Medical Errors: The Silent Killer in Medicine | Carol Gunn | TEDxFargo
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- Опубліковано 27 вер 2015
- Dr. Carol E. Gunn shares a powerful story about her sister and the obstacles they faced due to errors in healthcare. She openly wonders why, when medical errors are the third leading cause of death, there is little outage, transparency or accountability. In her unique position of being both a physician and a family member who has suffered a great loss, she understands the tremendous pressures facing both providers and chronically ill patients.
Medicine is Dr. Gunn’s second career. Prior to medical school, she worked as an environmental health and safety professional … which taught her the skills of accident investigations and root cause analysis. She began medical school later than most, at 37 years of age. She then completed medical school, a primary care residency, and her occupational and environmental medicine fellowship.
Dr Carol Gunn, an internist and occupational medicine physician, thrives on working with individuals and groups advocating for patient and employee safety.
She has been an agent of agent nearly her whole life. After completing her bachelor’s in chemistry and master’s of public health degrees, she was a safety engineer, during her first career. For twelve years, she focused on reducing workplace exposures to harmful chemicals.
With the goal of creating greater impact on others’ health, she then elected to attend medical school. She completed an internal medicine residency and a fellowship in occupational medicine, opening her own independent practice in 2007. She is boarded in internal medicine, occupational and environmental medicine, and industrial hygiene.
Outside of medicine, she lives with her wild Lab, and enjoys the varied activities of the Pacific Northwest. She valiantly attempts to balance her life of family, work, and play - but there never is enough play!
This talk was given at a TEDx event using the TED conference format but independently organized by a local community. Learn more at ted.com/tedx
"It's our 3rd leading cause of death. Where is the outrage?" Really!! Wish I could give this more than just one thumbs up.
Dear Dr. Gunn. I am an RN in a busy trauma unit. Thank you for sharing this powerful story. I’m so sorry for your loss. Unfortunately, here we are 6 years later and healthcare has gotten so much worse. Of course, transparency and communication are the keys to better patient outcomes, but in the wake of the RaDonda Vaught conviction, I fear that we are rapidly heading in the opposite direction. Until insurance companies get their boots off the necks of healthcare providers, I don’t believe that things will change.
Dr's and Nurses NEED to listen to the patient and family. NOT everyone is textbook. My husbands cardiologist and nurses ignored signs of a pulmonary embolism. I repeatedly asked them to do a CT scan to check for clots, he was spitting up blood, severe stabbing pain on his left side and chest area. The cardiologist said "We did a CT scan 3 days ago he was fine" The nurses never examined him and just said it's probably from coughing so hard. I kept pushing to the point of yelling at the dr and telling him I want my husband moved to another hospital...within two hours my husband was crashing and we were taken by life flight to a large hospital in another state and guess what? First thing they did when he told them his symptoms, a CT scan, guess what? A LARGE clot in his saddle area of his pulmonary artery and multiple clots in his lungs. The DR immediately put a swan line in and started TPA for 24 hours to bust it up and put him on blood thinners after that. The DR brought the medical students into his room, held up a scan and asked them what their diagnosis was. One student said the patient should be dead. The Dr said Yes, he should be, but you are looking at him now. This is a reminder to listen to your patients and do the tests and never get a GOD complex or you will lose patients. Forget about insurance and treat the patient to save his or her life. This Dr was awesome, he actually didn't bill our insurance for one test the insurance was refusing and the Dr ate the cost because my husband needed the test. Be your own advocate and don't be afraid to ruffle some feathers, it's called practicing medicine for a reason. They aren't GOD and if they don't listen, fire them and get a new Dr. They work for you.
the first few lines made me so angry and worried😥 ,good you got a better doctor.But,there are still doctors who are real heroes and others should definitely learn from them. Lots of respect for the doctor who saved your husband's life.Wish your family a happy and healthy life ahead .
My daughter was hospitalised last year for low sodium levels she has a number of chronic illnesses
what did u do to the previous hospital........bloody killers they r
@@selenajwallace294 What is her illness? How is she doing?
I am so sorry to hear about your husband's experience, but I am glad to read that he received the appropriate treatment at the second hospital. As you have stated, not all patients present like it was shown to us in the textbooks, and people are always going to present symptoms in different ways, just a little care and attentiveness could have caught that early. Your story highlights the importance of patient advocacy and the need for healthcare providers to listen to their patients and their families. I have had instances where family members or patients have felt like their concerns aren't taken seriously and it leaves them feeling frustrated that is definitely not a feeling you want to experience while your loved one is in the hospital and it also diminished the level of trust you have in the care team
As you pointed out, healthcare providers are not infallible and can make mistakes. It is important to have patients and their families involved in their care. Open communication and a willingness to listen are essential in providing high-quality care. As a second-year medical student myself, I have had a few interprofessional classes where we interacted with patients and other healthcare team members who share experiences about their ailment and hospital stay and they always try to emphasize the importance of listening to the patient and coming level with them, because they are the one who is actually experiencing the discomfort and we are privileged to be the one taking care of them. There are also a lot of communication steps and advocacy that have been developed and refined over the years to ensure that errors are caught quickly and communicated promptly.
Thank you for sharing your story, stories like these are things I would always remember to keep me grounded and provide safe medical care to my patients. And I'm glad to hear your husband had a good outcome eventually. I hope he is doing well now.
I just wanted to start of by saying that I am so sorry for the loss of your older sister Dr. Gunn, I cannot imagine the pain of losing a loved one in this way. It is truly inspiring that you are able to share this story with others to educate them on the harm the medical errors are doing to so many people in our system. You are incredible for turning pain into motivation to help others not experience what your sister and family did. As a future physician I am shocked that medical errors are the 3rd leading cause of death and this needs to change.
I think part of the causation of medical errors is due to the attitude of many physicians that “they know best”. Patients deserve to have their voices heard and sometimes know their bodies better than we do. When I was a medical scribe in college, there was several instances in which I witnessed a specialist get angry and annoyed for being consulted to see a patient for their symptoms. They would often leave the room saying something like “they don’t need to be seen by me, their chest pain is just from anxiety”. I really want doctors to drop this attitude because the patients’ symptoms are very real and scary to them in that moment and they deserved to be looked at with no pre judgements. This is the kind of attitude that leads to something like what happened to your sister. Medical errors are more likely to occur when physicians develop a pre-judgement prior to walking in and seeing the patient. This could lead to them overlooking something and not fully evaluating the patient. As the osteopaths say, humans are compilation of mind, body, and spirit. Even if the patient’s pain is “just anxiety” will can still greatly help them with human interaction and touch.
I encourage all patients to not suffer in silence. Speak up and advocate for yourself and health, because sadly, sometimes you are the only person that will. As a future doctor I think hearing stories like the one you shared with us Dr. Gunn is vital to our training. The emotion behind your story is something that will always sit in the back of my mind when treating patients. I hope that in my career I never let a patient go unheard, so thank you for your story and guidance.
Thanks Carol for your ongoing concern about medical error. Your work and voice are so important for the health of all.
It doesn't take "manpower and resources". It just takes communication. Doctors MUST call out/ confront other doctors who err. This goes for ALL doctors - even veterinarians.
Dr Gunn's talk brings me to tears. It reminds me of how much I have had to fight just to get my mom checked for strokes! I am appalled that ER drs are not aware of the fact, schooled in the fact that once you have a major stroke you do not have the same symptoms of a classic stroke! A care giver is more mindful and able to assist the drs in finding later strokes! My mom had a stroke on April 5 2013, it was not diagnosed until her birthday April 11, 2013. After I fought the entire time, and there was now nothing they could do!
Doctors need to take responsibility for medical errors. Let me give you an example. I've seen doctors write up scans for the wrong limb to be examined, write up medications incorrectly. Dosages 4 times higher than what is normally prescribed or write up a medication that the patient is allergic to. We are all human and errors happen, but no one in the healthcare industry should be stretched to the point that errors like this happen. Doctors and nurses are working under incredible levels of stress. What can we do to minimise this from happening?
Hi Reliability Training: Peer Checks, Validate and Verify (trust your gut and if something seems "off" ASK about it), asking Clarifying Questions, and training folks to bridge the power gap and raise a concern even with someone in authority if they have a concern (one of the biggest psychological barriers to preventing harm). Recognizing WHY folks make mistakes and establishing practices that make it less likely. It's work that our hospital is doing, and I understand that it's made a real reduction in instances of patient harm.From a consumer side, be AGGRESSIVE towards your own care, don't walk out with a "non-answer" and say, "Well, I guess it must be OK- the doctor said it was nothing." We often KNOW when something is wrong, and we need to advocate more strongly for ourselves. Anna knew, but she let her doctors put her off. No blame- I would have done the same thing, most likely, but we need to change that.
Lorelai the answer, those that see and know, should speak up, or it continues, sad but true
I remember going in for a hernia repair.
