A Personal Encounter with Medical Errors: Prevention and Awareness

Waiting to be seen two hours after arriving for my son's follow-up visit, it's dawning on me that we're still here because of a medical error.

I'll start at the beginning of this story by sharing how easily medical errors happen and why they matter. My 13-year-old son, Scott (not his real name, but he's given me permission to share our story), and I arrived for an appointment with his provider a few minutes early. We had a good idea about what to expect, even though it was only our second visit with this provider, who shares a waiting room and office space with another pediatric specialty. I went to the front desk to let a medical assistant know that Scott was here for his appointment. Our interaction was brief since I had already checked in and paid our co-pay online.

We waited a short time before a nurse took us to our room and immediately gathered routine vital signs. I was surprised when the nurse prepared to do a finger stick to check Scott's hemoglobin A1c. A patient's hemoglobin A1c is an important lab for patients with diabetes, in case you've forgotten from nursing school, and Scott isn't diabetic. When I questioned the need to check his A1c, the nurse was sympathetic about getting a poke but explained that it was necessary. As a bedside nurse, I know firsthand how explaining procedures sometimes feels like delaying my work. Additionally, Scott had just had outpatient labs drawn, and I figured that his provider may have had a good reason for checking his A1c at the visit. After explaining that Scott's A1c was within the normal range, our nurse left us to wait for our provider.

I've learned to take advantage of time alone with my adolescent son, so we passed the next 25 minutes talking about school, sports, and the unexpected finger stick. A knock on the door announced the end of our wait, but we were taken aback when we didn't recognize the provider. She began talking but quickly paused when she noticed Scott's A1c, announced that we were in the wrong room, and directed us back to the waiting area.

I began to feel that something was wrong and spoke to another medical assistant at the front desk, who was puzzled by the situation. She eventually explained that my Scott was checked in as another patient with the same first name and age who was scheduled with the other pediatric specialty. Frustrated that it was now 90 minutes after our scheduled appointment, I agreed to stay so that we could meet with Scott's actual provider once she was free. An office manager met with us in our new room to explain that Scott's vital signs and point-of-care lab results were charted under the other patient. She assured us that the staff were correcting the patients' charts and that my Scott was now checked in correctly. The office manager also apologized and recognized that several mistakes were made, including staff failing to check Scott's full name, date of birth, and reason for his visit before finishing the check-in process, taking vital signs, and performing his point-of-care testing.

Our appointment went well once Scott saw his correct provider, but I found myself thinking about the experience on our way home. I wondered what went wrong and how the medical errors we experienced could have been prevented. Put simply, a medical error is any mistake in healthcare that could have been prevented. Research suggests that at least 1.2 million Americans are harmed by medical errors every year, making them the third leading cause of death in the United States. Medical errors are expensive, too. It's difficult to determine the exact cost, but estimates range from $20 billion to $45 billion per year.

Our experience was far from life-threatening, but nonetheless, delayed patient care and exposed my son to an unnecessary diagnostic procedure. His medical information was also charted under the wrong patient, who then had access to his vital signs and A1c. Further, medical errors cause guilt and anxiety for the healthcare staff involved. As a nurse, I empathized with the office manager and medical assistants who wore expressions of guilt and anxiety when speaking with us. By and large, healthcare professionals are recognized as well-meaning and caring professionals. No one wants to be the cause of a medical error, even if the outcomes and costs fall far short of permanent damage or injury.

Healthcare mistakes fall into several broad categories, including surgical errors, diagnostic errors, medication errors, hospital-acquired infections, and communication errors. Surgical errors represent the highest risk of injury and death. Diagnostic errors are also significant because they delay patient care when a patient's condition is not understood and explained correctly. Medication errors and hospital-acquired infections are extremely common, but fortunately, highly preventable.

A simple but effective way to prevent communication errors, such as the one we faced, is to encourage patients to speak up about unexpected tests, medications, and procedures. Looking back, I wish I had questioned the reason for checking Scott's A1c more firmly. It would have also been well within my role as a parent to ask staff to verify Scott's full name and birthday.

In addition, healthcare staff should always verify the patient's name and correct date of birth before providing care. Neither the medical assistant who checked us in nor the nurse who took us to our room asked for Scott's full name and birthday. Most, if not all, nurses are trained early in their education to verify the correct patient with at least two identifiers. It's an easy action to omit during routine procedures over the course of a busy workday, but it can save time, frustration, and even lives.

Open dialogue is a crucial part of medical error prevention. As a parent, I appreciate that my provider's medical staff were direct and honest about the events that occurred. As a pediatric nurse, Scott's experience has strengthened my commitment to safe and effective communication with families. I am more mindful about verifying my patients' identities and responding thoroughly to parents' questions. Perhaps even more significantly, I shared this experience with my colleagues and coworkers to raise awareness of how easily medical errors can occur. I invite you to join this conversation and share your own experiences with medical errors in your hospitals and workplaces.

About the Author:

Matthew Turner, RN, BSN, CPEN, made a mid-life career change from project management to nursing and has never looked back. He began his career in pediatric emergency nursing and has also worked in pediatric med-surg and critical care. As both a nurse and a parent, he values every opportunity to connect with patients and their families, drawing on personal experience to deliver compassionate and informed care.

Matthew is an independent contributor to CEUfast's Nursing Blog Program. Please note that the views, thoughts, and opinions expressed in this blog post are solely those of the independent contributor and do not necessarily represent those of CEUfast. This blog post is not medical advice. Always consult with your personal healthcare provider for any health-related questions or concerns.

If you want to learn more about CEUfast's Nursing Blog Program or would like to submit a blog post for consideration, please visit https://ceufast.com/blog/submissions.