Medical Error

Few days ago I watched Oprah in Hallmark channel, it is a rerun program actually but it really shocked me!

Every year in the United States, more people die from medical mistakes than from breast cancer, AIDS and car accidents…combined. “It’s a major, major health issue that will touch almost every single American at one point in our lives,” Oprah says.

Ini kalimat pembuka Oprah saat itu….

Ada 3 kasus penanganan salah sisi terjadi perhari di rumah sakit di Amerika Serikat. Kalimat ini yang membuat aku menyimak lebih jauh….

Oprah dan Dr. Oz membahas kasus yang menimpa anak kembar aktor Dennis Quaid,  lalu kasus  Molly, ibu dua orang anak dan terakhir  Chef Grant Achatz.

Aktor Dennis Quaid nyaris kehilangan anak kembarnya di Ciders Sinai pada November 2007 karena salah dosis Heparin. Dosis yang diberikan seribu kali dosis yang seharusnya dalam dua kali pemberian. Penyebabnya sepele, perawat salah mengambil ampul yang diletakkan dalam nampan yang sama.

Namun pihak Ciders Sinai akhirnya melakukan investasi $100 juta dalam tehnologi baru untuk mencegah terulangnya kemungkinan terjadinya kesalahan sejenis ini.

Pada tahun 2008, Molly didiagnosa menderita kanker payudara sehingga harus menjalani mastectomy, pengangkatan payudara sebelah kanan, sampai hasil biopsi menyatakan negatif. Ternyata hasil diagnostik Molly tertukar  sehingga Molly dinyatakan menderita kanker payudara berdasarkan data milik pasien lain.

Chef Grant Achatz disebut genius dalam bidang kuliner, harus terancam kehilangan lidahnya karena kanker stadium 4. Hingga dokter keempat semua menyarankan mengamputasi lidah yang ditolaknya. Akhirnya dokter kelima yang ditemuinya setuju untuk mencoba melakukan sesuatu yang berbeda dari protokol medis standard. Akhirnya hingga setahun setengah setelah menjalani kemoterapi dan radiasi ia dinyatakan bebas dari kanker.

Apa yang dapat dimaknai dari para tamu Oprah ini?

Well…. mistakes do happen. Tak perduli dimana, siapa dan kapan saja.

Walaupun awam dalam hal medis dibanding para dokter atau perawat, namun kita tidak boleh lalai. Karena dokter maupun perawat juga manusia yang dapat melakukan kesalahan fatal. Kita sebagai pasien harus turut mencermati dan mencoba memahami perawatan yang akan diberikan kepada kita. Dan yang tak kalah penting….berdoa dan menyerahkan segala proses itu kepada Tuhan.

Ini kutipan lengkap yang diambil dari,

Every year in the United States, more people die from medical mistakes than from breast cancer, AIDS and car accidents…combined. “It’s a major, major health issue that will touch almost every single American at one point in our lives,” Oprah says.

In November 2007, one such mistake almost took the lives of infant twins, the children of actor Dennis Quaid and his wife, Kimberly.

Dennis and Kimberly’s story begins with two small blessings, Thomas Boone and Zoe Grace. “We were so happy to be able to be blessed by those two,” Dennis says. “They both came out so perfect.”

Days after the twins came home from the hospital, however, they developed serious staph infections. Doctors told Dennis and Kimberly to take their newborns to Cedars-Sinai Medical Center, where they were given antibiotics intravenously.

On their second day at Cedars-Sinai, Dennis says the twins seemed to be doing well, so he and his wife went home to get some rest. That night, Kimberly says she had an overwhelming feeling that something was wrong. Dennis called the hospital to check on their children, but a nurse assured him everything was fine.

They found out later that, at the time of the call, Thomas and Zoe were actually in serious danger.

When they arrived at Cedars-Sinai the next morning, members of the medical staff were waiting with terrible news. “This started probably the worst day of our lives,” Dennis says.

The Quaids learned that nurses had accidentally given their children two powerful doses of Heparin, a blood thinner that’s prescribed to keep IV lines clear and prevent blood clots. “They got a thousand times the dose of Heparin that they were supposed to get,” Dennis says. “They were supposed to get 10 units of Heparin, and they got 10,000 units of Heparin—twice. That’s when their blood turned to the consistency of water.”

When the Quaids finally saw their babies, Kimberly says they were black and blue. “It was a bad sight,” she says. “They were bleeding out.”

A series of errors led to the overdose that left little Thomas and Zoe fighting for their lives. First, a pharmacy technician made a mistake and put larger-dose bottles of Heparin in the same bin with the smaller-dose bottles.

Then, the nurse caring for the Quaid babies grabbed a bottle out of the bin without checking the label. The 10,000-unit and 10-unit bottles are similar in color, and some say it’s difficult to tell them apart.

