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

“My Patient Had a Life-Threatening Clot, But I Didn’t Know the Symptoms”
By Robert M. Wachter, MD

I was a second-year medical student at the University of Pennsylvania, and on my second day of rounds at a nearby VA hospital. Penn’s philosophy was to get students seeing patients early in their education. Nice idea, but it overlooked one detail: Second-year students know next to nothing about medicine.

Assigned to my team that day was an attending—a senior faculty member who was there mostly to make patients feel they weren’t in the hands of amateurs. Many attendings were researchers who didn’t have much recent hospital experience. Mine was actually an arthritis specialist. Also along was a resident (the real boss, with a staggering mastery of medicine, at least to a rookie like myself). In addition, there were two interns. These guys were just as green as I was, but in a scarier way: They had recently graduated med school, so they were technically MDs.

I began the day at 6:30 a.m. with a “pre-round,” a reconnaissance mission in which an intern and I did a quick once-over of our eight patients; later, we were to present our findings to the resident and then to the attending. I had three patients and the intern had the other five—piece of cake.

But when I arrived in the room of 71-year-old Mr. Adams,* he was sitting up in bed, sweating profusely and panting. He’d just had a hip operation and looked terrible. I listened to his lungs with my stethoscope, but they sounded clear. Next I checked the log of his vital signs and saw that his respiration and heart rate had been climbing, but his temperature was steady. It didn’t seem like heart failure, nor did it appear to be pneumonia. So I asked Mr. Adams what he thought was going on.

*Name changed to protect privacy

“It’s really hot in here, Doc,” he replied. So I attributed his condition to the stuffy room and told him the rest of the team would return in a few hours. He smiled gamely and feebly waved goodbye. At 8:40 a.m., during our team meeting, “Code Blue Room 307! Code Blue 307!” blared from the loudspeaker. I froze. That was Mr. Adams’s room.

When we arrived, he was motionless. The resident immediately began CPR while yelling: “Wachter! What did he look like this morning?”

I stammered, then lied: “He was a tiny bit short of breath, but he was okay.”

The autopsy later found Mr. Adams had suffered a massive pulmonary embolism. A blood clot had formed in his leg, worked its way to his lungs, and cut his breathing capacity in half. His symptoms had been textbook: heavy perspiration and shortness of breath despite clear lungs, with the right interval between his major hip surgery and the onset of respiratory symptoms. The only thing was, I hadn’t read that chapter in the textbook yet. And I was too scared, insecure, and proud to ask a real doctor for help.

This mistake has haunted me for nearly 30 years, but what’s particularly frustrating is that the same medical school education system persists. Who knows how many people have died or suffered harm at the hands of students as naïve as I, and how many more will?

How to Fix the Problem

What’s needed is this: Students and residents should participate in teamwork training, just like commercial airline pilots do. Such training stresses the importance of speaking up when they see something they don’t understand.

What’s more, before they start working on the wards, students should do exercises with computers or actors to help them better recognize the symptoms of common clinical syndromes.

Finally, attending physicians should be up-to-date in hospital care, and should have undergone special training to help them balance the amount of supervision needed for patient safety with the graded independence that will help trainees become practitioners.

Robert M. Wachter, MD, is associate chairman of the Department of Medicine at the University of California, San Francisco, and author of a blog and six books on health safety and policy, including Internal Bleeding, from which this story is adapted.

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  • Your Comments

    • Happy Place

      I like a National Healthcare System

    • 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.