“Being a doctor is unlike any other profession on earth. Being a doctor is the closest real thing that we can have on earth to being a God with the power to sustain life. Gods are imaginary, but Doctors are not. They are actual living beings on earth, with the actual expertise of giving life to others.”—Abhijit Naskar
“Whenever a doctor cannot do good, he must be kept from doing harm.”—Hippocrates
Doctors are amazing. They literally save lives for a living. How many people can say that? But, they are still human, and sadly that means that they make mistakes just like the rest of us. It isn’t all that rare for even the best of doctors to make mistakes, because we are complicated creatures, but we all hope to not be on the receiving end of that mistake. Here are some stories about the biggest screw-ups that doctors have ever made, as told on Reddit.
40. Almost Infecting Yourself
Pathologist here. Biggest mistake I ever made was cutting myself during an autopsy on an HIV patient. Lucky for me, I did not acquire the virus, so everything had a happy ending (For me, anyway. That guy was still dead.)
39. Ended up in the Wrong Place
I saw a patient once years ago for abdominal pain. She had had an IUD placed back in the 70s, a dalkon shield. Upon follow up, the GYN couldn’t find the string so he told her she must have passed it. Well guess what—she passed it alright. We found it in the retroperitoneal space near her right kidney 17 years later!! She wanted to sue him but he had retired.
38. Alien Abduction
OH BOY HAVE I GOT A STORY FOR YOU
A few years ago I worked for a medical device company and got to observe a surgical procedure that involves drilling into a person’s brain. My coworker who had observed 30+ times recommended to the surgeon to increase the patient’s posture angle to 60 degrees rather than 45. The surgeon, like many, thought he knew everything and just ignored his advice.
Fast forward about 50 minutes to the drilling phase, and the surgeon makes a bad drill angle and pulls the drill out too soon before the brain’s internal pressures can even out naturally. CSF (Cerebral Spinal Fluid) comes gushing out of the patient’s head, onto the floor, everywhere.
Not only is this a chemical hazard nightmare, and completely disgusting, but this is a procedure where the patient is AWAKE. The patient starts noticeably freaking out only they can’t move because they are strapped down and their head is head completely still by the machinery. They must have thought they got abducted by aliens. Darn surgeons.
37. Good To Hear You’re A Better Doctor Now
I left a swab in a patient once. He had a pacemaker and it was a complicated and bloody operation. We just lost count of the swab. Unfortunately for the patient his wound became infected and it only became apparent that there was a swab in when we went back in a few weeks later to take it out. Luckily as we were honest with the patient and open about the error it was only a slap on the wrist. I’m now paranoid about swab counts and demand rechecks every time. I suppose it’s made me a better doctor.
36. Withdrawal Is Serious
I had severe vertigo about 20 years ago. I did physical therapy for it, and they prescribed Xanax. I was on Xanax for about two years at higher and higher doses for it until they found a physical reason for the dizziness. My doctor then decided to take me off the Xanax cold turkey because I “did not need it anymore” as the treatment had changed. Within days I felt like I was dying, that everyone I loved had died, had restless legs (sounds silly but it is awful), and asked the doctor to be put back on the Xanax for a taper. I was so deep in withdrawal I could barely think straight. He left my exam room for about an hour then sent his nurse in to send me home. I went home, laid down on the bed, and had a grand mal seizure. Woke up with black and blue bruises in the shapes of my muscles all over my body, had bit right through my tongue, and my rotator cuff (shoulder) was broken. I went in for emergency surgery that night, ended up in severe withdrawal for weeks on end, and about 30k in debt from the medical bills.
35. Learning to Trust People
I’m a veterinarian… in general the biggest mistake I can make is to trust my clients to do the right things for their pets. The second biggest mistake is to assume all clients won’t do the right thing.
One lady went out and purchased her own insulin syringes when she ran out instead of calling for a new prescription—she got the wrong size, overdosed her cat, and the kitty died from complications of hypoglycemia. Another lady stopped giving her dog insulin at night and feeding it appropriately because she “goes to bed too early to give the insulin” and “the food is really really expensive.” Another lady told us her insulin fell and broke, and asked us to refill the prescription. Prescribing doctor was out, so I didn’t fill it and it slipped my mind… almost a week later she came in because the cat was ill. He went into diabetic ketoacidosis and died.
I have double-dosed a horse with a kidney-toxic medication, forgotten to follow up with a dog with heartworms to figure out how to get him treated, waited to diagnose a dog with a small mass on her leg until it became the size of a softball and was almost unable to be treated, didn’t run a parvo test on a puppy that ended up having parvo and dying due to lack of supportive care…..