This is when they would knock you out before surgery. They give me the shot to knock me out. A bit later I wake up and a person is shaving my chest. I ask why. "Aren't you having open heart surgery." He responded.
They have given me shots for things that I am allergic to. I have a lot of distrust for doctors.
Wow! What a painfully, yet insightful message. Dr. Gunn, thank you for your courage to share it.
I am so blown away by the power of this talk. May this message reach all who need to hear it and learn from it, so that they may take charge of their health and put the power back in their own hands. Bless you, Dr. Gunn!
trust me maam, putting health in patients hand is worst mistake. it takes huge amount of time and mental resources to juz understand one medication its uses or side effects, and forget about the recommendations and how to apply them. most of the time patients refuse treatment or press for unnecessary measures. errors do happen, but v r not robots. doctors and nurses try to do what's best possible ....but it sometimes backfires. u have to understand that even the best of the sportsmen can have a bad game as law of averages ultimately catches up.....u federer loses matches.....so try to see the big picture please.
+ed dc Well except neither are the Patients and we're not talking about just a few of Us (acceptable losses)here. Not to mention that it's not a game and the , "You win one and you lose some ", attitude not really applicable or appropriate when you're talking about someone's loved one. I suffered for 8 hours under their care, and I'm pretty sure they were waiting for me to die. Thanks to you, I now see that I was right. Just what big picture are you looking at?
+ed dc Understanding why these errors occur is important, as well as recognizing that the blame doesn't fall anywhere in particular. It's systemic, and there are realistic changes that can be made to improve the communication happening behind the scenes between providers. While you're right that the problem can't be fixed through better doctor-patient communication entirely, your resistance to even consider solutions or question the status quo is disheartening. That is the big picture, sir.
Carol mentioned that thousands of people die in result of medical errors every year like her sister. Doctors are only human and this controversial problem should be worked through instead of being made a stigma. By getting patients a second opinion, other additional help (maybe a specialist’s opinion), or not hesitating to ask if there is even a shadow of a doubt, misdiagnosis may lessen. Two doctors looking at the same set of symptoms could have two similar, but different diagnoses and that could make all the difference in treatment and recovery for that patient. Everyone, based on their past experiences, can look at situations in different lights. Inevitably as humans we make mistakes now and then, including doctors, and that’s okay. However, I believe that relying on more than one doctor, especially in serious circumstances, could greatly benefit medicine in many ways.
poop
Thank you for sharing this story - as a doctor and as a family member who watched a loved one suffer from medical errors. Sadly, three years later, medical errors are still the 3rd leading cause of death in North America. I gave a TEDxTalk about medical errors on March 3, 2018 in Vancouver BC in the hopes that bringing this subject back to the stage will help keep the conversation going. If we all work together, we can change these statistics.
BC is doing wrong by chronic pain patients. The doctors there are covering up Iatrogenic and post op injuries. They label CPP’s with a mental health disorder without doing a differential diagnosis or even examine the patient! It’s a recipe for disablement and death.
I’m so sorry for the loss of your sister.
Dr. Gunn, I want to start by saying thank you so much for sharing your story, and I am sorry for the loss of your sister. As a future medical provider, currently in training, I want to make it part of my days to find out where things went wrong and how to prevent negative patient outcomes, as happened with your sister. We cannot only celebrate the successes of our patients and those we were ablet to find answers, but also find out end stories for those who are still looking for answers. I don’t think that anyone would go into medicine intending to harm a patient, but by occasional carelessness and possibly letting slip “this one time,” huge mistakes are made, mistakes that cost patients their lives. I am currently in an ethics course and I the ethical principle of non-maleficence kept popping into my head as you spoke. For anyone reading who may not know the exact meaning of this, it is that physicians and other medical providers live up to the ethical standard to do no harm to their patients. However, here in Anna’s case, harm was done. Although one may point out that we are human, and we will all make mistakes - and I would say they are correct, entering the field of medicine means that certain mistakes cannot be made. Especially those of overlooked details or care where the outcome harms the patient. In moving on from a negative experience, I thought the action that Dr. Gunn’s family took was extremely honorable. Taking action to make sure that the mistake would not be made again is so much more helpful for everyone involved, and those who may one day be in a similar situation. Having over 200,000 patients die each year as a result of medical professionals errors is way too many. And by the time I am writing this comment, I can only hope we have started to learn and that number has decreased. Regardless, we should take awful outcomes and turn them into learning opportunities to ensure that the same procedures are not repeated, and a different patient will have a different outcome. I truly believe this is the way that we will end up living up to our ethical standard of non- maleficence. Finding out what caused the problem and taking all steps necessary to relearn how to do it the right way. It is a health care providers job to assist patients in times of need and when they need answers, and not to make it worse.
its really heartbreaking, sorry for your lost of your loving one.
Thank you so much Dr Gunn! This was really emotional,...May God bless and protect you.
What a beautiful attitude you have. This is something every hcp can do for their patients and each other. 😊
I’m sorry, Dr. Gunn, for your loss. This story truly is heartbreaking. And it’s heartbreaking that preventable harm and deaths like Anna’s are so common. As Dr. Gunn pointed out, mistakes are going to happen. But we as physicians and healthcare professionals need to be willing to fix mistakes when we discover them, and do all we can to prevent future mistakes. If we refuse to change practices, we’ll continue to harm people. That’s unethical. Even if it’s hard, we must be willing to accept responsibility and do our best to prevent future errors. I also agree with Dr. Gunn’s recommendation that physicians should be willing to offer feedback to colleagues when an error or unsafe practice is recognized. If you as a physician notice a colleague causing harm or not providing good care, and you don’t say anything, that’s unethical. Your silence is potentially causing harm, which is the opposite of our pledge to “do no harm.” As a profession, we need to become more willing to acknowledge our mistakes so we can avoid them in the future, be willing to provide respectful feedback to our colleagues, and graciously receive feedback from others. To do otherwise perpetuates the environment that has made medical errors the third leading cause of death.
Dr. Carol Gunn, thank you for sharing your story about your sister and her unfortunate passing from a preventable MI. Being a physician yourself, you brought up good points about your own mistakes and the growth you obtained from the feedback you received. You brought up a great point on the implementation of feedback to doctors. I am not sure what kind of up to date training doctors receive once they are practicing, but like you mentioned, why are students and other physicians afraid to talk to their peers about better methods? As a medical student myself, I am terrified of the idea that I may miss something that could cost a life. I do not see anything wrong with physicians having resources at their disposal to look at the latest treatment options, and what additional signs to look for when seeing patients. I think it is a good idea to have checklists when dealing with patients with certain etiologies. For example, you mention that the doctor you interviewed mentioned referring your sister to cardiology and how he could’ve been a “hero.” I don’t know why those cardiologist share some of their checklists with other physicians so that they do not miss urgent or even look out for silent signs to prevent deaths? Mistakes happen, and unfortunately some are more costly than others. However, being open about your mistakes to patients and showing sincerity for missed clues goes a long way. But most importantly, implanting change for growth to prevent senseless deaths in the future. As you mentioned, going through a lawsuit may have gotten you a case won, but not your sister. A lawsuit however may have pushed or forced the hospital to implement more training to physicians. Sometimes it seems that that is the only way someone does any sort of change, when they are forced to fork up a huge chunk of change. Insurance for doctors are going up every year and defensive medicine is another topic, but striving for that medium is what we should all strive for. Thanks for sharing!
Thank you for sharing your story about Anna, Dr. Gunn. It was very powerful and moving and I am incredibly sorry about your sister’s loss. I was surprised to hear that medical errors were the 3rd leading cause of death. Unfortunately, even in the year 2023, there still hasn’t been much change or improvement in medical errors. After the COVID-19 pandemic, the healthcare industry has been insanely overworked and stretched incredibly thin, only increasing the risk for medical errors and malpractice. Dr. Gunn’s statement at the very end of her talk really resonated with me: “The ultimate medical mistake is the deafening silence that continues to surround medical errors.”
To err is human and mistakes can happen, but Dr. Gunn is right - there needs to be a change. Healthcare providers must hold their colleagues accountable for their mistakes and not be afraid to educate and implement changes. By not doing so, they are violating the ethical principle of non-maleficence - to do no harm. By turning a blind eye and/or pretending like these issues don’t exist, they allow for more medical errors to happen, which then result in significant harm, including death, to happen to their patients. I can only hope that more protocols and trainings be put in place to allow for better communication within the healthcare community and to provide a safe space for providers and other healthcare workers to hold their colleagues, or those in a higher position of power, accountable.
I love it when family members don't listen to medical professionals that are only "family members"
Carol, I am so proud of you.
