Medical Errors: The Silent Killer in Medicine | Carol Gunn | TEDxFargo

Summary

This video script recounts the tragic tale of a woman who died due to medical negligence in a San Francisco hospital. It also shares the personal story of the speaker's sister, Anna, who suffered a fatal heart attack due to overlooked symptoms and inadequate medical care. The speaker, a physician, emphasizes the prevalence of medical errors, which are the third leading cause of death in the U.S., and calls for institutional change, transparency, and accountability in healthcare to prevent such tragedies.

Takeaways

• 🏥 A tragic incident at a San Francisco hospital in 2013 highlighted the severity of medical errors when a patient was overlooked and died unnoticed.
• 🩺 The speaker, a physician, personally experienced the impact of medical errors when her sister Anna suffered due to misdiagnoses and lack of proper medical attention.
• 🧬 Anna's health declined after a bone marrow transplant, with her symptoms being consistently overlooked, leading to a severe heart condition.
• 🚑 Despite being advised to go to the ER, Anna's chest pain was initially dismissed as nerve pain, which delayed her treatment.
• 🏥 The teaching hospital where Anna was treated had systemic issues, including outdated information in medical notes and lack of physician accountability.
• 🔍 The speaker's review of Anna's medical records confirmed that her death was preventable, aligning with broader statistics on medical errors.
• 📊 Medical errors are the third leading cause of death in the United States, claiming an estimated 200,000 lives annually, as reported by the Institute of Medicine.
• 🤝 The speaker calls for institutional change in healthcare, emphasizing the need for transparency, accountability, and improved patient/provider communication.
• 👩‍⚕️ Physicians are urged to listen to their patients, document care meticulously, and confront colleagues about patient safety concerns.
• 👨‍👩‍👧‍👦 Patients and their families are encouraged to be proactive in their healthcare, ask questions, seek second opinions, and advocate for their health if they believe they've been harmed.

Q & A

What was the tragic incident that occurred at a San Francisco hospital in 2013?

A confused patient wandered into a stairwell and died, with a hospital employee stepping over her body twice before finally notifying a nurse the second time. The body was not found for another week.

How did the speaker's sister, Anna, initially fare after her bone marrow transplant?

Anna did well initially after her bone marrow transplant in 2013, but seven months later, she began to experience odd neurologic symptoms.

What was the medical error that led to Anna's heart attack?

Anna's doctors did not take her complaints of chest pain seriously, leading to a delay in diagnosing and treating her heart condition, which resulted in a heart attack and significant damage to her heart.

What was the emotional impact on the speaker when her sister told her about her experience?

The speaker was deeply affected, feeling helpless and emotional, as both she and her sister cried together in the hospital room, with Anna expressing her fear of dying and her anger at the medical system's failure.

What did the speaker do after Anna's death to understand the cause?

The speaker reviewed all of Anna's medical records and conducted research to determine if her death was preventable, which she confirmed it was, and that it was not an isolated case.

What was the estimated number of Americans dying annually due to medical errors according to a 2013 report?

The 2013 report estimated that 200,000 Americans die each year due to medical errors.

What is the speaker's mission after realizing the prevalence of medical errors?

The speaker's mission is to openly share Anna's story and what she has learned about harm from medical errors, advocating for institutional change in healthcare to prevent such incidents.

What was the speaker's personal experience with making a medical error?

The speaker had a patient with belly pains, diarrhea, and weight loss whom she saw three times and referred on, but she missed diagnosing an infection that could have been fatal and prolonged the patient's illness.

What is the speaker's advice to healthcare executives to prevent more deaths like Anna's?

The speaker advises healthcare executives to commit manpower and resources to find safer ways to deliver care, lead with transparency and accountability, and help providers be more engaged.

What recommendations does the speaker have for patients and their loved ones regarding medical care?

The speaker recommends that patients know their bodies and question symptoms, seek second opinions if necessary, and speak up if they believe they have been harmed, sharing their stories to help prevent future errors.

