A number of small gaffes by healthcare providers, clinical staff, and the shortcomings of their tools can lead to a single serious or life-threatening medical error. Or they can serve as warnings that enable us to avert catastrophe.
Here's one way a medical error might happen. I know, because two weeks ago, one almost happened to me.
I emphasize almost.
After the mistake was averted, I retraced the excellent care I received in every other respect. Providers were professional, friendly, respectful, and even sympathetic to my health concern over what was ultimately a false alarm.
Maybe I was acting too much like the prima donna, expecting that even a minor episode of care should run perfectly when the patient is me, senior quality editor for HealthLeaders Media who writes about processes of care all the time. La de dah.
But here's the thing: Think about the potential consequences.
The averted error, had it come to pass, could have resulted in a serious mistake, a misdiagnosis, possible treatment with medications freighted with high risk side-effects, and the potential for invasive procedures such as catheterization or surgery.
Let me explain what happened two weeks ago.
During the fires and extremely high temperatures in Southern California earlier this month, I was hunkered over my computer monitor for a long stretch of non-air conditioned hours, sitting, standing and leaning against a chair.
One morning, I noticed my left calf, ankle, and foot were so tight and enlarged, I could barely get into a shoe. Was it a delayed strain from a hard-charging powerwalk over the weekend? Or was it something else?
Judging by my symptoms, I thought it might be a dangerous deep vein thrombosis. I know more than to take such a thing lightly, because years ago my mother died from consequences of a blood clot. So I ambled over to my doctor's office that afternoon to have him take a look.
I was fortunate that I was able to be seen that day. Yes, said my primary care doc with worry on his face. We need to get you checked out for a blood clot because if it breaks and gets into the lung, that might be all she wrote.
His nurse said she'd fax the order for a Doppler ultrasound to our nearby hospital's outpatient facility, which could fit me in quickly the next day.
I arrived at the hospital, and after being misdirected twice by hospital personnel on the ground floor to areas on different floors—a minor inconvenience— found my way to the right room. A friendly receptionist logged my vitals into her computer. I got the plastic bracelet.
The faxed order had not been received, but I shouldn't worry, she told me. The order would come. For many physicians affiliated with this hospital, an easy electronic imaging order system that would have made communication between the hospital and my doctor instantaneous, is not yet in place, I have learned.
So I settled in to wait. It certainly looked like they weren't busy; I had the waiting area pretty much to myself. About 40 minutes in, the sonographer appeared and showed me to an exam table in a darkened room.
When the procedure was done, she smiled reassuringly. "If this were bad news, I wouldn't be able to let you go home, but you can go now," she said with a grin. My doctor would convey the official result.
Thank goodness, I thought. A silly scare. But just then, the sonographer looked at the screen and her face changed expression. "Wait a minute. I'm so sorry," she said, apparently embarrassed. "Don't get dressed yet. I have to do it over."
Somehow the results of my test got recorded under a prior patient's name, she explained, and because of a flaw (or a safety precaution) in the EHR, she couldn't overwrite my name on top of the other patient's.
So she repeated the test and I got the go-ahead to leave.
A week later, to my confused surprise, a scheduler from a different outpatient radiology department phoned to inform me I was expected the next day to report for another Doppler. That facility had also received a faxed order for my Doppler, obviously sent in error to the wrong place.
I imagined how someone who didn't know the difference between the two facilities—the hospital and a privately owned outpatient radiology center—might show up for the second test, thinking the doctor wanted a follow-up.
I explained to the scheduler that the hospital had already performed the test a week ago. Frankly, I'm still scratching my head about that one.
The leg swelling went down over the next two days, its cause attributed to long hours of sitting in one place, and the heat. I'm reassured that my health is good and I powerwalked and jogged normally over Memorial Day weekend.
One might point out that here, the system worked. I was seen immediately by my primary care provider. The test he ordered was performed quickly, and a potential error on my patient record was caught and fixed. The duplicate order for the second test at another facility was cancelled.
I should brush it off and move on.
But I can't stop thinking about the potential for small glitches, like the ones that happened to me in one innocuously brief encounter with my local medical system, to lead to serious medical errors for many others.
A month ago, Sen. Barbara Boxer, (D-CA), issued a report saying that with 210,000 to 440,000 fatal medical errors occurring in U.S. hospitals each year, medical errors have become the third leading cause of death.
I just wonder: how many of them might start with one or more small mistakes, like the ones that I experienced.