Unfortunately, all of these things are learning opportunities—we are all human, and on our WORST days we are still fantastic healthcare providers who care about animals and want to do well. I will say, I have never made the same mistake twice, because the first time is always so close to mind.
34. Catching The Tumor
My dad had an interesting misdiagnosis a few years back. Since my dad was about 20 or so, he noticed that two of his ribs (opposite each other) stuck out slightly more than the others. He thought nothing of it, and his doctors always told him not to worry about it. It was especially pronounced when he was lying on his back—the two ribs stuck out about an inch above the others.
Anyway, one day he was forced to see a different doctor for his checkup for one reason or another. The doctor noticed his ribs and asked a few questions. He then strongly recommended that my dad get an MRI done on his brain, as he suspected something might be affecting the bone growth.
Sure enough, they found a golf-ball sized tumor. They removed it without issue and he’s been doing fine since. He switched to that doctor permanently.
33. Filling With Poop
I’m not the doctor, but a couple years ago my father went in for a colonoscopy after experiencing abdominal pain. His doctor was a pretty young guy, and the procedure went routinely, with one “growth” removed for biopsy.
Within hours of the surgery, my dad spiked a fever of 105 F and went to the emergency room. With no idea what happened, the doctors opened him up to find actual poop all over his body cavity. The young doctor had removed my dad’s appendix tie-off scar, which had been done using an out-of-date method from the 90s. He had no idea what it would look like, and didn’t realize what he was cutting off, basically popping a poop balloon inside my dad’s body.
He’s okay now, but he nearly died. We didn’t sue, but the hospital paid for the colonoscopy and the following emergency procedures for us, which was nice of them.
32. Not Really That Fun Of A Day
Not a doctor, but I’m a medic in the army. These are a few of my favorite things:
Two nurses were busy arguing while we had a patient having a pretty severe heart attack. After we stabilize him they continue arguing. Well we had to administer some aspirin, but the dude is unconscious, so we decide to just pump it into his stomach. One of the nurses crushes up an aspirin and dilutes it in saline. We drop a tube into what we thought was his stomach, and push the aspirin mixture.
I’m failing to remember why he needed an X-ray at the time but he got one. Nasal Gastric (NG) and Oral Gastric (OG) tubes are the tubes you see people get shoved down their noses and throats. At the very bottom there’s a tiny piece of metal weaved into the plastic so an x-ray technician can take a picture of the patient’s torso and check placement. Usually placement is checked up using your stethoscope and pushing air into the OG/NG tube, if you hear gaseous noises, it’s in the right place.
Well for some reason the nurses never checked placement, and the X-ray tech tells us the tube was in the guy’s freaking lungs. The nurses had just pushed an aspirin/saline solution into homie’s lungs. That was a fun day for everyone.
Another situation, but I wasn’t actually here for this. Heard it from the doctor who made the mistake though: Doctor wasn’t an attending physician yet. He was either an intern or resident, but I want to say resident. Anywho, so he gets this larger older woman in who is having some issues; I can’t remember what her deal was. Regardless, her body temperature was extremely high.
There is this really neat catheter that doctors can insert into your arteries and it will pump cold fluids to rapidly cool you down. The thing is, at the time they were pretty large and rigid. This isn’t conducive to trying to insert into one of the most sensitive and dangerous areas of the human body.
Well… when the doctor inserted the inter cooling catheter it actually completely shredded her artery long ways. He basically gave her a manual aortic dissection. The thing is, there was no way to immediately notice since it occurred within her body. It wasn’t until a few seconds later her blood pressure began to tank.
Since she was already really sick and they were trying to stabilize her they had trouble realizing what was going on. She eventually died. It wasn’t until afterwards that the doctor had heard what he had done. He didn’t get in trouble since it was just one of those bad mishaps. Apparently the family handled it really well and didn’t have any animosity towards the doctors or the hospital.
31. Doctors Are Humans Too
I was at a holiday party of relatives and friends. My older uncle is a radiologist.
He said (a story I’ve heard before) that he wrote left instead of right on one of his X-ray interpretations and because of that error the patient subsequently died (wrong lung with the tumor or something like that, but I really didn’t get the details).
Anyway, a doctor friend of his at the party said, “It happens to us all, it happens to us all” consolingly.
So people, it happens to them all. Be really vigilant, don’t have a naive, childlike view of your doctors—they’re human.
