Medical Error Averted

Cheryl Clark, for HealthLeaders Media , May 29, 2014

A number of small gaffes by healthcare providers, clinical staff, and the shortcomings of their tools can lead to a single serious or life-threatening medical error. Or they can serve as warnings that enable us to avert catastrophe.

Here's one way a medical error might happen. I know, because two weeks ago, one almost happened to me.

I emphasize almost.

After the mistake was averted, I retraced the excellent care I received in every other respect. Providers were professional, friendly, respectful, and even sympathetic to my health concern over what was ultimately a false alarm.

Maybe I was acting too much like the prima donna, expecting that even a minor episode of care should run perfectly when the patient is me, senior quality editor for HealthLeaders Media who writes about processes of care all the time. La de dah.

But here's the thing: Think about the potential consequences.

The averted error, had it come to pass, could have resulted in a serious mistake, a misdiagnosis, possible treatment with medications freighted with high risk side-effects, and the potential for invasive procedures such as catheterization or surgery.

Let me explain what happened two weeks ago.

During the fires and extremely high temperatures in Southern California earlier this month, I was hunkered over my computer monitor for a long stretch of non-air conditioned hours, sitting, standing and leaning against a chair.

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2 comments on "Medical Error Averted"

Michael Jon Cohen M.D. (5/30/2014 at 9:41 AM)
Just a couple comments in reference to your article on your near miss. While you did receive relatively prompt care in reference to your possible deep venous thrombosis, I would suggest that your doppler should have been the same day. A pulmonary embolus as a compication of DVT happens early, not later in the course. Additionally, ascribing your single leg swelling to excessive time in a dependent position is not appropriate. If this was the cause, your other leg should have been swollen as well. With swelling into your foot, I would consider a "minor injury" that you may have sustained, or lymphedema.

Julia Hallisy (5/29/2014 at 10:57 PM)
Thank you for this article. My family endured a cascade of seemingly minor errors during my late daughter's medical care that culminated in a tragic life-threatening infection. The smaller glitches are easier to recognize and to manage, so they can give patients and families a false sense of security that they will be able to avert real harm if they are just vigilant enough. We found out the hard way that vigilance alone is not enough. patients and families need information, tools, resources and confidence to speak up about their care and to truly work as partners with their providers. Our patient safety work centers on informing and engaging patients and their families so that others do not have to learn the hard way as so many have had to do. Thank you for your dedication to safety issues as we still have much to do to improve healthcare safety and quality. Julia Hallisy Founder The Empowered Patient Coalition




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