Medical Mistakes Are an
By Greg Fisher
Willie King went to the hospital to have his right leg cut
off, but woke up to find his left leg missing.
Carl Graham emerged from lung surgery with two massive incisions,
instead of just the one he’d expected.
Medical horror stories like these are part of an alarming
national trend. A recent Institute of Medicine (IOM) report
estimates that between 44,000 and 98,000 people die every
year from mistakes made in hospitals. The report concludes
that the level of safety in health care is unacceptable. And
President Clinton has declared it a national priority.
Becky Cherney is one of three consumer advocates on the Florida
Board of Medicine, the state agency that disciplines doctors.
She says the figures from the IOM report are the equivalent
of a jumbo jet crash per day — 200 people dying every
day from medical errors.
The crisis goes undetected, Cherney adds, because the victims
die one at a time, in hospitals all around the country, rather
than all at once in one giant catastrophe like a plane crash.
in the Details
During a typical surgery, doctors and nurses use hundreds
of instruments, sponges, needles and towels. And when they
lose track of them, it can be devastating for patients.
The Centers for Disease Control estimates that as many as
15,000 people have had foreign objects left inside their bodies
after surgery during the last five years.
Although doctors told Paul Young, of Alvarado, Tex., that
surgery for his stomach ulcer had gone fine, afterwards he
often spent hours at a time hunched over in agony from abdominal
pain. At the grocery store he manages, Young would steal
away to hide in the walk-in freezers so his employees would
not see him cry.
Even though he had seen dozens of specialists about the
pain, it wasn’t until five years later, during a trip
to the emergency room, that Young found out what was causing
it: A 13-inch surgical instrument, called a retractor, which
had been left inside him during the original ulcer surgery.
How could the surgical team have left their tools inside the
patient? At the time of Young’s operation, the hospital
did not have a system to count instruments, and the team that
used the retractor simply forgot to remove it when they were
It used to be the operating-room nurse’s job to supervise
instrument counts. But today, not only is there a national
shortage of 300,000 nurses, but as a cost-cutting measure,
many hospitals use technicians instead.
Like Young, 62-year-old Arlene Meisenburg of Orlando, Fla.
learned all about medical mishaps when she had surgery.
Seven months afterward, other doctors discovered that a 30x16-inch
surgical towel had been left inside her.
Her family took the case to court and settled with the doctor
and the hospital. In addition, the Florida Board of Medicine
signed a consent agreement with the doctor, fining him $1,000
and mandating five hours of continuing medical education.
Miss the Mark
In the last five years, some 50,000 people have
filed lawsuits claiming to be victims of the blunder known
as “wrong-site surgery.”
Carl Graham, of Tallahassee, Fla., for instance,
went in for surgery on one lung, but came out with massive
incisions on both sides of his body. Surgery had been mistakenly
started for his right lung, even though the CAT-scan clearly
showed the tumor was on the left.
Many still remember the case of Willie King,
who had the wrong leg amputated at a hospital in Tampa.
King’s surgeon is no stranger to the Florida Board of
Medicine. In all, he has been disciplined for King’s
botched surgery, for amputating a woman’s toe without
permission, and for putting a central catheter into the wrong
At one meeting last December, the Florida Board
of Medicine disciplined six doctors for wrong-site surgery.
Many hospitals now use a system where the patients
sign the site to be operated on to make sure there are not
any mix-ups, and most also follow the guidelines of the Association
of Peri-Operative Resident Nurses to count instruments and
sponges during surgery.
Can Be Difficult to Get
Experts recommend taking an active interest
in your own surgery. Ask your surgeon where you can
find information to read about your specific operation.
And find out if your respective state board of medicine has
disciplined your doctor in the past or if your doctor has
been involved in any malpractice lawsuits.
If you are interested in learning about your
doctor’s credentials and malpractice record, you’ll
quickly discover that although the information is out there,
it’s very difficult to track it down. As things stand
now, most of the information available on your doctor depends
on your state’s laws.
A growing number of states have “profiling”
laws requiring state agencies to compile data on doctors’
education, specialties and hospital affiliations. Several
states now include medical malpractice and hospital disciplinary
action on their state medical board web sites.
The surest way of finding physicians’
malpractice records is to search the legal record. This kind
of search is very time-consuming and can render mixed results,
since lawsuits can be filed in different courts and could
be overlooked in a search. Also, even though records
of malpractice and disciplinary actions exist at national
and state levels, current laws prevent them from being available
to the public. Just last month, however, President
Clinton announced his support for mandatory reporting of medical
errors through a nationwide reporting system like the one
used by airlines to record safety hazards. And the House Commerce
Committee is currently reviewing a proposal to open the National
Practitioner Data Bank to the public.
Organizations representing doctors and hospitals
have argued against making mandatory reporting of medical
errors public because they believe it could increase the number
of malpractice lawsuits and can provide those that sue with
stronger cases. They also say it would engender an environment
in which hospitals would be less willing to report their mistakes.
Consumer advocates like Ray McEachern, president
of the Association for Responsible Medicine, oppose the current
system because they think it is too protective of health-care
providers. “There are no vested interests behind the
demand for mandatory reporting of hospital mistakes, there
is only the public interest,” McEachern says.