30. Scrub Mistake
I remember back in medical school the first time I actually got to scrub in on a case. We were removing a small bowel obstruction from the patient and about mid way through the procedure my face mask started to fog up. At this point in my training I didn’t have the common sense to realize my face mask was not sterile. Needless to say I went ahead and face-palmed myself trying to adjust it… The scrub nurse lost her mind on me for that one and I had to go re-scrub. The whole ordeal was pretty embarrassing at the time.
29. Grandma’s Back
Not a doctor, but I have a story about one that screwed up and one that saved the day. My grandmother was seeing this physician because she had multiple issues with heart disease and high blood pressure. He prescribed about a dozen different medications to fix all her problems. Soon after she started to speak strangely. She would start accusing people of being in the Mafia, and wanted to kill her and the rest of us. This kind of talk became more frequent as time went on, until finally she just stayed in bed because if she left she would be killed. None of us knew what to do, because who really wants to have their grandmother committed.
During this time, my uncle (my grandmother’s son) goes to the supermarket to do some shopping. While there he meets her old physician, who just happened to ask how she was doing. My uncle goes into all the details on what we were going through. The doctor then says he wants to look into the case since she was a good patient of his, and asks for the phone number to the house.
The very next morning he calls and says he found what the problem was. The concoction of medications she was given had severely depleted the salt in the body causing her brain to swell. He was shocked that the other doctor had not realized this before over medicating her. His short-term solution was for us to give her one tablespoon of salt. The long term solution, of course, was to change her medications.
I have never seen such a change in a person before. We gave her the salt in a drink, and within the hour she was completely normal again. It really was an incredible moment for us. One hour before we thought we were going to lose grandma to some institution, and then the next moment she is downstairs in the kitchen making herself a cup of tea. That doctor saved my grandmother, and I can’t express enough gratitude to him.
28. Boy, That Was Close
Nurse here. I was assisting during a vasectomy. The doctor found the testicular artery and thought it was the vas deferens (the sperm tract) and was about to tie it off and cut it. In a very diplomatic way, I told him to double check the anatomy.
27. Don’t Burn Yourself Out
My parents are nurses. They knew a doc who’d been on a 36 hour shift. Patient came in with a punctured lung (I think) and the doc had to collapse the lung to fix whatever was wrong with it.
Through tiredness he collapsed the wrong lung, and the patient died. Doc ended up killing himself after being fired.
26. Second Time Is Not A Charm
This will probably get buried and although I am a doctor this was NOT me but this happened to a doctor I know.
A patient had gone in for surgery on their right knee. The surgeon did surgery and everything was fine except he did the surgery on the wrong knee. Fast forward a few days and the patient returned for surgery on the correct knee. The surgeon did surgery on the patient’s knee and forgot a sponge in the knee. The wrong knee, once again.
25. Count Them All
Fun story, while my wife was having her c-section for our daughter she overheard one of the nurses say “there’s only nine,” and my wife thought they were talking about my daughters fingers or toes. So she’s freaking out that our daughter is missing a finger or toe, and I keep assuring her that our daughter was perfect, which she was. We found out about ten minutes later that the nurse was talking about the surgical tools that were supposed to be accounted for, and one of them was missing. So my wife got to spend the next two hours in x-ray because they thought they had left a tool inside her and stitched her up. They found the missing tool, not inside my wife, a couple hours later, so that was a relief.
24. Mistakes Can Make You Better
As a very young doctor in training I misdiagnosed a woman with epilepsy. Some years prior she had sustained a gunshot wound to the frontal area, damaging the underside of one of her frontal lobes and severing an optic nerve to one of her eyes, as well as some of the muscles that rotated that eyeball. Surgery saved her life but the frontal lobe was scarred and the eye was blinded and always pointed down and at an angle away from her nose.
A few years after that she began having spells of a bizarre sensation, altered awareness, a pounding in the chest, and she had to sit down, stop what she was doing, and couldn’t speak. These were odd spells and I assumed she had developed frontal lobe epilepsy from the scar on her brain. Increasing doses of anti-seizure drugs seemed to work initially, but then the spells came back.
A couple years after my diagnosis her endocrinologist, who treated her for diabetes mellitus, checked a thyroid. It was super-high. The spells were manifestations of hyperthyroidism. She drank the radioactive iodine cocktail which ablated her thyroid, got on thyroid replacement therapy, and felt well thereafter. No permanent harm done and she was able to come off the anti epilepsy drugs.
