In his EMS World Expo 2018 presentation, “My Colleagues Killed My Mother and Sister: Why Are Medical Errors Still Happening?”, Robert K. Waddell II, EMT-P (ret.), BS, calls providers to reevaluate their patient care as he reveals the astounding rates of medical errors that plague the American healthcare system. His mother and sister were victims of this systemic flaw, whose tragic stories exemplify what practitioners have been doing wrong for decades and how they can start providing care the right way, so no patient will ever have to die needlessly at the hand of a completely preventable medical error.
“Do no harm” is one of the most “important tenets of healthcare,” says Waddell, and yet nearly 250,000 patients die every year in the U.S. due to providers’ mistakes, according to a 2016 Johns Hopkins study. With accidents being the fourth leading cause of death in the U.S., medical errors fall under that umbrella. In 1999, the Institute of Medicine estimated that between 44,000 and 98,000 people die each year at the hand of medicine—what’s going on here? With the continuous development of medicine, best practices, and school curriculum, these numbers should be declining, not rising.
In 1986, Waddell’s 28-year-old sister was the only survivor in a high-speed MVC. It took responders two hours to even realize she was there, tucked underneath the dashboard where she had suffered a brain stem contusion, fractured jaw, and multiple other injuries. She was transferred to a level 2 trauma center, where she was comatose for seven weeks until she awoke, during which time she underwent multiple surgeries and endured infections. By the time those seven weeks had ended, Waddell had filled four legal pads with complaints against the hospital staff for poor quality of care—incidents like nurses failing to check on her for multiple eight-hour shifts, and one nurse was found forcing banana slices between her wired-shut jaw because she “needed potassium.”
Finally, December 24, Waddell’s sister was declared awake. A day later, she went into respiratory arrest caused by a mucous plug in her double-lumen endotracheal tube, which led to cardiac arrest. She was resuscitated for 60 minutes by the cardiac arrest team and neurosurgeon who had been standing nearby at the nurse’s station, but their efforts were unsuccessful. Waddell says her death likely wasn’t preventable but could have been had she been given better quality care, citing the fact that baseline-trained nurses were assigned to her highly-complicated case.
A medical error is defined as “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result.” Cognitive science research shows that incidents in the field are often due to mental errors; providers are obligated to memorize tons of rules and acronyms to apply in the field, and often do so without achieving true mastery of each skill. On the other hand, there are times when providers can’t possibly remember everything—Waddell asked the audience if anyone could recite the rule of nines for burn patients off the top of their head. Most couldn’t, and the answer became especially murky when asked to recite the rule of nines for pediatric patients. Point being, under pressure, it’s easy to misapply rules considering all of the pertinent information providers need to remember, paving the way for harm to the patient.
Waddell also dove into the types of errors, like active failures (unsafe acts or omissions), description errors (working on auto-pilot), loss of activation (temporary memory loss), and errors of intention (tunnel vision, misapplication of rules, reversion under stress). “All errors appear astonishingly unique but are 100% preventable—you allow it to be a once-in-a-lifetime thing,” said Waddell. The Johns Hopkins study cited earlier found that 9.5% of patient deaths stemmed from medical errors. A study conducted by Mayo Clinic reported that 8.9% of surgeons believed they caused errors that resulted in 1.5% of patient deaths.
Medicine tends to be the least proactive in error prevention compared to other industries, says Waddell. For example, engineers assess errors in structural integrity to design better systems and the legal system utilizes errors to assign responsibility, with aviation being the most impressive in error prevention. Waddell says the airline industry accepts, tracks, and corrects errors while EMS simply tracks them without correcting them—publishing reports on errors in EMS and discussing them are not corrective actions. Airplanes are now required to have coffee filters locked in cabinets to prevent the risk of something as simple as a paper cut to the eye of a flight attendant during an emergency. Meanwhile, EMS providers have heavy equipment like oxygen cylinders and EKG monitors unsecured in ambulances while driving around. Safety reviews have shown that numerous “kill zones” are present in some ambulances during a crash. Some manufacturers are working to reduce or correct these problems, yet a lot more needs to be done.
“If we admit we can’t predict and prevent all errors, we must design for error tolerance,” says Waddell. EMS tends to focus on the individual and the incident, involving punishment or litigation for mistakes, but Waddell believes it’s usually the system’s fault, not the provider’s. This is why the medical field must allow providers to feel like they can admit to their mistakes without fear of severe consequences so that the mistakes can be corrected, creating an effective safety culture within agencies.
Waddell’s mother could have also been saved had her medical staff been more attentive. After getting a shoulder replacement, she went into respiratory arrest while being transferred to her room for recovery, but amazingly, this was not included in the patient report given to the receiving nurse. That nurse was later scolded by her supervisor for “spending too much time with the patient,” even though she needed constant stimulation following her episode. Per her supervisor’s order, she tended to other patients, and when she returned a half hour later, Waddell’s mother was in full cardiac arrest. Just nine days afterward, Waddell made the difficult decision to discontinue her life support. Her incident was undeniably 100% preventable.
Waddell says the most important way you can help prevent errors is to be an active member of your healthcare team. That entails 1) Being an advocate for your patients and for yourself, 2) Paying attention to the mastery of your skills, and 3) Double-checking your work—“Put your ego in your back pocket and ask your partner, ‘Is this the right dose/medication, etc.?’”
And perhaps most important, Waddell added, treat every patient as if they are your loved one.