Dr. Gunn’s message about medical errors was powerful. It is sad to see that among many physicians, there are many medical errors that lead to horrible outcomes, including death. Most of these medical errors could also be prevented according to Dr. Gunn. Her sister was having tons of chest pain, paralysis, and other similar symptoms. No one gave her Dr. Gunn’s sister a full evaluation, which ultimately resulted in her death since her heart was only pumping at fifty percent capacity. Thus, this topic brings up the ethical dilemma of justice. To be a physician, one must practice medicine in a way that treats everyone equal. Besides having all the knowledge to treat patients, a physician must also build trust with each one of their patients by being a steppingstone in their care. For a physician to be just, he/she must also dig deeper into the story of their patients. Prior to medical school, one of the physician’s I shadowed taught me a valuable lesson. He explained to me that I need to pay attention to the little details. For example, one of our patients came in with a cough, but the physician wanted to specify exactly how the cough felt (e.g., burning or stabbing sensation). By exploring something as minor as the type of cough, he was able to rule out many things and ultimately diagnose this patient with strep throat via the centor criteria. If the physician paid attention to minor details and really believed his patient’s cry, then he could have ultimately protected her from harm. Dr. Gunn is a practicing physician who was able to figure out that her sister’s death was preventable after reviewing her entire medical history. She was able to file a lawsuit that won in court. However, she made a great point that I also agreed with: did it have to come to this conclusion? Her sister’s life was priceless, and the fact that it could have been prevented had the physician been not have been so negligent and arrogant. The last argument that Dr. Gunn makes is that physicians must also keep each other accountable for patient safety. There’s a difference between getting a second opinion on a patient versus being transparent with a fellow colleague on their care plan. I plan to work as a hospitalist one day, and I know mistakes will happen. However, I want to be effective in reducing those errors via being transparent with my patient’s, accountability from my staff and colleagues, and by taking care of my physical and mental health. Dr. Gunn also ended with explaining that we need to advocate for ourselves. If we have pain, we need to question why it is there and why it is persisting. This is hard to do because we think that physicians are the expert, however, they do not know your body better than you do. Lastly, I believe that doctors are not horrible, but mistakes happen and that it should be brought to their attention.
I'm so sorry to hear your sister's story. I almost died while my doctor worried about my marriage and asked if I was depressed! Then they cut me as a client and sued me for my non payed bills.😢Doctors don't give a shit.
What a heartbreaking group of stories and I appreciate you sharing them. I think that the difficult part of this story is that it's very real given the recent RaDonda Vaught trial and conviction. She was publicly humiliated for a very serious mistake. However, when I read that story a year ago, I thought to myself, "Could this be me? Could this be a future colleague?" As a future physician, I worry that we are overworked--especially in residency. Nurses are also overworked and I've heard nurses worry about ratios. So many physicians, nurses, PAs, NPs, etc are afraid to admitting of a mistake because they are afraid of losing their licenses--their livelihoods. We learn in school the four bioethical principles: nonmaleficence, autonomy, beneficence, and justice. And when I think about medical errors I immediately think of nonmaleficence and beneficence. First, do no harm and then promote good. I believe that communication promotes good and prevents harm to families and friends. First, it's vital that doctors take the time to listen to their patients and listen to their families. think that it's so important for doctors and nurses and other providers to able to admit what they're doing is wrong but also be willing to 'call in' those who have made mistakes and to do it in a way that does not shame them, but rather promotes learning and further good.
My dad passed away from MEN2a in 2015 because the doctors didn’t use google to simply look up the procedure to fix him. No doctors were even in the room with him because they said he was fine. Since then I’ve never trusted doctors
Dr. Carol Gunn’s personal insight as both a physician and a family member of a loved one who passed away due to medical negligence, made her argument extremely moving and powerful. Her story shed light on a couple ethical components: to do no harm, and negligence. A physician’s first and foremost responsibility is to do no harm, and that includes harm due to not pursuing a patient’s complaint. Whatever guidance or procedure recommended by a physician, the patient’s well-being should come first and foremost. Just as a physician would not refuse to pursue care and treatment for someone with an obvious injury like a broken wrist, neither should a patient with a unseen illness or pain be ignored or have their experience minimalized simply because the physician doesn’t think it could be something else. There is a necessity in the medical field for physicians to trust their patients and the reasons for their visits , even if it’s something that the physician cannot see or think is highly unlikely. Just as Dr. Gunn’s sister was told to simply take NSAIDs for her chest pain by one physician, and then by another to reduce her bone marrow medication, neither physician took the time to pursue other options or consider that her experience might be as painful and bothersome as she said it is. The ethical meaning of “Do no harm “ doesn’t just mean not to physically harm the patient through a accidental slip of the scalpel or the wrong diagnosis, it also means harming through lack of care, by not giving the patient and their complaint the time they deserve. Secondly, the ethical component of negligence also came into play here, defined as when a physician breaches a duty to the patient, the patient suffered harm , and the breach of duty caused the harm. What happened to Dr. Gunn’s sister was due to negligence, as she was unable to receive the care she needed for her heart attacks before the damage to her heart was irreversible, due to the dismissive care of her physicians. Had her physicians referred her to a cardiologist sooner, or taken the time to truly search for a cause for her chest pain instead of shrugging it off, perhaps she wouldn’t have passed due to complications the way that she did. It is a physician’s responsibility to pursue all possible avenues, and to play an active role in looking at all alternatives of care, benefits, risks, and consequences of each alternative. Dr. Gunn made an excellent point in saying that the worst thing physicians can do right now is stay silent about this issue, and they need to have the courage to stand up when they see negligence occuring by both their peers and coworkers.
Good talk
I looked up the reviews on Dr Carol Gunn MD. It’s no wonder she is joining the speaking circuit
Dr. Carol Gunn brings up a lot of good points. She talks about medical errors and how scary they can be. I learned that medical errors are the third leading cause of death behind cancer and heart disease. Dr. Gunn tells stories about both sides. She is both a health care professional and someone who has lost a family member due to medical error. There are several terms that come into play when discussing Dr. Gunn’s point of view. The first one she talks about is negligence. The definition of negligence is “failure to take proper care in doing something.” Medical professionals take an oath to give every single patient 100% of their effort at all times because their career directly deals with the health and potentially the lives of other human beings. The term that applies most to the careers and lives of medical professionals is beneficence. Beneficence talks about actions that are done to benefit others. When Dr. Gunn talks about negligence being a main cause of medical error, it makes me angry that medical errors sit at number three in leading causes of death. This tells me that our third leading cause of death in the United States is completely preventable. However, as you watch more and more of the video, she beings to talk about negligence taking a back seat to accidental medical error. She says that the scariest form of medical error is not the one that occurs because a doctor or primary care physician intentionally did not give their full effort for a patient, but the one that occurs because they honestly thought they were doing everything they could and found out that they missed something along the way. I agree with her. I can only imagine how it makes you feel as a professional to find out that you were doing everything you thought you could do and then something goes wrong. Negligence seems like it should be fairly easy to fix. We should have nothing but the harshest punishments for a medical professional that knowingly cuts corners on their job as a deterrent. Unfortunately, I don’t think there is much that can be done to prevent accidents, other than to fulfill your obligation and your oath that you take to the best of your abilities. Healthcare workers are professionals, but they are indeed also only human.
Are you writing this to yourself?
Dr. Carol thank you for your powerful story about medical errors. I can relate to your story. Regarding a surgical procedure my Mom had to have several years ago the doctor wanted to replace the wrong hip. Interestingly, even in his office my Mom had to correct the doctor. He insisted that her right hip needed to be replaced when it was the left one that was shattered. Thankfully my Mom doesn't let doctors get away with stuff. She stands up for herself. Here's a suggestion for others going through medical issues and having to have a conversation with their doctor. FOCUS, as noted in "It's Just a Conversation" is an important acronym that my co-author and I created to take away the fear and emotion in dealing with uneasy conversations.
It was enlightening to listen to Dr. Gunn’s perspective on this issue that she has been on both sides of. She understands what it is like to be a physician that has made a medical error, as well as the family member of someone who has paid the ultimate price due to a health professional’s mistake. The statistic that she provided of 200,000 deaths occurring in the United States each year is overwhelming. A change within the culture of the medical field that she described could greatly reduce that number. An ethical principle that all physicians are to live by is non-maleficence. Non-maleficence is the duty of the provider to cause no harm. When a healthcare provider knows that an incorrect dosage is being made, or an inappropriate treatment is being administered, there is harm being done to the patient. It should be appropriate to correct or make recommendations to other providers caring for the same patient. It is better to take some correction from a colleague than to do harm to a patient which may end up in a malpractice lawsuit. A physician not doing something that is normally a locally accepted practice and it results in harm is one definition of malpractice. It is unrealistic to expect perfection in that no medical errors will be made, but they are preventable and the number of deaths can be reduced. However, I do understand that this is only the perspective of one medical professional and that the culture may not be exactly has she has portrayed in her talk. I am open to hearing the perspectives of other medical professionals and to learn more about other factors that play a role in medical errors that Dr. Gunn may have not addressed.