She was obese—not the typical skinny hyperthyroid patient—and if she developed thyroid eye disease, I couldn’t tell because her one eye was already so messed up. I see how I screwed it up, but in retrospect I have never been sure what I could have done differently, except test her thyroid at the outset of treatment. Hence, a lot of patients—thousands—have had their thyroid checked by me since then. Every so often I pick up an abnormality and it gets treated.
The lady was an employee of the hospital where I trained and I ran into her one day; she gave me a hug and let me know how this had all gone down. She made a point of wanting me to know she didn’t blame me “because I always seemed to care about her and what happened to her.”
I think about her, and how I screwed up her diagnosis and set back her care, almost every day. I am a much better diagnostician now but I always remember this case and it reminds me not to get cocky or be too sure that my working diagnosis is correct.
23. High Ranking Doctor
I’m in the military, and as I’ve gotten closer to 40, it seems I’ve begun to develop high blood pressure. On-base doctor insisted I needed medication to control it, so he wrote a prescription. To be honest, I hadn’t seen this doc before and seemed a bit…. off. Not sure how to describe it, but he just seemed a bit less than completely there.
Anyways, I walk down to the pharmacy area and wait my turn. I’m called forward and the pharmacy tech asks for my ID, looks up the order, and asks me some basic questions. “Name,” “Date of Birth,” and “Allergies.” I told her I was allergic to penicillin and sulfa.
The prescription was for Hyzaar. Any medical student can probably tell you how moronic this order was. Hyzaar specifically has side effects for those with allergies to penicillin or sulfa. I’m allergic to both.
The tech actually said out loud “What in the actual heck!” She calls the doctor on the phone and starts chewing his ass. Keep in mind she’s a civilian and he’s a commissioned officer. Neither of them “outrank” the other, so he’s arguing back with her, and then she says, “Your pill popping is officially over. You could have killed this patient today because you’re always too high to know what’s going on around you. I’m going to the wing commander over this.”
To shorten the story a bit, it’s brought before an ethics board and a court-martial. Seems he was “trading scripts” with other doctors in the area for pain pills, was high nearly every waking moment, and could have actually killed me. He received a sentence of over one year. I’m being a bit purposefully vague to prevent anyone from tracking me down personally (as I had to testify).
22. Pharma Phools
PharmD here. Couple different quick stories.
Heard of a pharmacist who filled a fentanyl patch incorrectly and the dose was so high that the patient went into severe respiratory depression and died. They’re still practicing.
Worked with another pharmacist back in the mid-2000s when I was still a tech who filled a script for Prozac solution (concentrated it is 20mg per mL. Average adult dose is 20 mg) instead of 1 mL once daily he filled it for one teaspoonful (5 mL). The child got serotonin syndrome and almost died. He is no longer working to my knowledge.
21. On-Call To The Rescue
My grandmother has had diabetes for about 20 years, and takes a handful of meds to help control it. About ten years ago, she developed a persistent cough. It wasn’t bad, she said it felt like a constant tickle in the back of her throat.
She went to her doctor to find out what was going on, and he ordered a battery of tests concerned that she was developing pneumonia, lung cancer, etc. All the tests came back negative, so he prescribed a cocktail of pills to help combat it. Over the span of five years, she had tried about 35 different meds and none helped.
One day when she went it for a routine check-up, her normal doc was out and she saw one of the on-call residents. He looked at the barrage of pills she was on and asked why. When she explained, he replied, “Oh, the cough is a side effect of this one particular drug you’re on to regulate your insulin. If we change you to this other one, it will go away.”
20. I Was New, It Was My Fault
Doctor here. I assume we mean medical errors and not general life decisions. No comment on life decisions. For medical error, I will not stay anonymous because I strongly think we should feel free to disclose our mistakes in order to improve quality and learn from each other.
My first week of my intern year (year one outside of medical school, when you’re on call overnight and all that, AKA “Season One of Scrubs“), everyone “signs out” their team’s patients to the doctor on call overnight. So that doctor (intern, with an upper-level resident also present overnight to supervise) is covering many patients they hardly know, maybe 60 or more. The situation was that a patient with dementia, unable to really communicate with people and clearly “not there” but conscious, arrived from a nursing home with I think some agitation as the original complaint.
Basic labs ordered in the ER show the kidney function is worse than usual, which could be due to many things, but what really MUST be distinguished is between “not enough blood pumped forward to the kidneys and rest of the body” (e.g. heart is failing and it’s backing up into the lungs) VS “not enough liquid in the blood TO flow” (e.g. due to vomiting a lot or something).
