At the Alliance, we pay attention to information about patient safety and preventable medical errors. We're the Wisconsin sponsor of the Leapfrog Survey on hospital safety and are involved in several other groups that aim to improve patient safety and reduce medical errors. The importance of this work hit home when my 77-year-old parents were recently impacted by a medical error. The good news is that the story ends happily. The bad news is that it could have been averted simply by checking the date on lab tests.
A Lab Mix-Up
My dad recently was hospitalized on two separate occasions to care for a complex combination of heart and digestive problems. A week after his latest hospital stay, Dad went to a medical clinic to have blood drawn for lab tests and then to his doctor's office for an office visit. The doctor gave him the news: His new test results were bad. In fact, they were just as bad as before his hospitalization and surgery.
The doctor planned to consult with specialists, but said the short-term future would definitely include another visit to the hospital. Potential treatments included one or more additional surgical procedures for his digestive system and heart. Another option was inserting a feeding tube to sustain him without eating while his digestive system and heart healed.
My dad might have been rushed into the hospital had the doctor not realized the mistake.
The doctor recommended immediate hospitalization, but my parents begged to go home for the night. In the morning, my mom called to check the doctor's plan for the day, only to learn that the office was planning to call her. There had been an error. The doctor failed to check the date on Dad's test results, which were the "old" results from before he was hospitalized. The "new" results were apparently overlooked.
The doctor apologized for the error and assured my parents that this time, everything had been double-checked. The new tests showed Dad was doing much better.
The Cost of the Error
Unfortunately, the error was a setback for my parents physically and emotionally. Dad had been ordered to eat five small meals a day, but due to the error had nothing to eat for 24 hours. He was encouraged to take short walks frequently, but instead spent 24 hours off his feet.
Dad and Mom spent a night in sleepless worry. Mom canceled appointments for her own medical care to clear her schedule to care for Dad.
Other lives and plans were disrupted as well. Family members changed work schedules so they could help out or huddled around the telephone to worry together.
If my parents had agreed to the doctor's recommendation for hospitalization, they would have been billed for hospital and physician visits and more lab tests.
And, of course, there will be a bill for the lab test that started the entire process, although my parents hope they don't have to pay for the doctor's decision to run the same test twice to double-check the results.
What Patients Can Do
The outcome could have been much worse: Preventable medical errors contribute to the deaths of as many as 440,000 patients each year, according to a study published by the Journal of Patient Safety. The Alliance website offers tips to make health care safer and avoid medical errors. Asking questions about treatment and lab tests both appear on the list.
While those tips might not have helped my parents, you can be certain they will ask more questions in the future. The next time a doctor sorrowfully shakes his head over a test result, it's a safe bet they will respond by asking, "Can you please double check that?"
Given all they've experienced, it's the smart thing to do.
This post originally appeared on the Alliance's blog on December 9, 2013.