This is a very powerfu story and wakeup call to the health professionals to work harder and harder to avoid medical errors. Most of the patients died due to medical harm. We need instutional change in the health setting to promote safety of patients, Tomorrow I will be the one lying n bed waiting for service.
i'm surprised that this nurse didn't suspect that her sister's symptoms may have been indicating a heart attack and seek a second and even 3 opinion if necessary to get down to the bottom of it. i'm not in the medical field, but i knew something was odd, that something was wrong, that something was happening which id' never before experienced when i was having a heart attack almost 4 years ago. it started on Saturday after my daughter, granddaughter and i ate chinese food. i felt over heated while having a cig break outside a store where we'd gone to shop. the top of my head felt hot. i chalked it up to sitting in the bright sun while smoking. my tummy was upset, i felt weak, and i just didn't feel quite right. i told my daughter, and i sat outside the dressing room for her to be done shopping. i went home and took a nap and felt better about 4 hours later when i woke up. by wednesday morning, it started up again. i had that same odd feeling that something wasn't right, and i had an upset stomach. i thought it would subside when i woke up more, but it didn't. when the tummy upset continued, i called my clients and cancelled my appointments for the day, something i very rarely do. after a couple of hours, i started getting pain spanning across my back at the shoulder blade level. i knew that women don't necessarily experience left arm referred pain when having a heart attack, so now i suspected that i may be having a heart attack. however, my breath was not labored, and i didn't feel like an elephant was sitting on my chest. i got out my blood pressure cuff and started taking my BP / pulse. they seemed to be within reasonably normal limits from what i could recall from when my friend first taught me to use it a couple of years before. i had no health insurance at the time. (you know what it's like when you have no health insurance--you have to be half dead before you seek medical care.) so i waited a while longer before seeking medical attention. i think i even googled "heart attack symptoms in women." about 6 hours after it started, i called my daughter and asked her if she would take me to the ER. when i walked in the door, i told the staff that i was having a heart attack, they believed me, and they started my assessment and treatment, which led to a triple bypass. unless you are a chronic hypochondriac, trust your intuition when you get that peculiar feeling that "something just doesn't feel quite right." know also that hospitals are obligated to treat you if you go in through the emergency room. hospitals receive generous donations to help people who have no means to pay for emergency care and followup.
I can not afford to seek diagnosis from 1 Dr., let alone having to go to multiple for a diagnosis. Medical cost in the U.S. is absolutely crazy! $2,000.00 per C-Scan etc.....
a. Thank you Dr. Gunn for sharing this difficult story. The ethics regarding medical errors seem to be under discussed and too often forgotten. With such a high prevalence, it seems like such a preventable tragedy would be a focus of the healthcare system. Medical errors often have extremely serious consequences to patients and the affected patient's family. Healthcare professionals generally want to provide quality care and never intend to harm their patients, and I can assume that most professionals would support eliminating these detrimental mistakes. In a way, medical errors are a breach of a professional's duty to care for their patients. Patients should have access and the right to receive safe and high quality care, and medical errors directly violate these rights. Another mistake too commonly seen, is that professionals do not disclose the errors to the affected patient due to fear of repercussions. By not disclosing these mistakes, you are directly violating patient's rights to understand the care they receive and you are impeding the ability to improve and prevent similar errors from occurring in the future. Without honesty and transparency in the healthcare system, there will be a failure of patients to trust providers and receive adequate care. Another point however, is that many healthcare systems may not provide a safe culture or environment in regards to reporting adverse effects and improving upon them. Providers are much less likely to report events if they fear that they will face serious repercussions for an error. It is an ethical responsibility of every healthcare organization to maintain a system that uses to data to improve patient safety and protects both patients and providers. In reality, everyone makes mistakes and healthcare providers are no different. The unfortunate aspect is that these mistakes often carry heavier consequences than other professions. Overall, there should be a focus on protections for the families, patients, and professionals with an overall goal of improving patient safety, transparency, and continuous improvement and reevaluation.
I reported my sister’s home bound doctor for neglect that ultimately (in my opinion) hastened her death. He ignored her symptoms while checking the boxes Medicare required. The state, after 3 years (delayed by COVID) of “ investigation “, found no fault on his part.
Thank you, Dr. Gunn, for the candid and passionate talk about medical errors. Medical errors would happen far less if there were better communication between healthcare providers, healthcare providers gave and received feedback from one another, and there were more providers. At least one of these three items is lacking in any medical error. Communication is a cornerstone for preventing medical errors, and many such practices have been standardized to help streamline these practices. Communication strategies like the “Handoff” and “time out” have both had a positive effect in reducing medical errors. But these are only the bare minimum and only proved a scaffolding for communication; providers must continually practice and train their communication skills to prevent medical errors actively. Dr. Gunn pointed out that very few medical providers give each other feedback in practice. Feedback is an unbelievable opportunity for intervention; medical providers must be able to give and receive constructive feedback. Medicine is continually changing, and providing constructive feedback to a provider practicing outdated or wrong medicine is an excellent opportunity to help prevent other medical errors. Providing constructive feedback to peers is not common practice in the US and needs to be adopted by more providers. One of my mentors had a patient enter the ED with a cervical fracture from a chiropractic adjustment. The chiropractor did not know the woman had come to the ED, and instead of throwing him under the bus, my mentor, the ED physician, called him up and explained the situation and what he thought was the best course of action. He took time to bring the chiropractor back into the healthcare team, allowing him to retain his dignity. The patient underwent successful fusion without complication. The ethical principle of nonmaleficence, or not inflicting harm, does not apply to our colleagues. We need to change the mindset of defensive behavior in medicine and take the viewpoint of everyone trying to help me become a better provider and person. Through this practice, providers will be able to continue to reduce medical errors.
It is always devastating when a doctor makes a mistake or a medical error that may lead to an early death in someone’s life. Doctors practice the ethical principle of beneficence, where they try to seek what is best for the patient. They attempt to always give the patient the best care they possibly can in order to benefit them to the best of their ability. However, doctors do occasionally fall short. I believe that in the case of Carol’s sister, the physician committed negligence to her. In order to be negligent, the patient must have been harmed, the physician must have breached a duty, and the breach of duty must have caused the harm. In this scenario, her sister was harmed since she died as a result of the lack of treatment she received for her heart attack. The normal standard of care for someone coming in with the symptoms of heavy chest pain that Carol’s sister had would be to recommend a cardiologist or at least get imaging done. The doctor failed to listen to his patient and understand her symptoms enough to get further testing, and as a result, Carol’s sister was misdiagnosed and eventually passed away. Like Carol says, doctors like her focus on giving patient’s the best care they can, but unfortunately, mistakes still happen resulting in medical errors.
I don't understand how someone just walks past a body laying on the floor. That is unbelievable to me because especially at a hospital you'd think people would find her right away. I understand why Dr. Gunn's sister would be so upset. She told her doctors for months about her heart pain but they didn't take her seriously. If they did, maybe she could have been saved. I know we can't expect doctors to always be correct and all humans make mistakes but it really surprises me that the third leading cause of death is medical errors. These doctors should take these as learning opportunities and not as critism. Health care should be saving lives and not the third leading cause of deaths. If this was more focused on I believe doctors would have more survivors and if patients made sure their doctors listened to their symptoms, it would really help. 200,000 americans dying every year due to medical errors is a huge number. I believe that if they focus on that then many of those lives could be saved. Also, there needs to be more communication between the nurses and doctors. Like Dr. Gunn's example of the nurse not putting the right amount of dosage of drugs into their patient, she said no not to tell the patients doctor. Not telling the doctor could lead to other complications. They need to have better communication so both the doctor and other staff members are on the same page.
A lot of healthcare institutions and insurers dissuade the physician from referring to specialties. The big reason? Money. Especially the insurers. A lot of the times the physicians have their hands tied. Nevertheless, that is not to say that all physicians are as proactive as they should be.
I agree with Dr. Gunn. Change needs to take place for better patient outcomes. Medical errors come in direct conflict to two of the primary bioethical principles of medicine: Non-Maleficence and Beneficence. However, I feel that staying silent about your own or another’s medical errors is a form of medical negligence. For those who don’t know, medical negligence has a very specific legal definition. As Bernard Lo, MD puts it in his book, “Resolving Ethical Dilemmas: A Guide for Clinicians,” [the definition of] negligence: the physician breached a duty to the patient, the patient suffered harm, and the breach of duty caused the harm.
I believe all physicians have a duty to a patient to whom medical error is perceived, whether or not they have direct responsibility for that patient. Thus, if harm comes to this patient because of an ancillary physician’s silence about medical error, this is negligence.
As a medical student, I know that medical errors will happen because physicians are human. Doctors have a lot of stress and they make errors. I understand that. However, further harm need not come because feedback was not given to the physician in error.