This is critical to distinguish because for the first you give medicine to make them pee out the extra liquid, and in the second you give more fluid. Either treatment for the opposite problem is catastrophic. Fortunately it’s usually easy to distinguish “wet” from “dry,” based on listening to heart and lungs, chest X-ray (is there “congestion” evidence?), blood pressure and heart rate (tend to drop BP and raise heart rate upon going from laying down to standing positions if you’re too “dry”), looking at neck veins while sitting up at an angle (they bulge if too “wet”), and so on.
This patient was unable to cooperate with exam, answer questions, and the X-ray was sort of borderline (unchanged from the last X-ray maybe several weeks ago). My resident instructed me to sign out the patient with instructions to continue a 500mL saline inflow, then reassess to see whether the patient looked more “wet” or less “dry.” I signed this out, and forgot to make the order to stop the saline after 500mL, so it ended up running slowly in all night.
The intern on call (also first week as doctor) forgot to re-assess at all or shut off the saline if it had been noticed because so busy with new admissions. We’d also ordered three sets of “heart enzymes” meant to diagnose a heart attack, one reason for a patient suddenly getting “wet” (i.e. heart pump failure), since the EKG was not interpretable (had a pacemaker which makes it impossible to tell). Lab messed up too, because hospital policy was that if the first set of “heart enzymes” was negative, apparently the 2nd and 3rd sets, each traditionally spaced 6-8 hours later to catch a heart attack if it starts to evolve and become detectable by blood test, were both cancelled.
I came in and first thing in the morning checked on this patient, who was screaming things nobody could understand and the nurses had chalked up to dementia and agitation. I checked the labs and saw the second and third heart enzymes hadn’t been done. I went to the bedside and saw the IV fluids still running. I immediately ran to the overnight intern, who said things had been so busy and nobody had called to notify that things were wrong.
We stopped the fluids, immediately got a heart enzyme test, learned this patient was by now having a massive heart attack made much worse by the addition of IV fluids all night to this frail failing pump.
I can’t get the screams out of my head, and cried a lot and was pretty depressed for a few weeks at least after this. The patient died because the status ended up being decided as not to resuscitate based on what the nursing home had on file, although no family members were known at all.
This patient was totally alone, and spent the last night of their life in physician-induced agony. But I acknowledge the failure of two interns, the nurses, and the lab. Ultimately the blame fell on the lab and I think someone was fired, but I made clear to everyone that I felt to blame and wanted quality improvements made to prevent future errors, or at least catch them early if they happen. That’s I think the best you can do when you make a mistake.
There’s a Scrubs episode where as I recall at the end there’s a brief scene where the ghosts of dead patients representing medical errors follow around the physicians like little trains. It’s very poignant. That’s what it’s like.
19. Near Miss
I missed a gunshot wound once. A guy was dumped off at the ER covered in blood after a rap concert. We were all focused on a gunshot wound with an arterial bleed that was distracting. The nurse placed the blood pressure cuff over the gunshot wound on the arm. We all missed it because the blood pressure cuff slowed the bleeding.
I was doing the secondary assessment when we rolled the patient, and I still missed it.
We didn’t find it till the chest X-ray. The bullet came to rest in the posterior portion of the thoracic wall without significant trauma to major organs.
The patient lived. But I still feel like I messed up big time.
18. Butt Shot
When my dad was a resident he had a guy come in with a gunshot wound to the shoulder. The guy had been caught with another man’s wife and had been shot while running away naked. In addition to the shoulder, the patient kept saying he had been shot in the gut. Dad searched all over and couldn’t find a wound. But the guy kept complaining about excruciating pain in his lower abdomen. X-ray revealed that, indeed, there was a bullet in the abdomen. Took a while to find, but my dad finally found the entry wound… The guy had been shot directly in the butthole. Swish.
A few years ago, I saw something very similar on ER. Guess if enough people get shot, there are bound to be a few one-in-a-million shots.
17. He Might Not Know, But I Won’t Forget
This thread is pretty depressing, so I’ll lighten it up a bit. A few months ago, I accidentally ran a creatinine test on a patient when a comp metabolic wasn’t ordered. It turns out that the guy was in renal failure, and no one knew. He was about to go in for surgery (I believe it was a bypass, but could be wrong), but I got the results in in time to stop them from putting him under.
It could have been messy. I’m glad I screwed up, and I’m sure he has no idea that he could have died.
