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Minor Mistakes, Deadly Results
Thousands die in hospitals because of simple oversights made by doctors and nurses. Here’s how hospitals can improve patient safety. By Bara Vaida
Comments () | Published January 27, 2012

When Frances Barnes had a stroke in August 2008, she was taken by ambulance to Howard University Hospital. The 80-year-old grandmother was there for about two weeks when she began complaining about pain in her legs. Her daughter Althea Hart pulled back her mother's blankets and noticed a strange odor. Hart thought the smell was coming from the compression stockings wrapped around Barnes's legs to help with circulation, so she took them off. She found that her mother's left foot had turned black.

Hospital staff had failed to follow physician orders, which required taking off the compression stockings after each shift for at least 30 minutes, according to a DC Department of Health investigation.

"We called a nurse right away, and they tried to heal her infection," says Patricia Moss, another of Barnes's daughters. "But they couldn't."

Barnes's family moved her to Providence Hospital in Northeast DC, where she had to have her lower leg amputated. Barnes moved to a nursing home, where she continued to get infections; she died at Providence in February 2009, five months after her foot turned black. Barnes left behind eight children, 15 grandchildren, and 16 great-grandchildren. Moss filed a lawsuit against Howard University Hospital. The case was settled last year, but details weren't made public and the hospital denied liability.

"I miss her every day," Moss says. "She was doing okay until she went to Howard. She had no ulcers and no sores. Her feet were okay." If it weren't for the infection, Moss says, her mother might still be alive.

As sad as Barnes's story is, it's far from an isolated event. Alarms have been sounding for more than a decade, ever since the Institute of Medicine--the health arm of the National Academy of Sciences--estimated that as many as 100,000 people a year were dying in US hospitals due to preventable errors.

Despite those warnings, the situation has gotten worse. In 2010, the federal government estimated that faulty medical care contributed to the death of about 15,000 Medicare patients per month. By these measures, faulty hospital care is one of the leading causes of death, behind heart disease and cancer.

Why haven't hospitals made more progress on patient safety? The reasons are multiple and complex, but they boil down to the fact that hospitals are hierarchical organizations resistant to change, they haven't done enough to create environments in which patient safety is a priority, and they've been reluctant to share patient-safety data with the public.

Even getting full compliance on basic safety standards, such as washing hands, has proved elusive because hospitals are busy, high-stress places full of distractions.

"We are humans and are destined to make mistakes," says Nancy Foster, vice president of quality and patient-safety policy at the 5,000-member American Hospital Association. "The question in health care is: Can we design processes and have them in place so when an individual makes a natural mistake, that mistake doesn't result in harm to patients?"

I spoke with a dozen hospitals in the region to ask what they're doing to address patient safety. All are working on strategies--including using checklists to ensure that hospital employees consistently follow safety standards, ramping up pressure on employees to wash their hands, flattening hierarchies to improve communication between doctors and nurses, designing equipment to reduce errors, and digitizing patient records.

Five hospitals--Georgetown, Holy Cross, Inova Fairfax, Shady Grove Adventist, and Suburban--opened their doors to me to provide a fuller picture of what they're doing regarding patient safety. All five say they've improved but have more to do.

On September 22, 2010, Nadege Neim, a 28-year-old married medical student, was admitted to Baltimore's St. Agnes Hospital to have a cyst on her left ovary removed. Neim's doctor removed her right ovary and fallopian tube, according to a lawsuit she filed.

The case highlights a persistent problem: A small number of surgeries are conducted on the wrong body part. Neim didn't know about her doctor's alleged error until a month later, when she went to Howard County General Hospital's emergency room complaining about right pelvic pain and learned that her right ovary had been removed and that the cyst on her left ovary remained. Neim is now at risk for infertility.

"I felt so violated," she said in a statement. "I can't believe my doctor did this to my family and my future."

The doctor, Maureen Muoneke, has filed a response to the suit denying liability, according to the plaintiff's attorney.

Wrong-site surgeries keep happening--as often as 40 times a week in US hospitals and clinics.

There are safety measures in place designed to prevent such mistakes. Since 2004, the Joint Commission, the organization that accredits American hospitals, began requiring doctors and nurses to follow a short checklist called the "universal protocol" as a way to eliminate wrong-site surgeries. Before an operation, hospital staff are supposed to verify and mark the part of the body to be operated on, and surgical staff are supposed to take a time-out right before the surgery to ensure they're operating on the correct part of the body.

Yet wrong-site surgeries keep happening--as often as 40 times a week in US hospitals and clinics, according to the Joint Commission. Patient-safety experts aren't sure why, but they think it's related to increased time pressures in health care as well as doctors' tendency to underestimate their vulnerability to error.

"There is this conspiracy of exceptionalism" in the culture of health care, says Carol Haraden of the Institute for Healthcare Improvement, a Cambridge, Massachusetts-based nonprofit.

Because of the hierarchical nature of hospitals, in which the senior doctor is the leader, there often hasn't been a culture of collaboration and teamwork, Haraden says. That's been an obstacle to improving patient safety, because while doctors are expected to be confident about their decisions, they also have to accept that oversights can happen and that sometimes a nurse or another colleague might know better.

Next: "Avoidable failures are common and persistent, not to mention demoralizing and frustrating"


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  • It’s really horrible to see doctors do such small mistakes that leads to major incidents. One of my unforgettable moment is where my cousin had an eye surgery on his left eye but the surgery was done to the right eye.

    Had to hire a good lawyer get a compensation from the hospital.

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