A personal encounter with the complexity and errors of the modern healthcare system.
Image from Flickr via robert.harwig
By Marshall Allen
By arrangement with ProPublica
For Dr. Elaine Goodman, the strongest lessons in patient safety didn’t come from her training. They came from her mother’s death.
Goodman had just finished her first year of medical school when she found herself spending months at the bedside of her 63-year-old mom, who was battling breast cancer in the hospital.
Nursing Home Inspect
One morning she arrived to find her mother’s face and hands bloodied. Hallucinating and disoriented, her mom had yanked the cranial staples inserted during a recent procedure from her head.
Another time, a stethoscope fell on her mom’s face and gave her a black eye. She suffered frequent falls and preventable side effects from drugs. And she narrowly missed having an unnecessary brain operation and getting an incorrect drug.
“It was really eye opening for me to see the reality of how difficult it was to keep her safe in the hospital,” Goodman said. “It’s not enough just to have caring, qualified people to keep the patient safe.”
Goodman believes the incidents hastened the decline of her mother, who died in 2008 after six months in the hospital. A Harvard Medical School grad, Goodman is now a second-year resident in internal medicine and primary care at Brigham and Women’s Hospital in Boston.
Goodman shared her story after completing our Provider Questionnaire, part of our ongoing reporting on patient safety. ProPublica confirmed details of her mother’s story with one of the physicians who treated her and by reviewing her records. This interview with Goodman has been edited for clarity and length.
What did your experience with your mom teach you about medicine?
The hospital she was in is a nationally ranked hospital near Seattle. It wasn’t that we felt the place was not up to snuff or not capable of providing good care. But I hadn’t realized how hard it is to keep a complicated patient safe in the hospital. The harm is rarely caused by actual negligence. The vast majority of cases involve a lot of people doing fairly reasonable things, and somehow something just falls through the cracks.
One day my mom fell out of bed in middle of the night. They had bed alarms to notify nurse if a patient starts to fall out of bed. But there’s also a chair alarm, and the nurses showed us that there were only enough electric outlets for one alarm at a time, and the alarms had identical cords—making it hard for the nurses to tell which alarm was plugged in. The day my mom fell, the wrong alarm was plugged in.
There are lots of easy solutions to this. They could make the cords different. Or they could have two outlets, so both could be plugged in. I certainly hadn’t thought about that as a medical student, but all of a sudden it became the most important thing in my day when my mom was in the hospital.
Medication errors were frequent. My mom was on a seizure medication that needed the dose adjusted according to her nutritional status. The physicians probably knew this, but with all the handoffs, a new doctor would come in, see the drug level was low in her blood—and without carefully observing her nutrition—and then up the dose. She was being accidentally overdosed on the medication which caused her to sleep for days. As somebody who has a life expectancy on the order of months, those days were very important to us.
It was a case that illustrated what they call the “Swiss cheese model” for how errors occur. All the holes just line up and then the mistake is made.
The biggest error related to her chemotherapy, which was administered by a device straight into the fluid of her brain. They’d give her the chemo about once a week, and it was supposed to last an entire week. One weekend her normal oncologist wasn’t on so the covering physician administered the chemo. About a week later her normal oncologist came to us in tears. She’d discovered that her colleague had not administered the right chemotherapy drug, and the type she’d received had only lasted a day, not a week. My mom had effectively gone for a week without getting any treatment. For her this probably didn’t change her life expectancy drastically, but it probably changed it a little bit. But this event itself was really terrifying. It had the potential to make a huge difference in the life expectancy of other patients.
How did the hospital doctors and officials respond?
We [family] had a lot of conversations with the hospital administrators about what they were going to do about such a big medication error. We arranged to become members of the hospital’s patient safety committee. That got us involved in a way that made us feel they were addressing it.
On the committee I watched how the hospital addressed the error. It turned out the drug that had been incorrectly administered had a name that was almost identical to the name of the correct drug, and the labels were almost identical. Plus, the hospital did not have a pharmacist who had specific expertise in chemotherapeutics. It was a case that illustrated what they call the “Swiss cheese model” for how errors occur. All the holes just line up and then the mistake is made. There were no good systems in place to make sure that if somebody didn’t catch it, there was some hard stop to keep this from happening.