16. Glove on My Face, But Don’t Call Me a Gloveface
Not a big mistake but definitely awkward at the time. I was gluing up a laceration on a 14-year-old girl’s forehead. Anyone who has used dermabond before knows that stuff can be runny and bonds very quickly. I glued my glove to her face. Her mum was in the room, and I had to turn to her and say “I’m sorry, I’ve just glued my glove to her face.”
15. I Would Have Noticed
I’m going to eliminate pronouns to further de-identify the circumstances. This didn’t happen to me, but a doctor I worked with a long time ago.
Doctor saw Patient regularly for medication management. Patient came back for a follow up appointment with a very telling side-effect from a very low dose of a medication and no improvement in symptoms that the medication was intended to target.
Because this particular side-effect is relatively mild early on and can also be caused by many other variables, Doctor was not duly suspicious of the medication being the cause of the side-effect and increased the dosage of the medication. Patient became very gravely ill several days later, and died a few days after that due to complications of the side-effect of the medication. It was a huge mistake and I can’t help but think if I had been the doctor, I wouldn’t have overlooked the side-effect, and Patient would still be alive.
14. Wrong Patient
I’m a nurse. I’ve given an anticoagulant (blood thinner) to the wrong patient. Over the the next day his red blood count dropped. He ended up in ICU.
13. Luckily That Tooth Was Bad Too
Dentist here. I was performing a simple extraction and preparing for the case when I didn’t realize that I had the X-ray flipped the wrong way the whole time. I was viewing the film backwards, and pulled out the wrong tooth. When I realized my mistake I started freaking out, only to find out that by some dumb luck, the tooth I extracted had to go as well.
For the record, this happened in dental school, so safe to say it was a learning experience. It was my first and very last time to make that mistake…And yes, we are doctors.
12. Heartbreaking Experience
As an ICU nurse, I’ve seen the decisions of some doctors result in death. Families often times don’t know, but it happens more than you’d think. It usually happens on very sick patients that ultimately would have died within six months or so anyway, though.
Procedural wise, I have seen a physician kill a patient by puncturing their heart while placing a pleural chest tube. It was basically a freak thing as apparently the patient had recently had cardiothoracic surgery and the heart adhered within the cavity at an odd position. I’ll never forget the look on his face when he came to the realization of what had happened. You rarely see people accidentally kill someone in such a direct way. Heartbreaking.
11. Working In An ER Is Hard
ER resident here. I have two (that I know of).
Tried to protect the kidneys of a gentleman who had to get just a TON of contrast. Ended up giving him too much fluid and pushed him into pulmonary edema. Spent about an hour on bipap but did OK after.
Did an FAST ultrasound on a trauma patient. Thought it was negative, but in retrospect had a small pericardial effusion. He coded about 30 min later after said effusion expanded. Had so much head trauma everyone told me he wouldn’t have lived anyway… but still feel awful about it.
EVERY resident and doctor makes mistakes and the ER is basically a perfect storm of the factors that contribute to errors (multiple patients, constant interruptions, fast paced environment, lack of familiarity with patients, ETOH/drugs, incomplete histories, and multiple providers). You just hope that when they happen your mistakes are small.
Our hospitals and programs try VERY hard to have a blame free work environment as when you review common medical errors they are usually caused by a culmination of circumstances rather than one person just not doing their job right. Residents routinely present M&Ms (morbidity and mortality conferences) that go through the scenarios that led to the mistake and analyze the reasons and fixes that can be made. It’s universally thought of as our best conference because you can often see how very easily one could have made the same mistake in the other person’s shoes.
As has been said, we try our best to do right by patients and to get the right answer. I work with incredibly smart people every day who are driven, committed, and who have excelled their whole life in order to be incredible doctors. Unfortunately errors are part of the job. We just need to do your best to recognize them, learn from them, and most importantly prevent them from occurring more than once.
10. Saving The Day
Here is a good one I didn’t cause but “saved the day” as a resident that was surgically assisting. C-section for failure to progress and ugly looking fetal strip… all went perfect, time to take cord blood and I am to fill up the test tube… surgeon looks at it and it has one very large chunk of glass broken off of the rim (3x4cm)… there is an open abdomen in front of us with blood clots everywhere. So as safely as possible we are sticking our hands around to try and find this glass… if it is inside the abdomen the chance of even seeing it on X-ray is minimal and this will dice up this patient’s bowels/blood vessels and God knows what else.
After approximately 3-4 min (felt like 10) I feel an edge of something firm just inside the edge of the incision… pull up a blood clot with the glass piece inside…didn’t go into the cavity and all is well. Surgeon said she’d buy me a drink…never did get it.
