Disastrous medical errors can occur during routine procedures too These stories of human errors in medicine may be relatable, as many occur during routine procedures, in the hands of perfectly competent professionals. It is only a matter of the right – or rather, wrong - time, place, and person coming together to orchestrate these errors into a final, disastrous outcome. 1. Impregnation of the wrong sperm An embryologist at New York Medical Services for Reproductive Medicine made a mistake with sperm samples, leading to the insemination of a woman’s eggs with another man’s sperm. The patient, Nancy Andrews, and her husband were unaware of the mix-up, until Andrews gave birth to baby Jessica in October 2004. The couple realised the error after noticing Jessica had a significantly darker skin colour than both of them. Although they will continue to raise Jessica as their own, they have filed a malpractice suit against both the embryologist and the clinic owner. 2. A fatal consequence of neglecting to check blood type Dr. James Jaggers, chief of paediatric cardiac surgery at Duke University Medical Center received a midnight phone call informing him that donor organs were available for one of his patients, 17-year-old Jésica Santillán. However, he did not cross-check the blood type information, which ultimately led to Santillán receiving the heart and lungs of a blood type-A donor - a mismatch for her type-O blood. "I had satisfied in my own mind that if they had offered the organs for me that she was a match,” he said. In between the phone call and the fatal transplant, other doctors and nurses involved had also overlooked the mismatch. A second transplant to correct the error was unsuccessful , causing Santillán to die shortly after. "I'm ultimately responsible for this because I'm Jésica’s doctor and I'm arranging all this," Jagger said. 3. The wrong testicle removed Benjamin Houghton, a 47-year-old Air Force veteran scheduled to have his left cancerous testicle, removed. The procedure ended with a USD200,000 lawsuit from Houghton and his wife when his healthy right testicle was removed instead. A series of events at the West Los Angeles VA Medical Center – an error on the consent form and failure of medical personnel to mark the surgical site before the procedure - led to the mishap. Dr. Dean Norman, chief of staff for the Greater Los Angeles VA system said: “We are making every attempt that we can to care for Mr. Houghton, but it's in litigation, and that's all we can tell you," he said. “The hospital changed practicesas a result of the case.” 4. Cerebral angiography on the wrong patient In a classic illustration of ‘wrong-patient’ procedures, 67-year-old Joan Morris (a pseudonym), underwent an invasive cardiac electrophysiology study meant for another patient of a similar name. She was then transferred to the oncology ward instead of her original bed, after the cerebral angiography procedure. As the study went on, the electrophysiology attending received two calls, one from Morris’ neurosurgeon, and another from her interventional radiologist questioning Morris’ absence from her bed and reason for undergoing the electrophysiology study. A detailed inspection of Morris’ chart revealed the mix-up - a miscommunication between the electrophysiology laboratory and the oncology ward. To add on, Morris had no idea about the procedure and there was also the absence of a written order. The study was immediately aborted and fortunately, Morris returned home the next day in stable condition. 5. Three wrong-sided brain surgeries in a year Three similar mistakes, where the wrong side of patients' heads were operated on, occurred at Rhode Island Hospital – all in the span of one year. One case resulted in the death of an 86-year-old man. In another, a neurosurgeon began drilling the left side of the patient’s skull, despite a CT scan showing the bleed on the right. Fortunately, the mistake was caught early and the procedure was shifted to the correct side. The third patient, an 82-year-old man also fell victim to the same error but was stable after the procedure. "We are extremely concerned about this continuing pattern," Director of Health David R. Gifford said in a written statement. The hospital received a USD50,000 fine, and was ordered to develop a neurosurgery checklist. A statement from the hospital read "We are committed to continuing to evaluate and implement changes to our policies to help ensure these human errors are caught before they reach the patient." Source
