Patient Beware
We all want to trust our medical system, but medical errors happen too often for us to ignore them

A COMPILATION

---

Every year an estimated 10,000 Canadians die in hospital as a result of medical error. Such was the sad case of 11-year-old Claire Lewis, whose father fought for two years to have her 2001 death after brain surgery recognized by Ontario authorities as a case of medical error and incompetence.

After we told Claire’s story in our December issue (“A Tragedy of Errors”), we heard from readers across the country. Anguished and angry e-mails and letters pointed to a host of mistakes, including botched surgeries, misdiagnoses, sloppy postop procedures and incorrectly administered medications.

While many who wrote acknowledged the difficulties medical staff face as they strive to provide life-saving care—inadequate staffing, long hours, underequipped facilities—others wondered at the lack of adequate supervision and accountability when serious mistakes occurred.

What follows is a sample of the stories we heard. We debated whether to print them. After all, we need to be able to trust our medical system, and exceptional cases can too easily make for fear-mongering. But something is clearly wrong, and hiding our heads won’t help.

Our editorial researchers have made every effort to verify the circumstances and events in the accounts we received, but given the privacy rules that prevail in hospitals, doctors and specific medical facilities were not consulted. Nor are they named in these stories.

Patient, Protect Thyself! Media coverage of cases involving medical error have made many Canadians question what goes on in hospitals. John Lewis, the Hamilton nurse whose daughter, Claire, died in hospital in 2001 as a result of staff errors, offers the following advice to patients and their families: 1. Be vigilant. Ask questions. Keep careful records, perhaps a diary of medications, and note the names of all doctors and nurses. 2. If you have a loved one in hospital, you are the person who best knows the patient. Report any changes in their status to the medical team. 3. If you’re afraid that something has gone wrong in the patient’s care, try to set up a meeting with the hospital’s patient services department. 4. If you get no results from the hospital, remember that every prov-ince has a College of Physicians and Surgeons and a College of Nurses. These colleges must investigate all complaints. And in all but a small number of circumstances, it is your legal right to have access to your medical files. 5. If a patient’s care has led to further sickness or disability, and communications with health authorities have yielded no results, talk to a lawyer about beginning a civil suit. This should be considered a last resort. For more information about patient rights, visit the Canadian Patients Safety Institute at www.hc-sc.gc.ca/english /care/cpsi.html.

It Was “Nothing”
In January 2001 I underwent surgery to have my ovaries removed. Having had a partial hysterectomy 17 years before, I was familiar with the care the wound would require afterwards.

On the third day a redness appeared around the incision, indicating a possible infection. An intern drew a circle on my abdomen with a ballpoint pen, outlining the area. She said she would check again the following day, and if the redness overlapped the inked circle, we would know that the wound was infected. No one returned the next day to check, and not a single doctor or nurse examined me. I was not offered antibiotics, nor was my wound cleaned. Just minutes before I was to check out of the hospital, a nurse did examine the wound and noted the redness.

At home three days later, I was still concerned about the risk of infection so I phoned the surgeon. He was quite casual and felt that it was “nothing” but told me to go to the ER if I was worried. By then I had fever, chills and nausea and, being a health-care aide, I knew I was in serious trouble—even if the surgeon didn’t think so.

At the ER I was finally given antibiotics and the original surgeon was called to discuss the infection and treatment. Even though he was in the hospital, he never offered to come and talk to me or answer my questions.
Two days later, back at home, as I attempted to get up from the couch, my incision burst open from the pressure of the infection. I was rushed by ambulance to our local hospital (not the same hospital where I’d had my surgery) and for the next three weeks, instead of my being on the road to recovery, my wound had to be cleaned twice daily—a painful process—until it could close on its own. It turned out that I had three infected areas, all related to my surgery.

A combination of little or no postsurgical care in the crucial days following my procedure—and a doctor who never once checked on me himself—could have been lethal for me.

Donna Maschke, Ontario

 

Tissue Damage?

On December 13, 2002, my 16-year-old son was playing a junior hockey game when he checked another player and they both fell. Mitch landed on the other player’s elbow and hurt himself. He was taken to the ER, where the doctor on call told him he probably had tissue damage. Mitch spent a total of ten minutes in emergency without even having an X-ray. One of the other parents drove him home. He arrived home at 3 a.m. but did not bother to wake us up.