9. Poisoning Someone on the First Day of Work
My first day as a camp nurse for people with intellectual disabilities I gave nine pills to the wrong guest. I didn’t know who I was looking for and asked my friend to send out the guest.
His hypochondriac roommate walks out, tells me he is the person I’m looking for, I asked my friend for confirmation who THOUGHT the correct person had come to me and confirmed from afar that it was, and I administered the meds. He had a LOT of drug allergies. Stomach dropped when the actual person I was looking for came out 12 seconds later.
Luckily, we called poison control and most of the pills were vitamins and the ones that weren’t were either similar to ones the guy was already taking, or in therapeutic low-dose form. He was fine and still continued to ask for everyone else’s pills at all times.
Worked there two summers and thankfully had no other disasters like this one.
8. Can’t Get Worse Than That
I’ve posted this before, but I’ll copy it here.
I had a nine-year-old girl bought in one night with her parents complaining of fever and respiratory distress, presenting with coughing and wheezing. The kid was really out of it and the parents were very upset. I thought it was Bronchitis, but I admitted her and ordered treatment for her fever and cough as well as throat cultures.
I was with another patient when the kid started hallucinating, sobbing and spewing everywhere. I figured it had to do with the fever, so I packed her with ice, but she died maybe a half hour after that. This wasn’t my first death, but it was one of the worst. I couldn’t tell the stiff neck since the kid was out of it. She also couldn’t tell me anything else that would point to simple or complex seizures.
She died of neisseria meningitidis. Completely wrong diagnosis. To make matters worse, we called in all her schoolmates and anyone else we could wake up just in time to see three other kids go. The rest got antibiotics quickly enough.
Probably my worst day in medicine.
7. Having Your Heart Ripped Out
My brother is a surgeon, and during part of his residency, he had to work in the pediatric unit. He was working with two newborns. One was getting much better and fighting for life. He was going to make it just fine. The other baby was hours from death. He wasn’t going to make it. My brother was in charge of informing the families. My brother realized about 15 minutes later that he had mixed up the families. He told the family with the healthy baby that their baby wasn’t going to make it, and he told the family with the dying baby that their baby was going to be just fine. He then had to go back out to the families and explain the situation to them. How devastating. To be given a glimmer of hope and have it ripped away from you not even an hour later. That was most upset I’ve heard my brother. He felt destroyed.
6. Severe Shingles
Someone else’s mistake directly affected me.
I was working in Yosemite as a camp counselor, so there was no internet access or anything. I started to get a red rash on my chest, and then on the same place on my back, and it started to expand and crawl up towards my armpit. And it hurt, really, really, really bad. As if you had the worst sunburn ever and someone slapped it really hard every time you moved.
I went to see the nurse (a new nurse gets cycled in every week) and she looked at it and goes “Ohhh that’s poison oak!” I was like, really? I haven’t really gone hiking anywhere… and she assured me that it was poison oak and that I must have accidentally gotten the oils in my clothes or something. She then proceeds to rub in hydrocortisone cream into my chest and back as hard as she can. I’m literally tearing up its so painful, and all she can say is, “I know dear, I’m sure it’s painful.” She gave me a bottle of the stuff and some antihistamine pills and told me it’d be gone in two days.
It wasn’t. I couldn’t move without being in terrible agonizing pain. I returned to the nurse and told her, “I don’t think its working.” She says to me, “Oh, my brother who’s a doctor knows what it is and he doesn’t even need to see you. He says it’s something called ‘Herpes Zoster.'”
For those of you who don’t know, Herpes Zoster is Shingles. I had been living with undiagnosed shingles for like five days, and at this point the rash was the most disgusting collection of painful, pus-spewing pimples ever.
Ended up getting driven to the closest clinic which is 40 minutes away, and the doctor said it was one of the most severe cases of shingles she’d ever seen. Gave me some Vicodin to put me in “feel good” mode and told me everything would disappear in three weeks.
Since that time, I have a rare complication called Post-herpetic Neuralgia in the spot where my shingles was that causes me to feel basically the same pain because my nerve endings are too screwed up in those places. Turns out Hydrocortisone cream is the worst thing you could put on shingles.
5. Oh NO
Not me, but my mom. She just retired as an OB/GYN and she told me about a time early on in her career when, while not a real medical mistake, she still almost ruined the operation. She was performing a c-section I think, and she dropped her scalpel on the floor. Before she could think, she blurted out “oh crap” as a reaction. The mother, thinking something was wrong with the baby, started panicking. It took a team of nurses, the husband, and the mother of the patient to calm her down.