What exactly could've the doctors done about the chest pain in Anna? I ask because I actually want to know concretely what thye shouldve done.
I am a registered nurse in the states of New York and here in Korea.
Medical errors are common in Korea as well. I have stopped visiting Ob&Gy because I would always get infection every time. A donor friend came out of a surgery room, his buttocks, entire back and back of his arms all came out grilled. It was a 2nd degree burn on half of his back and the rest part of body were a 3rd degree burn. And Did Ajoo hospital apologize for that? I would be surprised if they even wrote it in a chart.
😖
"Where is the outrage?"... reminds me of n episode of Dr House
Dr. Gunn’s story about her sister is very sad and troubling. Even more troubling is the statistic that medical errors are in the top 5 leading causes of death in the United States (200,000 + per year). It is a problem. I believe the best way to avoid preventable errors is to establish transparent lines of communication between health care workers without losing confidentiality and to establish protocols for potentially life threatening conditions. For example, if an individual who is post bone marrow transplant has persistent chest pain, they get an EKG. It may sound trivial but obviously it is not. In fact, I recently watched a different Ted Talk video in which the speaker mentions that physicians once thought it insulting to be forced to wash their hands before dealing with pregnant women. Today, this is common practice and common sense.
Without a doubt, negligence plays a role in cases like Dr. Gunn’s sister’s. Negligence is defined by three distinct parts in “Resolving Ethical Dilemmas: A Guide for Clinicians” by Bernard Lo, MD: a physician breached duty to a patient, the patient was harmed, and the breach in duty caused the harm. These types of errors are inexcusable and should be eliminated by establishing specific protocols and creating dialogue about the issue like we are right now. Of course mistakes happen, but encouraging health care providers to slow down and error on the safe side will prevent major forms of negligence from occurring.
I also want to encourage others watching this video to not lose faith in the health care system or in doctors. Although there are many, many preventable deaths that occur in hospitals each year, there are also many, many miraculous stories of doctors saving lives. Every medical student begins medical school wanting to help others. No one wants to make a fatal mistake. What is important is teaching medical students early on about communication, teamwork, and being detail oriented to minimize breaches in duties to patients.
I, and my mother and boyfriend, have been the victims of near fatal medical errors. While I know they can happen without bad intentions by the provider, I would say any provider that sees a patient more than once with a very serious and persistent complaint should really take it seriously, do referrals or diagnostic tests. It's almost never "in our heards."
I need a new one for me!
This isn't medical error... it is negligence!!!! As women age, the more we are medically neglected.
In youth, all our symptoms are said to be from "stress/anxiety". In senior years, it's said to be from "aging". There is no point in saying more!!!
It is ridiculous that the third leading cause to death in Americans is medical errors. I agree with Doctor Carol Dunn, healthcare providers should receive feedback from one another. Humans are not perfect it is inevitable for them to make mistakes. However, they should be doing everything in their power to prevent medical errors. Feedback from coworkers and patients is one of the many ways that could cut back on these errors. If someone notices a provider incorrectly treating or diagnosing a patient they should speak up. These providers should look at this as a blessing, not a criticism. Patients deserve the best care, but being sloppy and having numerous errors that could be easily avoided needs to change. There should be constant improvements in prevention of errors. It cannot simply be put on the back burner. It is time to step up and as Dr. Gunn says, "lead with transparency and accountability".
I would first like to say that I agree with you 100% that the fact that medical errors is the third leading cause of death for Americans is shocking. Since it's obviously expected that humans make mistakes, we cannot always expect doctors to be perfect with every single patient, but I agree that I think there are definitely ways to prevent the high number that there is of medical errors. Pointing out that more feedback would help because as patients working as a team with doctors instead of expecting them to know everything, is a good idea, because doctors would be able to learn more along the way as well as decrease sloppy errors. Overall, I agree with your points and that Dr. Gunn's comment is correct as to "lead with transparency and accountability."
wow wow wow
this is Sad 😫😫😫😫😥😥😥😥😥😥😥
I believe that medical errors are prominent, and not purposeful. Even medical professionals are humans and tend to make mistakes. However, I believe that many medical doctors or other professionals are too confident with a sense of "know-it-all" mentality. They don't want to admit that they may be wrong, or that there may be other alternatives. Dr. Gunn discusses how her sister fell victim to medical errors, and her symptoms being ignored and that resulted in, ultimately, her death. Most doctors focus on giving the best care they can, and sometimes fall short of that. Dr. Gunn made a good point when she said the best thing a patient could do, was inform her on her error. The worst errors are the ones that go unnoticed. The fact that the third cause of death is medical errors is outrageous and needs to be more focused on. Healthcare should not be our cause of death, but elevate our health. Dr. Gunn makes a good argument that we need change, we need to give feedback on outdated practices, or wrongful practices. I feel as though this always comes back to listening to patients as well, patients are their own advocates and their concerns should not be ignored.
14 years I've been trying to get the right treatment for my illnesses. All they have ever done is throw more medication at me and ignore my issues. How do you get a GOOD doctor, who will actually help?! I'm running out of time :(
Healthcare workers are suppose to work as a team to give their patients the best care possible. Yes we are all humans and we make mistakes, but why not do anything to help lessen those mistakes? When Dr. Gunn mentioned that another doctor noticed someone else's mistake but did nothing about it threw a red flag for me. How can doctors let their colleagues continue to make mistakes that they know are occurring. People's lives are on the line in the medical profession and no one can afford to continue to make the same mistakes over and over. It is the healthcare worker's duty to alert the people that work with when they spot a mistake. They must realize that no one is perfect, and that covering up wrong doings will only make things worse. If no one owned up to the mistakes they have made, can you imagine what the healthcare system would be like? No one would want to go to the doctor knowing that they may make a mistake and not ever bother to tell them. Yes it may be hard to own up to mistakes and may make you feel less powerful, but whatever the reason may be one must push them aside and realize it can only make them better. Being in a hospital is a very fast faced environment but if you think about it, healthcare is the one area where nothing should be rushed. Doctors jump to conclusions right away to save time, but they should take the time to make sure what they have decided is correct. Dr. Gunn's example of the doctor who said "Then I would have to refer all my patients to cardiologists", brought something to my attention. Why is referring a problem? Yes it will save time to try to figure it out yourself, but is it really the correct thing to do? If having a cardiologist assess a patient helps aid in the process of finding a correct diagnosis then by all means it should be done. 'Saving time' should not be something that's said in the healthcare field. If doctors told their patients to their face "I'm doing this to save time", how do you think that would make them feel? I would be terrified. But of course they don't disclose that information with the patient. Being transparent as Dr. Gunn mentioned is a great way to change what is happening. Doctors should let their patients know they made a mistake, they should be open to criticism, they should be willing to accept that sometimes referrals are a must, and they should accept that they can't always figure out the diagnosis on their own. All of those things are their duty as doctors. Now of course not every error is known, but shouldn't someone inform that person as soon as they find out? its easier said than done and may even cost someone their job. That's why mistakes continue to happen in the healthcare system everyday.
😞 was it an error or negligence??
A STEMI is quite easy to diagnose.....if someone dared to do an ECG. Even a nurse can do one and show a doctor to reassure.... If a patient told me of her symptoms I would have done one within 5 minutes and ran for aspirin. There is a machine literally on every ward if not more .....so every nurse can grab one every moment if needed. And here in Austria of course the doctor would be told if he prescribed a wrong dose, as a nurse I would even correct it and let it sign him and look over it - 4 eye protocol....
The laws in the USA make practicing good medicine, in many cases, illegal. For the patient, there is not enough transparency to make any kind of educated decision. Bad doctors are allowed to continue on hurting patient after uninformed patient. Doctors are quitting because the laws have ruined it, the "Affordable care act" ruined it even more. Medical errors are probably much higher than 33%. Now there will be a doctor shortage, which means the percentage of bad doctors will continue to increase. Mexico, where I live, has much better health care.
May I inquire as to the laws in the USA preventing patients from having transparency in making educated decisions? From what I understand, doctors are required to provide the patient with risks and benefits of accepting or refusing treatment. Additionally, alternative treatments will usually be discussed with the patient. A doctor’s job should be to provide the patient with different alternatives and they can tailor that information given. Now, there are different standards of disclosure, so even “bad doctors” must disclose at least a professional standard of disclosure, which is what a reasonable physician would disclose in the same circumstances. From there, the patient can decide whether to undergo certain treatments or diagnostic tests.
To address your further concern of uninformed patients, there is a standard as to whether a patient is competent enough to make their own decisions. At the end of the day, if a patient is deemed competent, I feel that it is up to them to make the decision whether to pursue another avenue of treatment. If anything, I feel that the laws in place are designed to help keep the patient informed, while at the same time prevent the doctor from doing harm to the patient.