Outlines

00:00

🏥 Medical Errors: A Personal Tragedy

The speaker recounts a tragic incident from 2013 at a San Francisco hospital where a patient died after being overlooked by hospital staff. This story serves as a backdrop to the speaker's personal experience with medical errors when their sister, Anna, suffered a series of misdiagnoses and mistreatments following a bone marrow transplant. Despite being a physician, the speaker was unable to prevent the mismanagement of Anna's health, which ultimately led to a severe heart condition and her death. The narrative emphasizes the systemic issues within healthcare that contribute to medical errors and the emotional toll they take on patients and their families.

05:00

🔍 The Reality of Medical Errors and Their Impact

The speaker delves into the broader context of medical errors, acknowledging that no healthcare provider is infallible. They share a personal story of a patient they failed to diagnose correctly, which could have had fatal consequences. The speaker discusses the lack of progress in reducing medical errors, citing a report that estimates 200,000 Americans die each year due to such errors. They highlight the importance of feedback and transparency in healthcare, sharing an anecdote about a time when a colleague's feedback improved patient care. The speaker calls for institutional change, emphasizing the need for healthcare leaders to commit resources to improving patient safety and for physicians to be more engaged in error prevention.

10:00

💬 Advocating for Change in Healthcare

In the final paragraph, the speaker addresses the need for change in healthcare to prevent medical errors. They stress the importance of listening to patients, documenting care meticulously, and confronting colleagues when patient safety is at risk. The speaker encourages patients to be proactive in their care, seeking second opinions and advocating for changes when necessary. They also call for a cultural shift in healthcare, where medical errors are openly discussed and learning from mistakes becomes the norm. The speaker concludes with a call to action, questioning the lack of outrage over the third leading cause of death in the U.S. and urging for a collective effort to break the silence surrounding medical errors.

Keywords

💡Medical Errors

Medical errors refer to mistakes or adverse events that occur during medical treatment or care, which can lead to injury or death. In the video, the speaker's sister, Anna, experiences a series of medical errors that contribute to her deteriorating health and eventual death. The video emphasizes the severity of medical errors, highlighting them as the third leading cause of death in the United States, after heart disease and cancer.

💡Bone Marrow Transplant

A bone marrow transplant is a procedure that replaces diseased or damaged bone marrow with healthy bone marrow stem cells. Anna underwent a bone marrow transplant in 2013, which initially seemed successful. However, complications arose later, leading to her experiencing neurologic symptoms and chest pain, which were not properly addressed until it was too late.

💡Neurologic Symptoms

Neurologic symptoms are indications of disorders of the nervous system, which can include a wide range of issues affecting the brain, spinal cord, and nerves. Anna developed odd neurologic symptoms seven months after her bone marrow transplant, which were initially overlooked by her healthcare providers, contributing to the delay in diagnosing her heart condition.

💡Coronary Stent

A coronary stent is a small mesh tube that is inserted into a narrowed coronary artery to help keep it open, improving blood flow to the heart. Anna required a coronary stent after a cardiologist finally evaluated her chest pain, but by then, she had already lost 50% of her heart's pumping power.

💡Healthcare Feedback

Healthcare feedback refers to the process of providing information to healthcare providers about the quality and outcomes of their care. The video discusses the importance of feedback in improving patient care, noting that the speaker rarely witnessed such feedback during her medical training, which may have contributed to the lack of timely intervention for her sister.

💡Institutional Change

Institutional change involves altering the policies, practices, and culture within an organization or system to improve outcomes. The speaker calls for institutional change in healthcare to prevent medical errors like those that occurred with her sister, emphasizing the need for leadership to commit resources to finding safer ways to deliver care.

💡Transparency and Accountability

Transparency and accountability are principles that involve being open and honest about actions and decisions, and being responsible for the outcomes of those actions. The speaker advocates for healthcare leaders to lead with transparency and accountability to improve patient safety and reduce medical errors.

💡Patient Advocacy

Patient advocacy is the act of speaking up for oneself or others in healthcare settings to ensure proper care and treatment. The video encourages patients and their families to be advocates for their health, questioning symptoms and seeking second opinions if necessary, as part of the effort to reduce medical errors.

