Medical Errors： The Silent Killer in Medicine ｜ Carol Gunn ｜ TEDxFargo

In 2013 , a horrific story came out of a San Francisco hospital , where a confused patient wandered into a little used stairwell and died .

Later , it was learned that a hospital employee had stepped over her body twice , only telling a nurse the second time .

And even though that nurse notified security , they still didn't find the woman's body for another week .

An extreme example of medical errors , for sure .

As a physician , I'm very aware of medical errors .

But it wasn't until last year that medical errors knocked at my front door .

My older sister , Anna , she had had her health struggles , and in 2013 she had a bone marrow transplant .

Initially she did great , but 7 months after her transplant she began to have some odd neurologic symptoms .

And 5 months after that , she began to have chest pains .

When she told me about the chest pains , I told her she had to go to the ER .

But even though I'm a doctor , to her I was just her kid's sister .

So she asked her physicians at the teaching hospital the first recommended acids .

When her chest pain persisted , another told her her nerve pain medicine was treating it , and no one bothered to look any further .

Anna got worse .

She lost sensation below her waist and was hospitalized near her home .

After she was transferred back to the teaching hospital , her neurologic symptoms improved .

But her chest pain was continuing , and she was very short of breath .

It wasn't until the 12th day at the teaching hospital that a cardiologist finally evaluated her .

And by then , she had lost 50% of her heart's pumping power , and she needed a coronary stent .

My sister had had a heart attack .

The morning after she received her stent , I was with her in the hospital room .

And she would doze on and off , and I just sat quietly in the corner .

And during one of her waking moments , she said to me , I thought I was dying the other night .

I didn't even know how to respond .

I just reached for her hand , held it ever so tightly , and we both began to cry .

And we sat there crying .

And she went on , she said , I am so mad .

And I knew instantly why .

For months , she had told her doctors about her chest pain , and no one had taken her seriously .

And now she'd had a heart attack , and parts of her heart were deemed unsalvageable .

Due to her physicians not pursuing her symptoms , she literally paid with her health .

So we sat a while together , just holding hands , tears streaming down our faces , and she said to me , Are you going to go after this ?

And my response was , Well , do you want me to ?

And emphatically she said , No one should ever go through what I've been through .

We never spoke about it again .

Unfortunately , she died several days later .

Her autopsy said she'd been having ongoing waves of heart attacks .

Initially after her passing , I was in shock .

And then my anger my anger was off the charts .

I was convinced her death was preventable and I was driven to find the truth .

So I reviewed all of her medical records .

And I was right .

Her death was preventable .

And from all my research , I also knew hers was not an isolated case of a death from medical errors .

My mission now is very clear : silence is not an option .

I openly share Anna's story and what I've learned about harm from medical errors .

Like most doctors , I focus on giving the best care possible .

But none of us none of us are perfect .

No way .

And like all providers , I can count the several patients I have harmed significantly , but inadvertently while treating them as a doctor .

One patient of mine , she was about 50 , and she had belly pains , diarrhea , and weight loss .

I saw her three times , ultimately referred her on , but she had an infection that I should have diagnosed and treated , but I definitely missed .

Luckily , she survived , but her illness could have been fatal .

And it did last much longer than it should have .

But she gave me the ultimate gift .

She called me and informed me of my mistake .

In medical errors , the ones I worry about the most are the ones I don't know about the medical errors that have not yet come to my attention .

Those are the ones that I agonize over .

In medicine , the first large focus on medical error reduction began in 1999 , when the Institute of Medicine released its report to is Human , which highlighted how medical errors harmed a huge number of patients .

In an independent follow-up report in 2013 , it showed no real progress had been made on medical error reduction .

And it estimated that 200,000 Americans die each year .

200,000 Americans die each year due to medical errors .

It's our 3rd leading cause of death in this nation .

It follows heart disease and cancer .

A new Institute of Medicine report is due out in the fall of 2015 .

And my prediction ?

The estimated lives lost will remain astronomical .

And in excuse me the culture of healthcare is only starting to embrace the statistics around medical errors .

I graduated in my fellowship in 2,005 , and as trainees , we received almost continuous feedback .

But in my 9 years of medical training , training .

I was working alongside an orthopedist and he noted the wrong care given previously by a nurse practitioner extending a patient's recovery time .

He called her , he thanked her for caring for the patient , and then recommended a different splint for the next time to improve care .

On the other hand , I remember numerous examples when I was a medical student or a medical resident , when I'd asked my faculty mentors , why weren't we giving feedback to physicians on outdated or incorrect care ?

Once , while working alongside a cardiologist , he noted that the primary care physician was not dosing their mutual patients' medications correctly .

When I asked him , shouldn't we inform that doctor ?

He said , we don't do that .

Why not ?

So where do we go from here ?

What about my sister , Anna ?

Our family chose not to pursue malpractice .

Money won't bring her back .

We want more than money .

We want change .

We want institutional change in health care .

And I think that's the hope of most families that have been afflicted is to know that their loved one did not die in vain .

So I returned to that teaching hospital multiple times , in fact asking to hear what changes had been put in place to prevent more deaths like Anna's .

You see , when I reviewed her medical record , it was full of cut and pasted notes with outdated information .

One of her physicians confessed to me that although he'd written a note on her , he'd never seen her because it was late at night .

Another , when asked , Why didn't you pursue her chest pain symptom ?

Said , I'd have to refer all my patients to cardiologists .

For which I said to him , Sir , you could have been a hero .

So what do I say to the healthcare executives those in leadership positions to prevent more deaths like Anna's ?

It's time to step up .

You need to commit manpower and resources to find safer ways to deliver care , lead with transparency and accountability , and help your providers be more engaged .

And what do I say to my fellow physicians those alongside me in the trenches to prevent more deaths like Anna's ?

We all must listen to our patients and document care like we'd want our own loved ones' care documented .

We must confront our colleagues if there's any question about a patient's safety .

And consider it a gift if a patient or a colleague approaches you with a safety concern .

And what do I recommend to you or your loved ones of undergoing care today as lessons learned from my sister's death ?

Remember , you know your body better than anyone else .

If a symptom persists , question why .

If necessary , get another opinion and another .

If you or your loved one believe you've been harmed , speak up .

Request changes .

Share your story .

So I wonder , hopefully along with all of you now , how can we get the nation's attention on preventing medical errors ?

It's our 3rd leading cause of death .

Where is the outrage ?

How many more Annas must die ?

For you see , even over the death of my precious sister , the ultimate medical mistake is the deafening silence that continues to surround medical errors .

Thank you .