@@kalvinzee5172 yes, that's how it's meant to be but in my case it wasn't. Also their % risks aren't correct because so many errors aren't counted so NO info on risk is truly honest. Plus of course they use the same % risk for every doctor, surgeon and anaesthetist etc. when of course some will be far better (less risky) than others - we should know the docs' experience & errors they've made in order to give informed consent.
In the UK with the NHS it's quite rare to be treated by a consultant unless you work for the NHS or are well-known/wealthy (or royal!), most of us are treated by juniors and at the weekend there are even fewer consultants/senior docs around (& general lack of enough staff at all times) - that was the case in 2005 when I became disabled by medical errors, I don't know if that's changed, I really hope so.
Hi, trying to assess ur FRCEM notes,
These stories are truly tragic. I feel for those that were affected by these mistakes and hope that my thoughts will not offend those that have been personally affected by medical errors during their lives. As a studying physician, however, I not only feel for the patients in these instances, but I feel for the doctors who were at fault as well. I fear that these physicians are considered “bad doctors” or are being labeled as “murderers” because a patient died while in their care. The medical education process is very strenuous and intensive. Not only is the science involved in medicine a dominating portion of a training physician’s education, but many ethical principles are learned and practiced as well. In fact, in order for a student physician to become board certified, they must demonstrate an understanding of many ethical principles, policies and laws in order to keep the patients they serve as safe and healthy as possible. That being said, doctors at times fall short of these standards. The two main ethical principles specifically that come to mind while watching this video are non-maleficence and beneficence. For those reading that are not aware, non-maleficence is the practice of not causing a patient intentional harm, while beneficence is the act of trying to do what is best for the patient. During a physician’s medical education and while taking the Hippocratic Oath, physicians learn and commit to these principles. Based on these principles, believe that physicians (for the most part) are not out to harm people. I believe the majority are intending to help as many people as possible. Do mistakes occur? Absolutely. But I think it is important to remember that abiding by the ethical principles of beneficence, non-maleficence and many others is an important part of a physician’s duty.
This is all good. The bad comes in when who made a mistake does not admit it. Or, worse, when the doctor attempts at hiding it.
I've been a nurse for 45 years and for the last 25 years I have not worked at the bedside so for 20 years I administered thousands of procedures and gave thousands of medications. Of course I made errors I'm human and I'm not making light of it at all I'm just saying it's theoretically impossible if you do thousands of procedures or give thousands of medications or shots at an error at some level doesn't happen! And with all the procedures and medications that I've done the worst thing that ever happened was something that was exceedingly common. I left the bed rail down and a patient fell out of bed and almost died I was 19 years old and at 65 the thought of it still turns my stomach. A few seconds of being in a hurry and not putting a bed rail up on someone who is agitated and they crack their head on a cement floor. I still remember the sound.
Physicians have a primary charge to not only care for patients, but to avoid harming them in the process. Dr. Carol Gunn’s knowledge as a physician and her personal experience of losing her sister to a medical error makes this video both powerful and memorable. Her story illustrates the ethical principle of nonmaleficence (i.e., do no harm) and clearly shows that not harming patients requires more than simply being experienced and having a strong knowledge of medicine; physicians must also treat patient concerns as valid, even if the doctor doesn’t consider them a problem (as in this instance). As Dr. Gunn explains, ‘For months, she [her sister] had told her doctors about her chest pain, and no one took her seriously.’ It’s pretty incredible that not one doctor took a closer look at the chest pain; instead they prescribed or took away medications to treat the issue. By the time doctors did look, it was too late. I in no way wish to demean the physicians who serve our society. I think we can all appreciate the hectic schedules that most doctors deal with daily, and I’m sure the doctors treating Gunn's sister were doing what they thought was best at the time. Yet a physician’s good intentions don't erase what happened. Nor do they justify the roughly 200,000 other deaths caused each year by preventable medical errors, as cited by Gunn. In fact, what happened to Dr. Gunn’s sister equates to medical negligence.
Negligence, another principle of medical ethics, occurs when a physician breaches his or her duty to the patient, and results in the patient being harmed. (Bernard Lo, Resolving Ethical Dilemmas: A Guide for Clinicians). Dr. Gunn’s sister’s unfortunate passing appears to be a result of medical negligence, as her heart was permanently damaged due to the dismissiveness of her physicians. Had one of her physicians listened and recommended she visit a cardiologist sooner, it seems reasonable to assume she may be alive today, or at least lived a longer and healthier life.
I am not sure how really they assessed this ...Medical error does not mean by definition thats it was caused by the doctor. The doctor is at the helm of a long chain of a system . The doctor rarely adminster medication . Nurses are the ones who sometimes mistake the dosage of prescribed medication. Also wrong medicine of are often given by pharmacist. The health admistrators who care more about money making than giving a good standard healthcare will load doctors with so many patients they cannot refuse and must see within a limited time. Doctors often go 36 hours without sleep , and many have died after they drove home from their shift. Do not point fingers when you dont understand how the delivery of healthcare works
2013 my girl lost her bowel...it was avoidable. 5 years later...they deliberately killed her because her underlying diagnosis...trisomy 18...was incompatible with life...Brennagh had a full life, she was 11. Genocide is a silent practise in New Zealand and our officials are turning a blind eye. I begged for help and was silenced...but i can't shut up. I miss her so much...they kill them late in pregnancy, the day or week they're born. They make sure their lethal stats stand.
I have often wondered why one doctor is so reluctant to say another doctor was wrong or made a mistake when you get to their office with problems stemming from misdiagnosed or mistreated ailments. I've heard it called professional courtesy, but is it courteous to let a doctor go on with their erroneous ways?
How can they be better if they don't know they are making errors?
And why are so many so arrogant? Heaven forbid a nurse points out something they missed. Even when a patient is just questioning their judgment, the hackles go up.
My own experience with doctors in hospital settings is they have little time for you and are mostly dismissive of complaints or concerns with other areas of the body. Maybe the biggest issue is there aren't enough on staff to do the work the way the job really requires. Spending time with them, listening, looking at the patient as a whole, not just their specialty.
How can we change this?
My doctor told me I had an ingrown toenail. I didn’t believe him and got a second opinion. I had 2 stents implanted due to a blood clot that could have killed me. I advised my doctor of his error and he threw me out of his office. I told him I wasn’t there to fight him, I came to educate him. I have a new doctor.
This happens every single day to people unfortunately. Unless a medical error affects you directly doctors dont get it. I've worked in ED's for 20 years and the reality is that judgement and bias comes ahead of science and listening when it comes to physicians. If they cant see your illness in a blood test or radiological test its perceived to be psychosomatic. Yes this pt told dr Gunn about her error but very very few patients return to the medical professional who misdiagnosed them. They go and see someone else. Which means the one who misdiagnosed you continues on thinking they did the right thing. I think it's so so sad and it frustrates me that it's just excepted in medical practice.
So small in comparison to now.
this is negligence not error
Access to equal medical care is important.
Ask for a second opinion?
Most medical insurance won't pay for that.
Until everyone can get equal access, no change will happen!
I would first like to offer my sincerest condolences for the loss of your sister. Secondly, I would like to mention that this is in no way an effort to belittle the loss you have suffered. Instead, this is my attempt to offer you additional insight into what was discussed in Dr. Gunn’s video presentation.. To begin with I also understand Dr. Gunn’s strong drive to prevent medical errors, yet she herself states that she herself have been in the position while dealing with different patients that she has “harmed significantly, but unintentionally while treating them as a doctor”. She goes on to give an example of one of the case patient she mis-diagnosed but luckily survived. If that particular patient had died, from what Dr. Gunn is saying, medical error took away her sister from an preventable death would be her case scenario. In addition, in this age of medical care, where medicine line have travelled to interdisciplinary management line, we cannot blame in a particular doctor seeking patients for medical error as they all work together to get patients the best treatment needed for them. To extend further, doctors are human beings and no one lies in boundaries of perfection. Besides I assume all of the health personnels are bound in oaths of beneficience in medical profession. This defines that doctors have a moral imperative to act for benefit of others. I would argue that since the job of a doctor is to save lives so I believe any of the doctors would do their best to save life a patients. Yet I strongly agree that mistakes happens from any of human beings. Furthermore, I believe the philosopher John Stuart Mill outlined it best when he described how individuals should have a described how individuals should have a desire for perfection and sympathy for fellow human beings, meanwhile recognizing that this state of perfection is not attainable in its entirety. In summary, the world that currently exists is subjected to human nature and with that comes the knowledge that perfection is not a reasonable or plausible outcome in any regard. So, to ask that doctors emulate a component of our society that is perfect is unfair, unethical and irrational to say the least. I understand that medical error have to be reduced as much as possible and Dr Gunn’s advice of speak for the medical error is valid and justified. But I argue with the statement given by her in video that ultimate medical mistake is the deafening silence that continues to surround medical errors as I do not believe errors to be ultimate and precise out of negligence rather than occasional human errors caused due to miscommunication, team work and work load.