Dennis says nurses across the country have made the same mistake. “A very similar incident killed three infants in Indianapolis a year before that,” he says. “Even after our incident, two other fraternal twins in Texas, in Corpus Christi, died last summer because of this.”

Most people—including parents—don’t question nurses and medical technicians enough, Dr. Oz says. In fact, Dennis claims his twins’ first overdose occurred while he and Kimberly were in the hospital room. “The nurse came in to change the medication, and we were there,” he says. “At the time, we weren’t really informed.”

For 40 hours, doctors monitored the Quaid twins closely. Dennis and Kimberly say they were in a state of shock. “It was like the floor was pulled from under our feet. I didn’t understand it, to tell you the truth,” Dennis says. “It was the scariest day of our lives.”

After two days, the twins’ health began to improve as the blood thinner wore off. When they were sleeping comfortably, Dennis says he realized Thomas and Zoe survived this ordeal for a reason. “[I thought,] ‘These two little kids, 12 days old, they’re going to change the world in some way,'” he says.

Now, Dennis knows why this happened to his family. “I think that the reason is to raise public awareness and to get something done about computerized record keeping and bar coding in hospitals,” he says. “That’s going to save lives—a lot of lives.”

In February 2009, Dennis returned to Cedars-Sinai for the first time since his twins were sent home. “Being here brings back a lot of memories…not all of them good,” he says. “But today, I feel like it’s a day to really go forward.”

Dennis meets Linda Burnes Bolton, the chief nursing officer who was called in the night his twins were given an overdose of Heparin. Linda says that night was life-changing for the nursing staff. “It was a wake-up call,” she says. “It served as a catalyst to find ways to prevent those errors.”

Cedars-Sinai has invested more than $100 million in new technology to make sure this kind of mistake never happens again. They’ve installed a computer bar code system for their medications, which helps to eliminate human error. Dr. Oz compares this technology to grocery store scanners.

Patient information must also be entered into a computer and is then checked multiple times. These computers are linked to automatic dispensing machines. “The key to this is that it dispenses only that dose that’s ordered,” Linda says.

Dennis says he applauds Cedars-Sinai for stepping up to the plate. “They spent a substantial amount of money, and they were very concerned about alleviating this [problem],” he says. “I think they really are up at the top now as far as raising the standard of care.”

Dr. Oz says many factors contribute to medical mistakes. First, he says doctors shouldn’t be using pens and pencils—19th-century tools—in a 21st-century world. “Computerized order entry and, more importantly, these bar coding systems that Dennis is talking about have dramatically changed the way practice is conducted in hospitals,” Dr. Oz says.

Over the past five years, Dr. Oz says hospitals that have adopted the “grocery store” system have eliminated dosage errors. “We’re not talking about a small little jump here,” he says. “We’re talking about a dramatic shift.”

Mistakes also happen because hospitals are busy places. “There’s a lot of things happening at once. People get tired,” Dr. Oz says. “They get interrupted all the time.”

How can you protect yourself? Dr. Oz says everyone in America must learn to be a smarter patient .

Since they left the hospital, Dennis says his twins have thrived. “They’re just little toddlers, and they’re healthy and they’re happy and they’re growing,” he says.

What’s in store for their future? Dennis predicts that Thomas will play football for the University of Texas, while Zoe will rule the world.

In 2004, Molly, a mother of two, was diagnosed with a rare, cancerous lump in her neck. Doctors told Molly that since they’d caught it early, the cancer was very beatable. “My doctor was very optimistic, and he said, ‘You’re going to get through it,'” she says.

Molly went in for surgery on her neck, and soon afterward, doctors noticed a slight swelling under her arm. Just to be safe, her medical team ordered a biopsy on her breast tissue.

The results came back 24 hours later. “My husband picked up the phone, and he was talking to one of my doctors,” she says. “I remember him saying, ‘The tests came back for breast cancer.’ I remember being upstairs crying and just saying, ‘Okay, I have two cancers now.'”

Molly says she went in for two mammograms, a breast ultrasound and an MRI, but doctors couldn’t find a tumor. “I just remember being so scared and so confused about this because I had this cancer in me, and nobody could find it,” she says.

Doctors diagnosed Molly with a rare form of breast cancer in which there are cancerous cells but no tumor. They recommended a mastectomy.

Molly had her right breast and 24 lymph nodes removed and then returned home to wait for more news. “I was at home waiting for the call. … How many lymph nodes have been affected? Where is it?” she says.

Eight days after the mastectomy, Molly got an urgent call from her surgeon asking her to come in. “At that point, I was thinking to myself, ‘Okay, it’s not going to be good,'” she says.

The day of her appointment, Molly prepared herself for the worst. “[The doctor] sat across from me and just was bawling,” Molly says. “I remember thinking, ‘My God, now what?'”

