PATIENT GOES BLIND NINE MONTHS LATER- Example #1
She's in a car accident.
She has CT scan of her head.
Radiologist sees a tumor.
He fails to communicate that finding to the patient.
She goes blind nine months later.
She worked as a home health aide.
She was taking her patient in a van to a doctor's visit.
The van was involved in a motor vehicle accident.
She hit her head.
She was taken to an emergency room directly across the street from where this accident took place.
The physicians in the emergency room did the right thing.
They did a trauma workup including x-rays of her head and a CT scan of her head.
She felt fine.
She wanted to go home.
The emergency room doctor encouraged her to wait until the results of the CT scan came back before he released her.
Many hours later, her CT scan had still not been read.
The emergency room physician took it upon himself to read the CT scan on his own.
His interpretation was that it was totally normal.
So, he sent the patient home.
That was a clear violation from the basic standards of medical care.
Turns out, he was not qualified to read and interpret CT scans.
Hours later, unbeknownst to the patient or the emergency room doctor, the radiologist read and interpreted this CT scan.
He observed that the patient had a tumor in her brain.
The tumor was not yet compressing any vital structures.
It was most likely a benign tumor.
Left untreated, it would grow and compress the optic nerve that controls vision in her eye.
Rather than pick up the telephone and communicate these findings to the emergency room doctor, the radiologist simply dictated his report and moved on to the next film to read.
This radiologist had no idea whether the patient was still in the emergency room.
He never forwarded a copy of his report to the ER doctor who had requested this CT scan.
Nor did he ever send the patient a copy of the CT scan report.
This radiology report was never communicated to the patient or to the emergency room doctor.
Here we had a doctor who correctly interpreted her CT scan films.
He violated the basic standard of medical care by failing to communicate those findings to the patient or to the emergency room doctor.
Because of that miscommunication, this patient's tumor continue to grow untreated.
Nine months later, the patient was diagnosed with a massive tumor that put significant pressure on the optic nerve causing her to go permanently blind in her eye.
His injury was totally preventable.
Her tumor was not cancerous and was simply occupying space in her brain.
Had this been recognized and communicated at the time of her car accident, she could have had immediate treatment that would have removed the most of her tumor and prevented her from going blind.
PATIENT FALLS OUT OF HOSPITAL BED & DIES WEEKS LATER- Example #2
Patient has orders to be physically restrained in his hospital bed.
He's sent for a CT scan and then transferred to a different floor.
Nobody bothered to read the physician orders and this patient was not restrained when he was admitted to a new floor.
Patient fell out of bed, hit his head and died three weeks later.
Here's what happened...
He was in the hospital being worked up for delirium.
He'd recently been diagnosed with lung cancer and was having episodes of confusion.
His doctor had written an order that he be physically restrained to his bed as a precaution.
He did not want the patient getting up and wandering around for fear that he might fall and hurt himself.
This physical restraint worked properly for the first few days he was in the hospital.
However, during the course of evaluating his confusion, he needed to have a CT scan performed.
That went well.
But rather than returning him to the floor he was on, he was to be transferred to a new medical floor.
On arrival, he was greeted by the floor nurse.
Both the radiology transporter and the floor nurse failed to read his existing orders.
After he was tucked into his new room, the floor nurse said goodnight.
At no time she ever read the order sheet for this patient.
At no time did she ever communicate with any of the nurses or doctors on the other floor where he had been transferred from.
Patients on this floor were checked approximately once every 4 to 5 hours.
During the next round of patient check-in's a nurse found the patient unconscious on the floor with massive bruising around his face and head.
He was never restrained.
He got up to use the bathroom and as was attempting to get out of bed, tripped, fell, hit his head and suffered massive head trauma with bleeding in his brain.
Because he was on blood thinners, the physicians could not stop the internal bleeding in his brain.
He lapsed into a coma and died a few weeks later.
His death was entirely preventable.
His head trauma was entirely preventable.
His injuries and untimely death occurred because of miscommunication between the receiving floor nurse, the radiology transporter and the floor where he had been transferred from.
24 YEAR OLD WOMAN'S BREAST CANCER NOT TIMELY DIAGNOSED - Example #3
She noticed a breast lump.
She went to her gynecologist.
Her gyn correctly told her to have a breast sonogram, a mammogram and a visit to a breast surgeon.
The radiology facility tells her after her 'normal' sonogram that she doesn't need a mammogram.