In NZ if you have no degree they won't listen, the Dr is right and we are just emotional parents. You can have proof beyond doubt and they silence you. They use emotional and psychological warfare. I didnt want anything but change but we are shut down. Fraudulent entries, lies and denial of accountability. Good luck to all who find themselves here
Unfortunately you are wrong!
America is a symptom based treatment environment. If they focused more on causes and actually treated the patient, there could be less fatality in USA. Once I was given help, I decided quickly it really was not designed to help me in any way. I have waited 2 months for a dental emergency requiring antibiotics to be treated, and even now I know this will not be addressed immediately, because full exhaust is needed to determine the exact cause of point of infection, ironically, I was told I needed a procedure they said was already done. The infection now is acute in my eye, requiring antibiotics and luckily it's a good optometrist.
Now it's in the nose and jaw.
I mean exray and exam. Possibly a cleaning
This video shows just how often and easily medical errors happen, and how they can be prevented. Health care workers are interconnected, they all work together to get patients the best treatment needed for them. We are humans and make mistakes, but if we are paying more attention and more than one person is checking over their work, these mistakes would be less and less than they are today. In a hospital, a doctor has many other workers looking over their patients such as nurses, CNA's, possibly other doctors from different specialities. Today, it seems as though medical errors are attempted to being covered up by these healthcare teams, and even being covered up by the healthcare management. We need to understand that it is not the medical errors that are what is so wrong, but these stories that are made up to cover up the errors made in the first place. As doctors, this is complete negligence and when they take oaths do be healthcare workers, they are breaking these promises. Neglecting the fact that a mistake was made, and making a story to cover it up, is absolutely ridiculous. Medical errors are inevitable, but the lying, neglect, and horrible choices of these healthcare workers are not inevitable. I strongly agree with the speaker in this video when she says that you know your body better than anyone else. If something does not feel right, you need to get a doctor's opinion. You need to get opinions until you believe they have found what is wrong, and if a doctor neglects your symptoms and your concerns, get a second opinion. Medical errors are a big topic in medicine today, and as i do not have any statistics to prove this, it seems as though doctors are becoming more lazy and less concerned with their patients, causing more deaths and error in their procedures. This is unacceptable, and this speech is a good call to action.
Maybe they should stop using 'teams'?!!! Maybe er doctors should be legally permitted to complain about a doctor who is making obvious mistakes that send the patient continually to the er for the same mistake. Maybe the colleges of physicians and surgeons should not wait until they receive 139 complaints before checking a situation out...but tey do. Maybe a coroner should be involved when a patient/family member thinks it needs to be done, and the report given to the person/family who have requested it. Maybe suicide is the only answer left to a patient...
I wouldn't call them medical errors either there is lack of concern or they are understaffed so that they cannot attend to the patients as they should. That human being lying on the steps was a lack of concern or caring on the nurses part and probably understaffed personnel in the security department.
I believe I have been harmed. I did get another opinion. And another one. Count about one opinion a week for over 12 years. Only a few doctors told me what they really thought, but it took over 10 years before one of them decided to write it down on a piece of paper. The code of silence, especially among surgeons, seems to be the rule. Particularly for cases in which they know that the scientifically more plausible cause (a colleague having injured a patient), can easily be hidden in favour of some mental disorder (which also comes handy for discrediting the patient’s opinion if a medical malpractice case is filed).
Yes, not only deaths but lots of us very seriously injured by medical errors, I was and the docs & hospital lied & denied and prevented me from knowing the truth (what happened) and prevented remedial care for my life-threatening injuries - especially to my throat but also my brain, neck and other places. Yes, a deafening silence about medical error and a refusal to learn from them so others don't get injured or killed in the same ways. And a huge wall protecting doctors and hospitals (the NHS in England): their legal teams and doctors' defence organisations (paid for by us, the patients) ensure patients can't get the truth and justice.
I got injured in 2005 and I'm still not allowed to know what happened and names for all the injuries I have - for example what is it called when you lose the colour from the top of both your irises in your eyes? I'm left to try to guess and get no care or rehabilitation or physio and cannot be correctly classified for my disabilities - this is cruel & wrong and must change.
I found the document she referred to 'To err is human', it says it was published in 2000, what has changed since then because she said in 2015 (?) follow-up document that nothing much had changed, why is this?
I really hope the NHS in the UK did learn from my tragedy (lost my health, my job, my home, my security & ability to work) so others won't have to go through what I did and still am 24/7 - plus my friends & family (especially my son) also suffer from it. So please: work for patient safety in every way possible!
I went through the same in British Columbia, Canada. Lost everything and I’m lucky to be alive .
@@elizabethmcleod246 Hello fellow Survivor. I so sorry they did this to you too. I'm alive (I think) because I was so fit & strong & healthy before (not because of luck), I don't think a frail person would have made it. People say what happened to me was 'bad luck' but of course it wasn't: so many medics chose to disobey laws & Rules/regs that were in place to protect me - & all patients; their terribly dangerous choices (things they did that they shouldn't have and things they didn't do that they should have) caused all my injuries. What about you? Best to you from England.
@@jennyhughes4474 Doctors are above the law. They don’t like a person who advocates for themselves. They’ll never admit they made a misdiagnosis or performed a failed treatment.
I’m in agreement with you. I survived because I was healthy and very fit.
I also had money saved which played a big role in helping me buy pain patches, pain balms , special seats, heating pads, Epsom salts, the list goes on and on. The money I spent at my Naturopath was $20,000!
I got the surgery that saved my life because I hired and paid a registered nurse consultant. No doctor would help me. They were certain I had a mental health problem. NOT!
I had a pinched nerve in my sacrum and I needed surgery.
Italy and Austria are no exception. The mental health route is common practice and deserves to be punished since it’s intentional. Physical harm from a doctor is most likely unintentional but again, any attempt to hide their errors should be opportunely sanctioned.
@@ruggerogabbrielli6831 Thank you & yes: I think this medical habit of lying & denying & covering-up is an international problem; they do it because they routinely get away with it: these criminal behaviours are not punished as they must be. Best of course is prevention & Patient Safety as foremost concern = medics' duty actually but they errrm 'forget' this.
In my own case several medics CHOSE to disobey laws (incl consent) & Rules/regs that would have protected me - those safety-nets were put there for this purpose & although all medics are taught to obey - too many of them don't when it suits them & for their own purposes - incl their personal training wants & needs and maybe access to restricted drugs.
So no: I was not harmed (very seriously injured) by mistake: so many medics made conscious bad/wrong choices that they knew might cause me harm but they didn't care; in other words: conscious acts not 'accidents'.
Yes: lies & cover-ups after medics have injured us must be robustly prosecuted because they prevented me from accessing info (my data) & remedial care - they knew I might die without this, & if I hadn't been so strong & fit & healthy before, I probably would have - & then they'd have faked my death certificate, I'm sure.
The one's in "leadership" are the ones covering it up...at least for me. . .
Sorry about the loss. Further sorry about the pathetic state of affairs in the US. In India n ofcourse noninsurance driven practice places, I'm sure your sister would have been saved. But I have begun to doubt,does the American docs seriously lack common sense, not to take an ecg n echo for a pt with chest pain and that too post bone marrow transplant on chemotherapy ? Strange 😯
My mom has now had at least 8 strokes and they say that there is nothing more they can do for any more strokes!! This is a crime!
+Becky Smith If she had a cardiac echocardiogram + a carotid doppler of her neck +/- thrombophillia screen in seleceted patients then in regard to her stroke evaluation no nothing further can be done, except good managment of your mom co-morbidites ie. better control of Glucose leves, Blood pressure, cholestrol levels, and body weight + Aspirin or Plavix, Sadly in 2016 nothing more can be don, if the doctors did all the above then it's not a crime, it's how young science is, and doctors are not to be blamed and accused of a crime.. I'm an internal medicine doctor
+Mytho Virus she had mris, mrvs, & mras to begin with and then they ( the er drs kept looking for only classic signs of stroke) and never notified the stroke center and because of this the neurologists in the center refused to even look into the matter as she was not referred by the er. I am currently as of 2 hours ago working with a nurse from the center who just so happened to have been my mom's nurse in the er when I kept bringing her in! And in her notes that she wrote at home to keep her sanity due to seeing things that she had been trained to report and she was told not to. My mom's neurologist had been on the floor of the er that night but he was never informed by my mom's attending that she was there and possibly had a stroke!
+Becky Smith because there were no classic signs!
+Becky Smith If passed the window time of 4 hours, since the start of a stroke no intervention can be done other than what i told you, correct all her medical conditions, give her aspirin or plavix as blood thinners as recommended by her doctor, and lastly echocardiogram and carotid doppler to exclude strokes originating from the heart or neck arteries as both have different method of treatment.. I hope your mom do fine
+Mytho Virus What we are working for is better treatment for others, nothing can undo what happened to my mom, she starts to get better with therapy, then falls back. Nothing can be done for her. But other patients can be salvaged if the attending will be bothered to listen to the care giver, I got my mom to the hospital within the golden hour! she could have been treated!