In the morning, I went into his room and he told me he had been injured but the doctor told him he would be okay, and he just wanted to sleep. Two hours later he came upstairs and told us he wanted to go to the doctor’s because something wasn’t right. I took him to the walk-in clinic. The doctor took one look at him and sent him to the ER, where they did emergency surgery on him to remove his spleen, which was in four pieces. He had been bleeding internally for 14 hours. Besides his burst spleen, Mitch also had cracked ribs and a bruised liver. The chief of pediatrics said we were very lucky he was alive, as he could have bled to death.

Cathryn Treiber, Alberta

 

Accidents Happen
Medical errors are not just associated with hospitals.

Our family lost our 90-year-old mother after she was given the wrong medication at a senior citizens home and was later found unconscious. She was sent to a hospital emergency ward with very low vital signs. The doctor there didn’t know what to do, however, because the home wouldn’t admit to the mistake. If they had, it is quite possible they could have lessened the effects of the wrong drugs she’d been given.

She lapsed into a coma for a couple of days, and all her organs began to shut down. She suffered for about a week and passed away on August 1, 2003.

The hospital informed us that an autopsy had been requested due to the nature of the death. When it was done, it was determined that our moth-er had died from a massive overdose of numerous drugs. We requested a copy of the autopsy report from the regional coroner, but to date we have not received it. A board of health rep who investigated the death basically said that accidents happen and to let it go. Our meeting with the director of the seniors home did not accomplish anything other than to make us very angry. One comment made by the head of the home was to the effect that your mother was old and she was sick anyway.

How many other medical errors are made at seniors homes that are covered up and passed off as age related? Just think of all the elderly people who do not have family to ask questions when they suddenly end up in the hospital for unexplained reasons.

Martin Lewis, Ontario

 

“Everything Is Fine”
Seven years ago, after 30 hours of labour, my baby was in danger and I had an emergency C-section. During the surgery, my bladder was punctured by an intern, and shortly after surgery, I started saying to every nurse I saw, “Something seems wrong.” Their response was: “No, you’ve just had major surgery. Everything is fine.”

About five hours after the surgery, my poor bladder became swollen and hard. A nurse came and put pressure on it, which led to me screaming, “Get the doctor—now!” Throughout those hours after surgery, no one had checked my urine output in the attached catheter bag, and it was only days later that we found out that the catheter bag was not inserted correctly.

For the next five years, I was on and off antibiotics for bladder infections. Finally, six years and three doctors later, after numerous tests and progressively worsening pain, I said to a doctor, “Maybe it is something else.” After an ultrasound, I was sent to a gynecologist. Thankfully, he said I didn’t need him. Because of the symptoms I described, he said that the infection was not inside the bladder but in the wall of the bladder. After some aggressive medication, I have started to feel better—but my bladder is still not right.

Carol Hume, Alberta

 

A “Learning Tool”
Just over two years ago, I lost my four-year-old son to a mistake.

My son had a persistent cough, so I took him to my family doctor. The doctor felt his tummy and said it was just a cough. But after my son started vomiting, I took him to the walk-in clinic, where I was told it was appendicitis. We went to the hospital and he stayed for a week. The doctors there said my little boy had mononucleosis, which could cause a child’s spleen to swell. We had to go back again for tests, and a week later he went to the children’s hospital, where I was told he most likely had a Wilms’ tumour attached to his kidney and would need to have it removed.

Surgery was postponed three times. When the day came, I carried my son up to the ICU, where he was anesthetized. Hours later I finally got to go to recovery, where he was talking and doing what the doctors asked him to do. In his room, he asked for water and told me he loved me.

The next morning we noticed he was not urinating, so a kidney specialist was called in. The next thing we knew, we were rushed to ICU with the original doctor saying everything was fine—even though my son’s eyes were rolled back in his head.

It seemed that the doctors felt his spleen had fallen back to where his kidney and the tumour had been, so they opened him up and found his organs dying off. It was hours before I got to see him, and the ICU doctor told me it would be a miracle if he made it through the night. My son passed away that very day, and the last time I held him, it was to hold his cold and bloated body.

