The Doctors Next Door

Medical SNAFU's In the News...Again

The findings at the the Ochsner Infertility Clinic which, in the words of their CEO, showed a "significant labeling issue which makes us unable to account for all the frozen embryos in our IVF [in-vitro fertilization] center" may make you shudder. While Ochsner Hospital representatives state that no improper implantations occurred as a result of these problems, I wonder how they can be so certain at this stage of the unraveling story. 


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In fact, as you probably also heard, a couple from Ohio carried the wrong fetus all the way to term. This is a high-profile news story and according to the American Fertility Association, an extremely rare event--on the order of one in a million. I wish I could say the same for the rest of the medical error continuum. Many errors happen quietly and even unknowingly to people everywhere at an alarming frequency. 

Consider a more common occurrence, getting your blood drawn for a medical test. What if the blood that was drawn from Mary Smith was inadvertently labeled with your name on it and yours incorrectly labeled Mary Smith?  This kind of mix-up is entirely feasible. 

Imagine have now entered...

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You go to the doctor's office to get a check up on your cholesterol. Mary Smith goes because she's having some vague symptoms--fatigue, weight loss, a yellow discoloration of her eyes.  Both you and Mary arrive at the doctor's office between 11:30 and noon on Friday.  Two different people check you in at the desk--Sheila for you and Noreen for Mary. 

Sheila went to school with your eldest son so you stop to chat and catch up. During the check in process Noreen notices that Mary's chart is out of name labels--used to identify a doctor's note in the medical record as belonging to Mary's chart, placed on a lab order or tube of blood.  Noreen runs her hands across the keyboard and generates a new page of stickers that say:

 Mary Smith


You finish chatting with Sheila and pick up a People magazine to catch up on Brangelina until your name is called. As you settle in, Sheila peeks inside your chart to find it is out of stickers too.  She creates a new page of

Your Name


The lab tech is ready for you. He hurriedly asks Sheila for the chart. Sheila grabs up the warm page of chart stickers and places it in the medical record, handing it quickly off to the tech. 

You can imagine where I'm going with this.  Yup--right chart, wrong labels.  The tech has a long line of people waiting at the lab so he calls Mary's name.  End result: Mary's blood is labeled with your name and your blood is labeled with Mary's name.  If all was normal on the labs, you might just be given someone else's cholesterol readings. If no medical treatment was needed, no real harm done. Just a little oops, right?

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Let's say that's not the case in my little story here.  Your lab tests come back showing you have Hepatitis C while Mary's reveals high cholesterol.  Mary is then placed on a cholesterol-lowering medication (which is particularly bad for her liver) and you are placed on two potent medications you will need to take for up to one year which have the horrible side effects of anemia, depression, and hair loss. 

Just a made up story, this one.  These are not real people, unlike my prior post describing my wrong site dental procedure, I have not experienced this specific case.  I am however aware that blood can get to the lab without a label at all or wrong name stickers may be found in a patient's medical record, and yes, blood has even been labeled incorrectly and sent to the lab as such. Sadly, these things happen in all healthcare facilities. No one really knows how often, but isn't once too many? I wonder how many times such mishaps have occured and no one even realized it???

To learn more, see this New York Times article about problems with hand-off of medical information from one clinician to another. The September 7, 2009 issue of Modern Healthcare headlines with stories of people who have experienced devastating medical errors and turned it around for good in their advocacy efforts.

We need your help. Healthcare is a very complex, high-risk undertaking.  An army of healthcare workers labors tirelessly to mitigate the hazards that lead to these tragic events. We need your full partnership in these efforts. 

So what can you do? Here's a few ideas:

  • Ask questions.  Ask questions. Ask questions. 
  • For important discussions with your healthcare team, have someone else that you trust present. It's really difficult to absorb all the medical mumbo-jumbo we are prone to throwing toward you.
  • Write things down--your medical history, your medication list (and keep it with you at all times). Write down your questions. Here's a great little pocket-sized tool for keeping all your pertinent medical information at ready hand.
  • When you're in the hospital, make sure your ID band is checked before any medication, blood transfusion, testing or blood draw occurs. When the same nurse does this for the gazillionth time, it may seem silly but believe me, it is essential. 
  • Make sure your healthcare workers wash their hands
  • Make a donation to the Coalition for Quality and Patient Safety of Chicagoland

As a result of being implanted with the wrong embryo, on Friday the Savage family graciously gave birth to a quadruple-y loved child and handed him over to his biological parents. Their physician notified the Savage's of the error right away--at the same time they learned that Mrs. Savage was pregnant.  I can only imagine that the physician who had to make that call saw his worst day on the job that day.  Full disclosure of an error is the only right thing to do.

However, it sounds like there's more communication to be had with this family.  The news reports state that they don't know how this happened.  Given that 8-9 months have passed, it seems that there should have been enough time to uncover the causes.  With full disclosure patients and families should be notified as information emerges regarding the causes of the error.  People need this information if there is any hope for future trust in the healthcare system and to be somewhat assured that others will not experience the same type of error.

So thank you for doing your part while we do ours.  These issues of unsafe medical care will not be solved overnight.  For today, we can go a long way toward prevention through a strong partnership between and your healthcare team.



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