Dr. Gunn has a unique perspective as a result of her position both as a physician and through the loss of a loved one. The statistic Dr. Gunn provided stating that medical errors are the third leading cause of death is astounding. Medical errors are undoubtedly going to occur. However, I disagree with the assumption Dr. Gunn is making that all medical errors fall under the same category. When addressing medical errors, it is critical to determine the underlying cause of such errors. Are these errors the result of an inadvertent mistake, or a purposeful error and lack of duty to the patient? If a physician knowingly harms a patient because of their actions or lack thereof, then they are violating their legal responsibility to do no harm. This principle of non-maleficence should be the most important factor when assessing medical errors. In the case of Dr. Gunn’s sister, the physicians in her care had a duty to do no harm to her, the patient. The physicians lack of acknowledgement with regards to her frequent complaints of chest pain are a breach of their duty to the patient. If Dr. Gunn’s sister had not mentioned chest pain several different times, the situation may be different. Having stated my opinion, I understand that the application of this principle of non-maleficence can be quite complex. To clarify, not all physicians who see the same patient with the same medical condition will perform the exact same tests, or even the same diagnosis. Perhaps one physician is wrong in their diagnosis. As a result, the patient could die. However, I do not believe that merits cause for that physician to lose their legal privilege to practice. Conversely, if a physician chooses not to investigate the patient’s signs and symptoms and simply ignores the patient’s concerns, then that physician is harming the patient. Lastly, the facility where the physician is employed should be examined. Physicians who are overscheduled with patients may have the tendency to hurry through their visits with patients. This could ultimately result in inadvertent mistakes, as well as the possibility for purposeful medical errors. Hospitals that ensure their physician’s work-load is not excessive can potentially reduce the number of medical errors that occur.
To new knowledge,
Yes, its not very nice and makes me think twice
To trust my child to the doctors that staple wild.
Once in the er I witnessed them staple a gash on top of a head. I feel that procedure was cruel and wrong his head being a most sensitive part. They can be so cruel.
Speaking from experience, open wounds stitched carefully back together can leave a scar that is so small that it can only be seen upon close inspection. However, if the same wound was stapled instead, that scar left can be huge. Meanwhile, doctors prefer the staple method because it is a quick procedure. Less time, more patients. More patients, more money. I also had 64 stitches on my scalp, so I am glad the staple method was not popular back then in 1967.
For those of us who have been victims of medical errors, we are usually so sick, dying, we don't have the energy to pursue a medical malpractice case. Doctors KNOW this. Oh, well. One more patient dies at the hands of an incompetent uncaring physician. Studies show as many as 400,000 of us die from med errors, every year.
Spot on. I was poly drugged and sedated and by the time I got my surgeries ( all done way too late ) the Statute of Limitations had expired.
What's sad is that 6 years later, health care has gotten 10 times worse. Covid was a huge wakeup call with how the US values health care. This upcoming financial reset or economic depression caused by corporations greed and government corruption will sink our Healthcare systems and other businesses sectors.
Totally unacceptable I had double pneumonia with delirium and they brought to roll me out to do a task and I guess they are switching shifts and I was laying there literally it seem like for at least 1520 minutes and nobody came to the security card finally came in with me to my room I couldn’t get up a double pneumonia with the Larry and I couldn’t move I couldn’t yell I couldn’t do nothing I just laid there seem to be a very long time like between shifts I’d say 1520 minutes but that’s too long nobody knew where I was until a security guard with a microphone or whatever
When western and eastern medicine becomes more integrated I see change. Today many Doctors are still very egotistical and reuse to refer out to a TCM practitioner. TCM has 1000 of years in understanding one's pattern and this condition explained could have been prevented if a TCM practitioner had seen Anna.
I am not very convinced that it was an error,it seems to me that her sister did not think the chest pains were significant enough,now how can we expect a Dr to know chest pains when the patient did not seem to think they are significant.She probably mentioned them last and did not place much emphasis on it which made the Dr not to think of heart attack.She did not even feel they were important enough to tell her sister who was a Doctor but somehow Dr s are expected to ignore all the other symptoms that she mentioned as more significant and focus on the chest pains that she probably mentioned last.Even when she was in hospital,if she emphasized the chest pains,she would have possibly told a family member especially one who is a Doctor to out pressure so that tests are done sooner than 12 days .I also assume she visited her sister before the 12 days in Hospital,maybe first 5 days since it's a sister she cares so much about,how come she also missed such a significant symptom that the sister was complaining about,since these chest pains were not being investigated while she kept on mentioning them to the Doctors,how come the caring sister also miss them.She is trying to blame the Doctors for errors that she also committed,both as a family member and a Doctor,and yes she was a Doctor as well and being a Doctor never stops even when chating to family members.
Doctors are more concerned about getting out the door in time for a lunch date, or paying off that 3rd home than about our health. Hospitals and clinics pay millions to protect their doctors from medical malpractice suits. Insurance companies ignore the claims. Change the laws to protect us from doctors without morals.
♥️This is so true!!! you can bet on it if your Correct you will be ignored/lied about/resisted/denied/ defamed ...No good deeds go unpunished ask Jesus Christ King of Kings and Lord of Lords...Yet do not turn your head the other way!!!
Personally I don’t see anything like these reported numbers.
Medical care even in its very best version is my it’s very nature uncertain.
Self promotion by belittling modern health care is shameful. It’s like people expect to have perfect lives and live for ever. Personally I don’t see anything like the numbers this doctor claims. I see people making the right call the great majority of time. No question there are plenty of people in medicine who are less than brilliant. If you to have equal representation in medical care rather than only selecting the best we will continue to have less than care.
I have been just as much a patient as I have been a provider. I personally feel like my care has been superb and far different than what is portrayed in this video. I say bravo to those who do so much to help our fellows.
Doctors and medical workers have a huge ego and a "GOD" attitude . A doctor admitting he/she made a mistake would be like a Chippendale Dancer admitting he was impotent . It just doesn't happen .
Who do you tell?!?! No one will listen!
All could be avoided if we just listen to the heroic medical media at CNN
This is horrible. I am a biologist. Chest pain, very serious. I had berried mom because undiognosed heart atak. Waives of hart atacks ???? Simple cayenn pepper drops could prevented her from this hart atacks.
Are you kidding Doctor? The reason why bad outcomes occur is not due to insufficient top down regulation but because our Doctor's are just mediocre. The cause of this mediocrity is a result of Doctor"s fear of coercive enforcement techniques employed by greedy administrators in search of more money. Excellence is needed to replace mediocrity, This excellence is where quality resides. This excellence cannot be coerced but must be volitional therefore related to that good old American word FREEDOM. We must therefore set aside our rational self interests and realize our true ethical goal the GOOD of each and every person who is under our care. In order to achieve this truly worthy goal we must prepare to confront the administrative power structures that are currently oppressing us. Frank A. Thomas, MD/FACS.
I have Seen 3 different New Drs -Neuro's for My PPMS and ,ecery one has Made mistakes on my chart and meds.I have lost All Faith in DRs peroid
are you willing to look at my wife's med files? Husband Bruce Smith caregiver
Hohoho
I am sorry that Dr. Gunn’s sister was lost, especially under her circumstances, but I do not think that her death can be classified as entirely preventable. I also understand Dr. Gunn’s drive to prevent medical errors, yet she herself says she knows there have been several patients that she has “harmed significantly, but inadvertently while treating them as a doctor”. She goes on to talk about an individual patient that she should have diagnosed, but missed. If that particular patient had died, from what Dr. Gunn is saying, that death would have been entirely preventable-on her part. No doctor wants a death on their hands, and will do whatever it takes to prevent it, yet they are people too, and they miss things and also make mistakes. As I continued to watch the video I realized how utterly important it is for physicians to work as a team and to constantly build and improve one another. The stigma around physicians being all knowing beings needs to end. Yes, medical errors will still happen. That cannot be entirely erased. Yet doctors do need to continue learning, continue helping each other, continue admitting their mistakes and moving on from them. Was her sister’s death preventable? Perhaps. Was it 100% the physicians fault? I say no. But that does not mean that physicians can let a case like this slide. Dr. Gunn is right. Doctors need to improve and change their ways of improvement and learning.
Doctors careless all they cared about was a paycheck 😞 ..
Ridiculous comment
Good topic, but very boring presentation
She died because of a heart attack, not a medical error. There's allot missing from this story.
error of omissions...happens every day
She had a series of heart attacks which could have/ should have been diagnosed.
an EKG should have done right away, or a blood test.... which obviously was not done.
Failure To Diagnose
Bingo! Failure To Diagnose. As said above.