Medical Errors: The Silent Killer in Medicine | Carol Gunn | TEDxFargo
Summary
TLDRThis 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
- π₯ A tragic incident at a San Francisco hospital in 2013 highlighted the severity of medical errors when a patient was overlooked and died unnoticed.
- π©Ί 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.
- 𧬠Anna's health declined after a bone marrow transplant, with her symptoms being consistently overlooked, leading to a severe heart condition.
- π Despite being advised to go to the ER, Anna's chest pain was initially dismissed as nerve pain, which delayed her treatment.
- π₯ The teaching hospital where Anna was treated had systemic issues, including outdated information in medical notes and lack of physician accountability.
- π The speaker's review of Anna's medical records confirmed that her death was preventable, aligning with broader statistics on medical errors.
- π 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.
- π€ The speaker calls for institutional change in healthcare, emphasizing the need for transparency, accountability, and improved patient/provider communication.
- π©ββοΈ Physicians are urged to listen to their patients, document care meticulously, and confront colleagues about patient safety concerns.
- π¨βπ©βπ§βπ¦ 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
π₯ 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.
π 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.
π¬ 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.
Mindmap
Keywords
π‘Medical Errors
π‘Bone Marrow Transplant
π‘Neurologic Symptoms
π‘Coronary Stent
π‘Healthcare Feedback
π‘Institutional Change
π‘Transparency and Accountability
π‘Patient Advocacy
π‘Documentation
π‘Preventable Death
π‘Silence
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]
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