Inexperience, deviation from standard protocol set stage for medical mistakes

December 1, 2010

The cover story on my office copy of this month's Readers Digest caught my eye. The title was "Doctors Confess Their Fatal Mistakes." The article recorded personal accounts of errors made by several healthcare providers. In the introduction, the author included a statement about being surprised that so many medical professionals were not only willing but also eager to share their stories.

Key Points

The cover story on my office copy of this month's Readers Digest caught my eye. The title was "Doctors Confess Their Fatal Mistakes." The article recorded personal accounts of errors made by several healthcare providers. In the introduction, the author included a statement about being surprised that so many medical professionals were not only willing but also eager to share their stories.

The most disturbing confession was that of a pharmacist who failed to catch a fatal, tenfold concentration error in an IV saline solution prepared for a child receiving chemotherapy. He not only lost his license but was convicted of involuntary manslaughter, fined, served time in jail and did 400 hours of community service.

My medical error

I was a second-year pediatrics resident, in the middle of a one-month NICU rotation infamously known as "mole call." The "mole" worked seven days a week, from 8 p.m. to 8 a.m., but in reality the shifts generally extended to between 7 p.m. and noon, leaving little time to go home and sleep.

I was responsible for overseeing one to two dozen critically ill premature infants and presiding over all the high-risk neonatal resuscitations. One morning, midway through the stressful month, my 6 a.m. rounds required a complex series of calculations to write TPN orders for a ventilator-dependent chronically hypokalemic infant with short-gut, renal insufficiency and severe bronchopulmonary dysplasia.

In those days, there was no pediatric nutritionist, no TPN team, no pediatric pharmacy and no electronic system to double-check my work. To make matters worse, there were only highly concentrated formulations of potassium chloride intended for adult supplementation. In my sleep-deprived state, I correctly calculated all the supplemental TPN electrolytes except the potassium chloride. There, I was off by a factor of 10, ordering 0.1 instead of 0.01 mL. Because the volume was so small, the pharmacist did not pick up on the error.

When I arrived the next night, the patient's potassium level was 10. The majority of my energy over the following 15 hours went into calculating IV glucose and insulin doses. The infant survived, only to die months later of pulmonary failure.

Reasons for mistakes

The fundamental reasons for these and the majority of medical errors have nothing to do with laziness, stupidity, selfishness or greed. Healthcare delivery is a very complex art and science. A 2008 study estimated the cost of medical errors in the United States at $19.5 billion. The bulk of that, $17 billion, was related to "prescription drug services," not poor decision-making.

Given the complexity of medical practice, I find it amazing that significant judgment errors do not occur more often. Although many articles have classified them in different ways, I think most mistakes fall under three main categories: duty overload, inexperience and deviation from standard protocol.