The next day the coroner phoned and told my mom that a stitch left in a main artery had cut off his blood supply. I had to go and dress my son for cremation.

My life since has fallen apart. I never received a letter or phone call from the hospital until my mother and I wrote them three months later. They said the tumour was very large, so it was more difficult than they expected. No apology, nothing. I contacted the College of Physicians and Surgeons, and basically they said the doctors described it as a tragic surgical misadventure and made me feel like a number.

So ends my story. My son is gone because of a mistake. The only thing that anyone did was tell me this would be a learning tool for doctors.

S. Ford, British Columbia

 

Does Anyone Care?
Our 33-year-old son died needlessly from a preventable medication error in 1996.

Jeffrey was in hospital for a kidney infection and was to receive Lasix, a diuretic. Instead, the nurse gave him a lethal dosage of potassium chloride, directly into his vein. When she began the injection, my son told her to stop, that it was burning and making him dizzy. She said she was only doing what the doctor ordered and continued. My son pulled his arm over his head with the needle still in it and told her again to get it out of there, she was hurting him. The nurse stood up and forced his arm down, telling him to hold on as she only had one cc to go. He died before she could finish, as we watched helplessly. We had asked what she was giving him only to hear that it was Lasix. The nurse ran out of the room to get a supervisor and never returned.

Eventually, we were told our son had died of cardiac arrest. A couple of days later, the hospital asked to see us. They told us our son had died ten minutes after a seizure, and although a medication error had occurred, given the state of his health (he was in a wheelchair), it wouldn’t have made a difference in the outcome. I told them this was not correct, and we began asking questions they could not answer. We left for the funeral home in shock and confusion. An autopsy was not done until after the funeral, even though they knew a fatal error had been made. This complicated our grieving process even more.

Since my son’s death, we have followed due process. The internal review concluded it was tragic error, with no one to blame. The hospital decided it was not a systems error, so no changes were made. The response to my complaint to the College of Nurses of Ontario was that the nurse followed procedure in principle and there was no wrongdoing. We have never received an apology from the nurse or the hospital, nor have they accepted any liability in my son’s death.

Because I so trusted this nurse’s knowledge, skill and judgement, I was told that I had contributed to his death by not stopping the nurse myself. After seven years, there has been no accountability. It is a sad reflection on our society when so many deaths occur in our public hospitals and there is no accountability. Does anyone care?

Nancy Brown, Ontario

Ten Questions to Ask Before Your Next Hospital Stay BY GLADYS POLLACK Prior to seeing your surgeon or entering hospital, be sure to ask the following questions and that you understand the answers. Since you may be apprehensive, it’s advisable to take a friend or relative along so that you cover everything that's on your mind. Prepare your list of questions before you go. 1. Prior to your surgery or hospital stay, ask your doctor if you should get a second opinion. Does your family doctor agree with your surgeon on what needs to be done? 2. Before going into the hospital, talk to your doctor about which facility best suits your health needs. Ask questions such as which hospital (if you have more than one to choose from) has the best care and results for your particular condition. 3. Make certain you understand what operation the surgeon is recommending and why you need it. Are there any alternatives to surgery? Inquire about the risks and the benefits. 4. Does the surgeon have experience doing the surgery? You may discuss the surgeon’s qualifications with your primary doctor if it is more comfortable for you to do so. 5. Ask how long the surgery will take. Are there possible complications? 6. Request the results of any test or procedure during your stay. Don’t assume because you do not get them that all is fine. If you’re back at home, call up your doctor and ask for the results. Ask what the test results mean for you and your care. 7. Ask what kind of anesthesia you will need. Make sure you inform the surgeon and the anesthesiologist about any allergies or bad reaction to anesthesia you may have. Inform them of all the medications you are taking. 8. Ask how long it will take to recover. What will happen after surgery, and who will manage your care when you are in hospital? 9. Find out about follow-up care. Ask when you will leave the hospital and what postsurgical care will be necessary. When can you return to work? 10. Last of all, appoint a family member or a friend to be your advocate. Choose someone who will get things done and speak up for you if you are unable to do so.