugs are prescribed. Doctors are human and there is often disagreement among professionals about the best treatment. If you ask questions, the doctor may realize while answering that he made a mistake or can reassure you that there were good reasons for this particular drug or procedure. In serious or questionable cases ask for and get a second opinion.

Above all, take care of yourself. The doctor might have hundreds of patients to care for, you have only one, yourself.