Then, the doctor broke some shocking news…Molly never had breast cancer. During testing, a medical technician accidentally switched her biopsy slide with another woman’s sample. That woman had breast cancer but was mistakenly told she was cancer-free.

As the information started to sink in, Molly says things began to move in slow motion. “I just couldn’t believe what was coming out of her mouth. Like: ‘Wait a minute. I didn’t have breast cancer?'” she says. “I was relieved because I thought: ‘Okay, now I’ll go back to my neck cancer, but what about that lady? What about the lady whose slide was switched with mine? Do you know who she is?’ … The carpet’s pulled out from under you, and you’re just left there thinking, ‘Now what?'”

Molly quickly began treating her neck cancer with chemotherapy and radiation, which had been postponed so doctors could focus on the breast cancer. Thankfully, the treatment was a success. She’s been cancer-free for almost four years.

Looking back, Molly says she wishes her doctors would have retested her breast tissue when they couldn’t find a tumor, and the results weren’t making sense. Dr. Oz says that while many doctors are smart and hardworking, they’re still human.

Since I’m on the inside, I’m telling you what it’s like. Once the first couple [of doctors] that you trust come up with a diagnosis, you don’t usually challenge them that frequently,” he says. “Guess who’s left to challenge them? It’s you.”

If only a few patients speak up and ask for second opinions, Dr. Oz says they may be labeled as “difficult.” But if everyone takes the extra step to protect themselves, it will make a difference in the medical community.

“The purpose of this show is to make it the norm that everybody out there says: ‘You know what? I’m going to make a difference. I’ve going to be brave. I’m going to stand forth, not just for me, but because people are going to see this story,'” he says. “They’re going to become part of the smart patient army .”

Molly also wants patients—and doctors—to know that people like her matter. “I hope my doctors and everybody that was a part of [my mastectomy] are actually practicing better medicine,” she says.

Chef Grant Achatz has been called a genius, a magician and the Beethoven of the culinary world. His Chicago restaurant, Alinea, is at the forefront of a food movement called “molecular gastronomy,” which uses scientific, nontraditional techniques like liquid nitrogen and whimsical ingredients like pillows filled with lavender air to evoke sensory memories. In 2007, Gourmet magazine awarded him its highest honor—best restaurant of the year.

Earning that honor was hard work, and Grant’s grueling 20-hour work days started to take a toll. One day, he noticed a very small, white spot on the left side of his tongue. Grant ignored the spot for months before asking his dentist about it. He says she thought it was probably related to stress and was nothing to worry about. Grant went to get a second opinion from a general practitioner, who told him the same thing. Eventually, the pain became so intense that eating became difficult, and Grant says he lost 20 pounds.

When Grant finally went to see an oral surgeon, they took a biopsy of the spot. The results came back, and the prognosis was grim—stage 4 cancer. “It was untreated and undiagnosed, and it went on and on for three years,” Grant says. “At that point, your treatment options are very limited and they’re very aggressive.”

The first doctor recommended the removal of the middle of Grant’s tongue, a radical neck dissection and removal of part of his jaw. Grant says this treatment was too harsh to accept. “Cooking and tasting and creating food is my passion,” he says. “Certainly what they were recommending was a very severe treatment that would compromise a lot of aspects of my life, but they were going to remove my soul, essentially.”

Grant began searching for other options, but the first four specialists he met all recommended the same thing—immediate surgery on his tongue, neck and jaw to remove the cancer. “We just kept saying no. There has to be something better. There has to be something more humane, something more contemporary,” he says.

Only after seeking a fifth opinion did Grant find a doctor willing to change the standard medical protocol—to hold off on surgery until after first trying to beat the cancer with chemotherapy and radiation. A year and a half after starting treatment, Grant is cancer-free and still has his tongue.

Grant says the experience taught him the importance of being your own medical advocate. “When somebody tells you that this is the recommended treatment, if it doesn’t sound agreeable to you, go get another opinion,” he says. “Everybody knows about their body.”

Dr. Oz says he hopes Grant’s story will help launch “the smart patient movement.”

“It’s about realizing that you are the world expert on your body, that you can hear your body shouting out things to you,” he says. “And if you’re not getting the feedback that you think you need to get, to keep pushing.”

Being a smart patient—taking an active role in advocating for the best care available—does not make you selfish. “It’s being brave enough to stand up and say, ‘I’m going to do this not just for me but for the guy behind me, because they’re going to benefit as well,'” he says. “That’s how we’ll make health care safer in America.”

Reduce the chances of a medical mistake by following  Dr. Oz’s eight steps.

Dan yang tidak boleh dilupakan adalah,

Step 0: berdoa sebelum memulai segalanya.


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