Medical Errors & Patient's Safety- Case Study

Description: Sameer was a runner, like his dad, who is a physician. One day, he collapsed during a run and was hospitalized for five days. He went through lots of tests but was given a clean bill of health. Then, a month later, he collapsed again, fell into a deep coma, and died. His father wanted to know what had gone wrong? His dad tells the story of how he uncovered the cause of his son's death.

The Case:

My son was born after my wife had three miscarriages. Sameer was an energetic, curious little boy who went through a long phase of asking me, "Why, Daddy?" It forced me to become creative with my answers, but there was always another "why" waiting in my son's mind.

Sameer grew into an active young man with a passion for running, soon beating me in races and greeting me at the finish line with a happy smile and the words, "Good race, Dad." Just before he turned 18, he became a computer science major at one of the Emirati Universities.

A call that changed lives

On September 15, 2002, a call to my home changed my life forever. It was late on a Sunday evening, and it came from a hospital doctor. He said that Sameer had collapsed while running. Sameer had collapsed in a similar incident a month earlier but recovered on his own. This time, he was down for some time, and the paramedics had to shock his heart three times to restart it. He was in a deep, unresponsive coma. I hurried to be at my son's bedside.

Sameer never recovered from his deep coma. Three days after I drove to see him, He died. Words cannot capture the pain experienced by those of us who were closest to Sameer his Mama and me, his little sister, and his much younger little brother. Our relatives, neighbors and many friends held us in their hearts as we struggled through the process of burying our firstborn son.

What had gone wrong? After his first collapse, Sameer was hospitalized for five days. He had various cardiac evaluations: numerous electrocardiograms, a cardiac ultrasound, an exercise stress test, and a cardiac MRI. He was also given a cardiac catheterization, which caused a painful hematoma, and an electrophysiology test. During his hospital follow-up visit five days after discharge, his doctor had given him a clean bill of health.

A series of errors

Since there was the possibility of a genetic cause of his death, I asked for his records. I received a quarter inch-thick pile at first, until I pressed for his complete record, which was three inches thick. As I examined his records and studied cardiology literature, I discovered that his cardiologists had failed him.

After his first collapse, Sameer had three types of heart arrhythmia (irregular heartbeat) and low potassium. Two years earlier, a guideline from the international health research centers called for potassium replacement in such patients. He never received potassium replacement, even though I had told his lead cardiologist about his low potassium. (I did not know enough at the time to connect low potassium with heart arrhythmia).

His cardiologists had also missed a diagnosis of acquired Long QT syndrome, a treatable heart rhythm condition that sometimes requires patients to avoid exercise. On a scale that suggests likely diagnosis for a score of 4 points or higher, Sameer scored 5.5 points.

A communication error was also apparent to me as I fixed together the records. No one warned my sone not to run after the hospitalization after his first collapse. His written discharge instructions specified only that he does not drive for 24 hours. There was no record of anyone warning him not to run when he had his follow-up visit, so he didn't realize he shouldn't have resumed running after his discharged. This was a catastrophic mistake.

In the spring after my son died, I learned of another major mistake. A radiologist at the hospital where my son received treatment got in touch with me. After we exchanged a number of emails, he told me Sameer's cardiac MRI was done incorrectly because the technicians had not been trained on new software for the machine. Sameer or us were never told about this, and this information was critical because the cardiac MRI was to be performed before any invasive testing.

To be frank, my son was deceived into signing consent forms for his cardiac catheterization and electrophysiology test. If his cardiologists had only recognized his need for potassium replacement, neither test would have been needed. They should have at least repeated his cardiac MRI with technicians who were properly trained to do the test.

Questions

Question 3: If you are a decision maker in healthcare, propose three applicable, achievable solutions to minimize the medical errors in in Emirati healthcare entities? (3x2= 6 Marks/ 15).

Question 4: Patients and families now have access to all kinds of medical information, just as Sameer's dad did when he researched his son's rare condition. Explain, in two points, how can healthcare providers make patients and families part of the care team to sustain patient safety standards? (2x2= 4 Marks/15)