💡Documentation

In healthcare, documentation refers to the recording of patient information, medical history, and treatment plans. The speaker points out that Anna's medical record was full of cut-and-pasted notes with outdated information, which may have contributed to the mismanagement of her symptoms and the delay in appropriate treatment.

💡Preventable Death

A preventable death is one that could have been avoided with proper care or intervention. The video's central theme revolves around the preventable nature of Anna's death due to medical errors, highlighting the need for systemic changes to reduce such occurrences.

💡Silence

In the context of the video, silence refers to the lack of open discussion and acknowledgment of medical errors within the healthcare system. The speaker criticizes this silence as a barrier to improvement and calls for a more vocal and proactive approach to addressing and preventing medical errors.

Highlights

A patient died in a San Francisco hospital after being overlooked by hospital staff.

Medical errors are a significant issue, with the speaker being personally affected by one.

The speaker's sister, Anna, experienced medical errors post-bone marrow transplant.

Anna's neurologic symptoms and chest pains were initially dismissed by doctors.

Anna suffered a heart attack due to medical negligence, losing 50% of her heart's pumping power.

The emotional impact of Anna's preventable death on the speaker and her family.

The speaker's mission to raise awareness about medical errors after Anna's death.

The Institute of Medicine's report in 1999 highlighting the harm caused by medical errors.

An estimated 200,000 American deaths per year are attributed to medical errors.

The lack of feedback and accountability in the medical field contributes to medical errors.

The speaker's personal experience with causing medical errors and the importance of acknowledging them.

The need for institutional change in healthcare to prevent medical errors.

The importance of listening to patients and documenting care accurately to improve patient safety.

Advice for patients to advocate for themselves and seek second opinions when necessary.

The call to action for healthcare leaders to commit resources to finding safer ways to deliver care.

The need for transparency and accountability in healthcare to reduce medical errors.

The speaker's personal commitment to confronting colleagues about patient safety concerns.

The importance of sharing stories like Anna's to raise awareness and prevent future medical errors.

Transcripts

[Music]