The hospital ended up hiring a new chemotherapy pharmacist, training the nurses and changing how the chemotherapy drugs were ordered and labeled.
What do you see as the causes of ongoing patient safety problems?
Complexity. There are exponentially more treatments, medications and technologies now compared to a few decades ago. We also have so many different ways patients are insured, different facilities they’re staying in and various aspects to their care. There are so many layers to manage.
There’s also a huge problem with overbooking our physicians and medical staff. The patient volume is high, and they’re in and out of the hospital more quickly. The demands on a physician’s time are incredible. Physicians are constantly multitasking—being paged all the time, distracted, working long hours—with no time to sleep. The list goes on and on.
And yet the emphasis is on the individual doctor taking care of all the issues. You take these caring, smart individuals and put them in a situation where they’re overtired with too many demands on their time, and they’re supposed to double check themselves and make sure nothing slips through the cracks. Frankly there aren’t enough hours in the day to make sure you do all of that. You also don’t have the mental bandwidth to do it.
How did your experience change the way you practice medicine?
It changed how I view interacting with families. Last year I was an intern here at Brigham and Women’s. I was working extremely long hours and getting hundreds of pages I had to respond to. When I’d get a page that said a family wanted to talk, sometimes my heart would sink. I was tired, hungry and had other patients to attend to. It’s terrible. But you can get to a place where if someone asks you one extra question you’re just going to snap. That’s another example of burnout or being overworked.
We’re not all the way there yet. People are still prone to taking these things as personal failings instead of thinking about the system.
When I was first in the hospital with my mom I tried not to ask too many questions. I didn’t want to be labeled “difficult,” or as the daughter in med school who thinks she can dictate decisions. As a result my mom’s care got worse. I realized that we family members had a lot to offer, especially in terms of handoffs between physicians. Sometimes the only person who’s been present is a family member. In one case with my mom, a radiologist had picked a chemo drug he thought was best and later I saw a nurse begin to administer a different chemotherapy drug in response to his order. I questioned the nurse. The nurse was kind of annoyed, but she called the radiologist and then administered the correct drug.
What did you learn about patient safety as a medical student?
We had some lectures peppered throughout the curriculum. No patient safety course, but we had talks here and there. I went to med school because I was passionate about science and care, so the patient safety topics weren’t the most exciting. They were about organizational structure and felt more like business school than medical school.
I would have been more attuned to this problem if the instruction had been tied to individual patients. When I came back to medical school [after caring for my mother], I did a patient safety elective—which was a new thing at the time—where students sit in on committees that are reviewing adverse events. Reviewing those cases made it easy for me to imagine myself as a physician who missed something important while caring for a patient.
What’s one way medical providers can reduce the number of patients who suffer harm?
Sometimes errors are not even tracked. When I returned to medical school after my mom’s death, I found that there was no way for medical students to report an error. There was an error reporting system, but the medical students did not have a login for it. Myself and a couple other physicians in the patient safety elective helped get that changed.
And when errors are reported, the response is not always constructive. I filed an error report a few days ago about a medication event. Most people responded well, but a few emails I got showed some people were not happy being involved in an error report. We’re not all the way there yet. People are still prone to taking these things as personal failings instead of thinking about the system. We need to move away from a culture of saying ‘error reporting is done to be punitive’ to ‘it’s everyone’s job to error report to make the system safer.’
We need to build a culture of patient safety. That means removing the stigma from patient safety and error reporting so we can collect data about errors and learn how we can fix things. That’s better than not knowing the scope of the problem because people are afraid to talk about it.
Marshall Allen is a reporter for ProPublica. His “Do No Harm: Hospital Care in Las Vegas,” written in collaboration with Alex Richards for the Las Vegas Sun, was honored with several journalism awards, including winning the Harvard Kennedy School’s 2011 Goldsmith Prize for Investigative Reporting and coming in as a Pulitzer Prize finalist for local reporting. His health-care coverage was recognized as the best in the country in 2009 by the Association of Healthcare Journalists (AHCJ). In 2007, he won second place for his beat reporting for the Sun where he spent five years before coming to ProPublica in 2011. Before he was in journalism, Allen spent five years in full-time ministry, including three years in Nairobi, Kenya. He has a Master’s degree in Theology.