This was very early in her career, and she practiced for another 25 years without major incident.
4. Pharmacist Saves The Doctor
Pharmacy student here. Wait what? Yeah, I didn’t do it. I saved the lady.
I was on rotations, we had a lady who was taking VERY high doses of Oxycontin (roughly 240 mg a DAY) for pain. I don’t remember what it was related to, she had a laundry list for her personal medical history. Let’s go with cancer, remission (to give life a good outlook). She is admitted to the general floor with altered mental status. She was out of it. Major side effect of opiates = altered mental status. Okay. No big deal, get the opioid out of there and the patient will probably come to.
Under my care (with my preceptor), the nurses on the floor had to use Naloxone on the patient. This hospital doesn’t mess around with pain control. Naloxone (or Narcan) is an opioid reversal agent. It wakes you up when you have so much that it is negatively affecting your chances at living (such as respiratory depression). Patient is taken off her 200mg+ Oxy to see where her pain is. She’s down to 20mg a day now. She isn’t complaining about pain. She’s still altered mental status. 24 hours pass, nurses Narcan her six times in 24 hours. SIX TIMES. Unheard of at a small hospital. She hadn’t had her Oxy in almost 16 hours when she got her last Narcan shot.
Due to her altered mental status, patient was put as a “fall risk.” As the nurses are putting the mats next to the patient’s bed, they turn around to get the pads that go over the sensors and the patient falls out of bed. Off the side? Nope. OFF THE END. They think she’s fine, put her back in bed. They find her home med of Oxy that she had been taking in her bed. That explains why she is altered mental status, she’s over-medicated. Problem solved? Nope. Patient is now 20 hours post dose (of hospital given medication).
I tell my pharmacist that we need to do a CT scan because she could have hit her head. ANYONE that falls should have a CT, especially if they are altered mental status. The nurse said she could have hit her head but the MD didn’t order a CT scan because they wanted to put in a pacemaker. The patient had a low heart rate too, so they thought that was the cause of the altered mental status.
I beg my pharmacist to let me talk to the Doctor myself. I just had that feeling. That bad feeling. I’m good friends with an anesthesiologist who works at this site, so the pharmacist suggests we ask them first. I talk to them, they agree with me and go tell the MD to get a CT of the patient’s head. They do it.
Two hours later, patient is in ICU, crashing. Why? Cranial Hemorrhage per CT scan.
Next day, doctor comes to thank me. They were going to put the patient under for the pacemaker right when they did the CT scan.
3. That’s No Scratch
I’m a nurse, but I was working in the ER when a guy came in for a scratch on his neck and “feeling drowsy.” We start the usual workups and this dude’s blood pressure TANKED. We scrambled, but he was dead within ten minutes of walking through the door. Turns out the “scratch” was an exit wound of a .22 caliber rifle round. The guy didn’t even know he’d been shot. When the coroner’s report came back, we found that he’d been shot in the leg and the bullet tracked through his torso shredding everything in between. There was really nothing we could’ve done, but that was a serious “what the heck just happened” moment.
2. Always Look Under the Pillow
One of my mentors (in life, not medicine) was telling stories from his college days when he was still an EMT and not a doctor yet. He was called to a house where the parents of an 18-year-old girl had called 911. They said their daughter was feeling really bad and having stomach pains.
So they arrive on the scene, him and his partner (both still pretty new to the whole gig), and the girl is laying on the couch in the living room with a pillow covering her stomach. They do standard EMT stuff and get her on a stretcher and into the ambulance. They’re on their way to the hospital when the girl starts saying she’s been shot.
And what my mentor was thinking was “Oh she’s in so much pain she’s become delusional and thinks she’s been shot.” Him and his partner decide to look under the pillow, which the girl still has covering her stomach, for the first time to find a bullet wound. She had tried to kill herself in the bathroom by shooting herself in the stomach. She used a small enough caliber where the bullet didn’t pass through her body so there was no exit wound. On top of that, her parents weren’t even aware of the wound.
1. Always Check the Decimals
I very nearly injected a premature baby that had Down Syndrome with ten times the amount of Lasix I was supposed to give him: I had put the decimal in the wrong place when I did the math on the dose.
That baby would almost certainly have died if I’d given it to him. I had the liquid drawn up in the syringe and had the syringe actually in the port ready to push through before I looked inside the chamber and realised how uncharacteristically full it seemed.
Paediatric IV doses of anything are simply tiny. I was supposed to give him 0.1 mls, and nearly gave him 1.0mls.
I needed a very large cup of tea after that.