Doctors Confess Their Fatal Mistakes | Reader's Digest

Doctors Confess Their Fatal Mistakes

Doctors, nurses, and pharmacists hold your life in their hands. Here, their shocking stories of what can go wrong—and what has to improve to keep us safe.

By Joe Kita from Reader's Digest | October 2010

“I Could Have Caused Permanent Brain Damage”
By Peter Provonost, MD, PhD

I was a young doctor doing specialty training in critical care, and I was exhausted. Partway through a 36-hour shift at Johns Hopkins Hospital, I was hungry and hadn’t slept for 24 hours, but I was facing an overflowing intensive care unit and somehow needed to discharge five patients to make room for more. Mr. Smith,* who’d had esophageal surgery, was a borderline call. But because of the pressure I was under, I decided to remove his breathing tube and transfer him to another unit.

*Name changed to protect privacy

That turned out to be a very bad decision.

Before long, his breathing sped up as his oxygen levels dropped dangerously. I needed to reinsert his breathing tube. But what I didn’t know was that he had severe swelling in his throat—in fact, the anesthesiologists in the operating room had had difficulty placing the tube in the first place. When I looked into his mouth and tried to identify his vocal cords in order to insert the tube, all I saw was a swollen mass of dark pink tissue, like raw hamburger meat.

I took the instruments out and started to bag him, breathing for him, but he vomited, making that almost impossible. I finally got the tube in—but quickly realized it was in his esophagus, not his airway where it belonged. Understand that when you insert a breathing tube, you give the patient medication to stop his breathing. You have about four minutes before he suffers brain damage. It took me between three and five minutes to get the tube properly placed.

I waited anxiously for the medication to wear off, which usually takes about 15 minutes. But after an hour, Mr. Smith was still asleep. After six hours, I was panicked. I explained the situation to the patient’s wife—well, I sort of explained it. Fighting back tears of shame and guilt, I told her I’d had difficulty reinserting the tube, but I didn’t mention that it was the wrong decision to remove it in the first place. Doctors, especially Johns Hopkins doctors, didn’t make mistakes. If you did, you suffered your shame silently.

Luckily, Mr. Smith regained consciousness shortly thereafter and recovered with no ill effects. I still remember my overwhelming feeling of relief.

How to Fix the Problem

Many medical errors occur because hospitals lack standardized checklists for common procedures designed to minimize the chance of bad judgment. Airline pilots and NASCAR teams have them—why don’t doctors? I think it’s partly because it’s so important for us to believe in the myth that doctors are perfect.

Before I pulled that tube, I should have had to complete a checklist that included input from the patient’s senior physician and nurse. If anyone had disagreed, I wouldn’t have been able to act. A simple system like this not only protects patients but also promotes honesty, respect, and teamwork among hospital staff.

A few years ago, I helped develop such a checklist for doctors and nurses in more than a hundred ICUs in Michigan. It focused on a common intensive care procedure: inserting a catheter into a vein just outside the heart for delivery of intravenous fluids. It ticked off five steps everyone had to follow, and in 18 months, it lowered the rate of catheter infection by 66 percent and saved 1,500 lives.

Mr. Smith taught me a lesson I never forgot. It’s time we let him teach us all.

Peter Provonost, MD, PhD, is a professor at Johns Hopkins University School of Medicine and the coauthor of Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out.

  • Your Comments

    • Happy Place

      I like a National Healthcare System

    • http://www.facebook.com/people/Rod-Venger/747469101 Rod Venger

      These doctors are horrible and their confessions do not absolve them of anything. I pity the pharmacist that took the fall or his tech’s error, but he was the supervisor…as for the nurse, God protect us from nurse-managers. No person can be intimidated or threatened unless they allow themselves to be. Nurses are like wolves, pack animals looking to protect each other from outside forces. The alpha nurse, the manager, like all others before her, used to be just a normal, hard working nurse. Once tapped for management, they lose all their humanity, working not for the good of the patient but for the good of the system. No surprise that this one lines up with a union. The pack can never be wrong nor accused of being wrong for they have all the fangs. That’s convenient when it comes to laying blame for someone’s untimely death.

    • Change is slow

      While I appreciate this article, there are many flaws in the system, just mentioned a tad in this article that could have books written on them, such as the intern system…the voices say it needs to change, but those who made it through perpetuate it. Right now it is nearly impossible to change. Or that Geisner systems improperly implemented give a physician incentive to hide the source of re-admission, and that going to another facility doesn’t mean the truth will come out, as doctors protect each other as a means of protecting themselves. Its a deep rooted complex topic, and those with advocates fare better in terms of protecting themselves from mistakes, but fare worse in terms of the backlash from the medical community, not just during their immediate care but any care related or not, afterwards.

    • CTG

      Obama Care is the best thing any President has ever put in place. Try getting insurance with pre-existing conditions – it is IMPOSSIBLE! You either get totaly denied coverage or they place riders and still charge prices so high you cannot afford the coverage. You need to do your research or try walking in someone elses shoes when you cannot get medical help!

    • CTG

      Obama Care is the best thing any President has ever put in place. Try getting insurance with pre-existing conditions – it is IMPOSSIBLE! You either get totaly denied coverage or they place riders and still charge prices so high you cannot afford the coverage. You need to do your research or try walking in someone elses shoes when you cannot get medical help!

    • Davekyguy

      Wait till Obamacare cuts the Dr.s pay and starts rationing care.

      They are going to save money all right, just like they did when they stole 500 billion from Medicare.

      • Bill

        Nonsense. Pure dittohead rubbish. You’re statement are wrong and taken just as fox misrepresented the,m.

        “Obamacare” rationing healthcare? You mean like the current HMO’s do? Why do you think this country is moving towards a nationalized healthcare system? Because of the corrupt insurance providers!

        Turn off fox and raise your IQ.