Coma after heart surgery Medical errors and their consequences

Consequences of medical malpractice

07/05/2014

Lack of laboratory tests, the wrong knee operated, respiratory arrest after excessive sedative: The list of medical errors is long. According to the Medical Service of the health insurance companies many treatment errors could be avoided.

Small mistakes with a big impact
Small mistakes often have a big impact. If medical personnel work incorrectly, this is particularly consequential: Missing laboratory values ​​and a woman remain serious brain damage. An arm grows obliquely because of a plaster and limits the mobility. Many such treatment errors could be avoided. The tricky question: „whose fault is it?“ has hindered the detection of treatment errors in clinics and medical practices for years - and still hinders them. Because no one likes to be guilty, hiding and concealing are close. According to the senior physician of the Medical Service of the German Health Insurance Fund Association (MDS), Stefan Gronemeyer, the question would be: „What can we learn from mistakes??“ helpful. Many problems arise from a concatenation of numerous small and often avoidable mistakes.

Treatment error reproaches have increased
The examiners of the Medical Service recognized a total error of about 3,700 times in their nearly 14,600 reports last year. Of these, 1,065 times after orthopedic or trauma surgery and 556 times in surgery, according to a news agency dpa. In addition, treatment errors were often found in dentists and homes. Dr. Gronemeyer said: „Compared to previous years, the number of assessed treatment error reproaches has increased.“ The extent for those affected and also the possibilities for remedy are clear from individual cases from the work of the experts in the cash order.

Wrong knee operated
For example, in a patient in his mid-20s, the knee pain just did not stop, so mirroring the affected knee joint should help. However, the wrong knee was prepared and mirrored in the hospital. The doctors still noticed the mistake in the operating room and operated on the right knee. However, the young man now had prolonged pain on the previously healthy knee as a result of the error. Another much more dramatic example concerns a woman in her early fifties. She has been suffering from constipation, hiccups, nausea and vomiting for some time. To find out the cause, a combined gastroscopy and colonoscopy was performed in the patient on an outpatient basis, for which she received a strong tranquilizer. Because of an overdose, respiratory arrest occurred. Because the required ventilation was difficult and the gastroenterologist was unsuccessful enough, the patient's brain was damaged because of the lack of oxygen.

Blood levels determined after surgery
Another peer-reviewed case was that of a woman in her early 70s who was going to be operated on a heart valve. Since the woman also suffered from a depressive disorder, she was treated with lithium. The elderly woman went into a state of confusion after the surgery, which increased to consciousness clouding and went into a coma. The woman's blood count was only determined after days in the lab and it was found that a strong hypothyroidism dropped her into a coma. This could have been caused by the lithium. A thyroid drug would have been enough, but the woman suffered a severe brain damage. A schoolchild, who got a plaster after the fracture of the upper arm, came away happier but also permanently damaged. At a follow-up inspection of the plastered arm an excessive malposition of the break was found. However, this was left and accordingly wrongly healed the arm. As a result, the young patient suffered a permanent restriction of his mobility. It is not just lay people who wonder why the boy's arm was not plastered differently again?

Mistakes are often easy to avoid
The errors would not have been difficult to avoid even in the other cases. For example, against a confusion of the body sides in the operating room, there are specifications that the area to be operated on should be marked by the awake patient, who could then sound an alarm in time. In addition, checklists should prevent the causes of suffering being overlooked. As the auditors believe, it may well happen that older patients are confused after an operation - but a hypofunction of the thyroid gland would actually attract attention. If the reviewers find a treatment error, the patients' chance for compensation increases.

Demands for more patient safety
The demands for more patient safety include training, critical drug questioning, the possibility of anonymous error message or hand hygiene against hospital infections. „A lot has changed in the past almost ten years“, says AOK board member Uwe Deh. However, experts such as the managing director of the Action Alliance for Patient Safety, Hardy Müller, criticize that there is neither an up-to-date overview of what is actually done in each house to avoid errors, nor that one knows how many times a year patients really fall victim to the clinic and practice. There are no comprehensive registers that could be used to teach lessons. (Sb)