Everyone tells her the sono is normal which leads her to believe she doesn't have cancer.
At the radiology facility where she had breast sonogram done, she was told by both the radiology technician and a nurse supervisor that she was too young to have any breast cancer.
She was also told that her breast sonogram was normal.
There was no need for her to have a mammogram.
Both of these comments to the patient violated the basic standards of medical care.
The radiology facility is not supposed to communicate directly with the patient.
Instead, they're supposed to tell the patient to return back to the doctor's office who will then interpret and relay the findings to the patient.
Also, the radiology technician and the nursing supervisor are not qualified to tell her not to have a mammogram, especially when her treating gynecologist had specifically requested that a mammogram be performed.
When she attempted to make an appointment for a breast surgery evaluation, the doctor did not take her insurance.
While attempting to get an appointment with another physician, she heard back from her gynecologist's office that her breast sonogram was normal.
The nurse who relayed that information did not ask whether she had a mammogram done.
Nor did she ask whether she had breast surgery evaluation as her gynecologist has recommended.
She was left with the distinct impression that she did not have any breast cancer.
There was no follow-up and coordinated communication between the gynecologist, the radiology facility and the nurse who followed up with the patient about the breast sonogram.
Had this patient had all of the testing that was recommended by her gynecologist, her breast cancer would have been recognized immediately and treated.
It would have been a stage I and localized.
By the time she was diagnosed more than a year later, her cancer had spread throughout her body.
She was now diagnosed with Stage IIIB advanced breast cancer.
Despite receiving surgery and treatment, her prognosis is extremely guarded.
HOSPITAL DOCTORS FAIL TO RECOGNIZE HER BLADDER CANCER- Example #4
Doctors in training.
They're called residents because they're still in training.
Supposed to be supervised by senior attending doctors.
Not always true.
This woman kept seeing blood in her urine.
She went to a local hospital clinic not far from her home.
She'd see a different doctor in training each visit.
They'd rotate weekly.
Each one would have her to a urine test.
Then, when the result would come back another doctor in training would get the result.
The results were clear.
There were red blood cells in her urine.
They shouldn't be there.
This finding requires further evaluating and investigation.
Each of these young doctors in training failed to communicate with the one from the previous few weeks.
None of them communicated with the senior attending physician.
They never discussed her findings with the attending doctor for the clinic.
They missed one opportunity after the other.
Many months after first complaining of blood in her urine she was diagnosed with bladder cancer.
Advanced bladder cancer that killed her.
All because of miscommunication between these doctors in training and the attending hospital staff.
DENTIST PULLS WRONG TEETH! - Example #5
It was simple.
The instructions were simple.
Pull these four teeth.
Then, her mouth will have room for her other teeth to come in properly.
Her orthodontist was very clear.
He was very specific.
He wanted four baby teeth pulled out.
This would give her adult teeth plenty of room to come down.
Then he could put braces on those teeth.
That would help her get perfect looking teeth.
Sounds simple, right?
Not for the dentist who was tasked with pulling these teeth.
This general dentist had never seen this young girl before.
He was a new dentist in this practice.
He read the letter from the orthodonist.
It said to pull four teeth.
It told him exactly which teeth to pull.
When the dentist looking in her mouth, he couldn't tell which teeth the orthodontist was referring to.
When the dentist looked at her x-rays, he couldn't tell which teeth the orthodontist was referring to.
He was confused about the location of certain teeth.
Rather than picking up the telephone and speaking to the orthodontist to make 100% sure which teeth he wanted removed, this dentist decided to go ahead and remove those teeth that he believed the orthodontist was referring to.
The reality was that the orthodontist wanted four baby teeth removed.
This general dentist removed two baby teeth and two adult permanent teeth.
After the teeth were extracted, he didn't take follow up x-rays.
Nor did he ever communicate with the orthodontist to confirm which teeth he had removed.
The orthodontist waited and waited for her adult teeth to come in.
Finally, not understanding why her adult teeth had not yet come in, he took x-rays.
What he saw was shocking.
Those adult teeth were missing.
It's not possible!
They were there before, but now they're gone!
After a bit of detective work and comparing the before and after x-rays, it was obvious.
The general dentist removed the wrong teeth.
This young girl now has two gaping holes in her mouth were no adult teeth will ever come down.
She will require dental implants.
This medical error was totally preventable with a simple phone call to the orthodontist.
These are just a few examples of medical errors that resulted from miscommunication between doctors and nurses.