in

2013 a horrific story came out of a San

Francisco hospital where a confused

patient wanded Ed into a little you

stairwell and

died later it was learned that a

Hospital employee had stepped over her

body

twice only telling a nurse the second

time and even though that nurse notified

security they still didn't find the

woman's body for another

week an extreme example of medical

errors for

sure as a physician I'm very very aware

of medical errors but it wasn't until

last year that medical errors knocked at

my front

door my older sister Anna she'd had her

health

struggles and in 2013 she had a bone

marrow

transplant initially she did great but

seven months after her transplant she

began to have some odd neurologic

symptoms and 5 months after that she

began to have chest pains when she told

me about the chest pains I told her she

had to go to the ER but even though I'm

a doctor to her I was just her kid's

sister so she asked her physicians at

the teaching Hospital the first

recommended acids and when her chest

pain persisted another told her her

nerve pain medicine was treating it and

no one bothered to look any

further Anna got worse she lost

sensation below her waist and was

hospitalized near her home after she was

trans back to the teaching Hospital her

neurologic symptoms

improved but her chest pain was

continuing and she was very short of

breath it wasn't until the 12th day at

the teaching hospital that a

cardiologist finally evaluated her and

by then she' lost 50% of her heart's

pumping power and she needed a coronary

stent my sister had had a heart attack

the morning after she received her stint

I was with her in the hospital room and

she would doze on and off and I just sat

quietly in the

corner and during one of her waking

moments she said to

me I thought I was dying the other

night I didn't even know how to respond

I just reached for her hand held it ever

so tightly

and we both began to

cry and we sat there

crying and she went on and she said I am

so

mad and I knew instantly why for months

she had told her doctors about her chest

pain and no one had taken her

seriously and now she'd had a heart

attack and parts of her heart were

deemed

unsalvageable due to Physicians not

pursuing her symptoms she literally paid

with her

health so we sat a while together just

holding hands tears streaming down our

faces and she said to me are you going

to go after this and my response was

well do you want me to and emphatically

she said no one should ever go through

what I've been

through we never spoke about it again

unfortunately she died several days

later her autopsy said she'd been having

ongoing waves of heart

attacks initially after her passing I

was in shock and then my anger my anger

was off the

charts I was convinced her death was

preventable and I was driven to find the

truth so I reviewed all of her her

medical records and I was right her

death was

preventable and from all my research I

also knew hers was not an isolated case

of a death from medical

errors my mission now is very clear

silence is not an option I openly share

Anna's story and what I've learned about

harm from medical

airs like most doctors I focus on giving

the best care possible but none of us

none of us are perfect no way and like

all providers I can count the several

patients I have

harmed

significantly but inadvertently while

treating them as a doctor one patient of

mine she was about 50 and she had belly

pains diarrhea and weight loss I saw her

three times ultimately referred her on

but she had an infection that I should

have diagnosed and treated but I

definitely missed

luckily she survived but her illness

could have been fatal and it did last

much longer than it should

have but she gave me The Ultimate Gift

she called me and informed me of my

mistake in medical errors the ones I

worry about the most are the ones I

don't know about the medical errors that

have not yet come to my

attention those are the ones that I

agonize

over in medicine the first large focus

on medical eror reduction began in

1999 when the Institute of medicine

released its report to air as human

which highlighted how medical airs

harmed a huge number of patients in an

independent followup report in 2013 it

showed no real progress had been made on

medical error

reduction and it estimated that 200,000

American Americans die each

year 200,000 Americans die each year due

to Medical errors it's our third leading

cause of death in this nation it follows

heart disease and

cancer a new Institute of medicine

report is due out in the fall of

2015 in my prediction the estimated

lives loss Will Remain

astronomical and in excuse me in the

culture of healthc care is only starting

to embrace the statistics around medical

errors I graduated in my fellowship in

2005 and as trainees we received almost

continuous feedback but in my nine years

of medical training I only recall one

example where I saw a physician who

actively gave feedback to another

provider who wasn't in

training I was working working alongside

an orthopedist and he noted the wrong

care given previously by a nurse

practitioner extending a patient's

recovery time he called her he thanked

her for caring for the patient and then

recommended a different splint for the

next time to improve

Care on the other hand I remember

numerous examples when I was a medical

student or a medical resident when I'd

asked my faculty mentors why weren't we

giving feedback to Physicians on

outdated or incorrect care

once while working alongside a

cardiologist he noted that the primary

care physician was not dosing their

Mutual patients medications

correctly when I asked him shouldn't we

inform that doctor he said we don't do

that why

not so where do we go from

here what about my sister

Anna our family chose not to pursue

malpractice

money won't bring her back we want more

than money we want change we want

institutional change in health care and

I think that's the hope of most families

that have been Afflicted is to know that

their loved one did not die in

vain so I returned to that teaching

Hospital multiple times in fact asking

to hear what changes have been put in

place to prevent more deaths like Anna's

you see when I reviewed her medical

record it was full of cut and pasted

notes with outdated

information one of her Physicians

confessed to me that although he had

written a note on her he had never seen

her because it was late at night another

when asked why didn't you pursue her

chest pain symptom said I'd have to

refer all my patients to

cardiologists for which I said to him

sir you could have been a

hero so what do I say to the healthc

care Executives those in leadership

positions to prevent more deaths like

anas it's time to step up you need to

commit Manpower and resources to find

safer ways to deliver care lead with

transparency and accountability and help

your providers be more

engaged and what do I say to my fellow

Physicians those those alongside me in

the trenches to prevent more deaths like

Anna we all must listen to our patients

and document care like we'd want our own

loved ones care

documented we must confront our

colleagues if there's any question of

about a patient's

safety and consider it a gift if a

patient or a colleague approaches you

with a safety

concern and what do I recommend to you

or your loved ones if undergoing going

care today as lessons learned from my

sister's death remember you know your

body better than anyone else if a

symptom processs question

why if necessary get another opinion and

another if you or your loved one believe

you've been harmed speak

up request

changes share your story

so I

wonder hopefully along with all of you

now how can we get the nation's

attention on preventing medical

errors it's our third leading cause of

death where is the

outrage how many more anas must

die for you

see even over the death of my precious

sister

the Ultimate Medical mistake is the

deafening silence that continues to

surround medical

errors thank you

[Music]