Friday, July 18, 2008


Have you all seen the latest article from CNN titled "Don't Become the Victim of a Surgical Error"? The article contains some good information, and, as patients and families, we should follow the steps listed.

But (and you knew there would be a but), the hair on the back of my neck always stands up when I read something like this. In the article, it does refer to the fact that these steps lessen the chance of a medical error happening. I feel, though, the story implies that if we follow a few simple steps, we can control our own medical outcomes. I did all those things prior to my surgery 9 years ago, and there was still an anesthesia complication that nearly took my life (see Linda's Story).

This past year, when I finally got my ankle replacement, I ended up with a post-op infection that I believe could have been avoided, but the systems in place made it impossible for that to happen. I ended up with two more hospitalizations, confined to bed with my foot elevated for three months, and on IV antibiotics for 7 weeks. I tried to advocate for myself, but the pharmacy and my insurance company made it impossible. With both experiences, I was left with the woulda, coulda, shoulda feelings that are quite normal after these types of events.

Is this a set up for people to think that if they do all the right things, they will be safe? So, I ask you, what do you think of the article?



  1. I had a similar reaction to the article, when I saw it. While the suggestions may help prevent errors, they are starting to blur the line about who is responsible for patient safety. As patients, are we now responsible for preventing surgical errors? I fear that this article will encourage "blaming the victim" - a trend which is already so prevalent in our society.

  2. The article bothered me too.

    If only it were that simple! In reality, patients often have little control over the environment around them and the team who's assigned to their care.

    I question how much of the responsibility should be placed on patients who are already sick, hurting, vulnerable and/or anxious. Not to say we shouldn't be asking questions - I narrowly avoided a wrong-site surgery by speaking up - but I think patients have a right to expect that they won't have to nag and prod the provider to ensure their care is safe.

  3. I was recently asked if I would be interested in partaking in an interview regarding what I, as a parent, wished that I had done differently regarding my son’s death. I quickly answered; YOU can’t be blaming this on the parents now! Needless to say, I didn’t get the interview (and it may have been this article) but I think I made my point about shifting or insinuating blame. Parents carry more guilt than anyone when something goes wrong. It was our job to protect our child no matter what and keep them safe. Why would journalits cause increased guilt by even asking such a question of families?

    Working in healthcare and having an adverse medical event occur also adds additional guilt. We should have known to speak up; we should have known to ask if you are implementing the safe surgery saves lives check list; we should have know that docs don’t often communicate with each other and share information; we should have known that labs are forgotten and meds wrong; we should have known better…

    So, I thought about it further. What would have relieved a bit of my angst about my son’s unexplained death following ankle drainage? How could I assist other healthcare families so they wouldn’t feel like they could have prevented their child’s death? I asked a friend to assist me in developing a Patient/Family Anesthesia Check List, which is still in draft form but referenced on my site. We created it for those of us that work in healthcare, and others, to be discussed at pre-op visits. It may not save many lives but will make us feel that we did everything in our power to keep our child safe and be a team member. My hope is to initiate a conversation with the surgeon and anesthesiologist, asking for them to slow down a bit and listen to those that really know the patient.

  4. I agree with the previous posts. When we as patients can acknowledge that, despite our best efforts, we can NOT always control our own outcomes and hospitals/providers stop trying to shift blame onto individuals and patients and instead examine the systemwide weaknessess and factors that lead to medical errors, then we'll start making some real progress. Of course, it's always easier said than done.

  5. CNN titled "Don't Become the Victim of a Surgical Error"?
    This article is useful in describing ways in which patients can be proactive in the prevention of medical errors and receiving safer care. However, it does not mention that tragic outcomes can still take place even when patients clearly identify who they are, insist on the surgeon marking the surgical site, and bring along an advocate to the place of treatment. Systems errors that result in bad outcomes will continue until all members of the health care team including physicians, nurses, pharmacists, administrative leadership, non-professional staff and trainees all adhere to the principles of patient safety.
    John A. Fromson, M.D.
    MITSS board member



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