medical error, medical errors, oral surgery, sentinel event, snow in June, wrong person surgery, wrong site surgery
Yesterday I had oral surgery and today it snowed. I don’t think there is any real connection but the alliteration of surgery and snow was interesting, and snow on June 17 is certainly interesting.
This week I was reminded, again, at how happy we are to be here. I have had difficulty with my teeth for several years and the ongoing dental work has been tedious at best and downright difficult at the worst. In 2007 I developed an abscess while working in Amman Jordan. I was in serious pain but did not realize how much trouble I was in. Having finished my work in Jordan, we traveled to Southern Germany to take a few days off before beginning continuing to a professional meeting in Berlin. When the plane hit the ground in Germany I told my spouse I had to find a dentist. The altitude changes from the plane flight had been horrid and I knew things were not going to get better. With the help of our hotel we found a very kind dentist who relieved the abscess and provided me with antibiotics. When we returned to Idaho my dentist and it was determined that the tooth was not salvageable. We decided on an oral implant.
My dentist recommended an oral surgeon and the surgeon’s reputation was good. When I awakened from the conscious sedation used for the surgery I immediately realized the surgeon had taken the wrong tooth out. He had done wrong-site surgery. The tooth he removed was a healthy tooth. I told him he removed the wrong tooth and without discussion with me he put me under again and removed the intended tooth. That was a very bad day. In addition to losing one healthy tooth along with one unhealthy tooth, I had an adverse reaction to the medications they used and spent the afternoon in the emergency room. Recovery from having teeth pulled on both the right and left sides of my mouth was difficult. I was on soft foods for months. Speaking was difficult and my smile was a grimace.
Wrong site surgery is one of many preventable medical errors. Because it is impossible to count completely, it is unknown exactly how many medical errors are made in the United States. Medical errors associated with negative health outcomes may never be counted or even noticed. Medical errors that result in death are counted as best as possible but it is very difficult to ferret out the chain of events in regard to how and why a person dies. The methods for recording causes of death are labyrinthine and it is often a judgement call as what caused what. Medical errors are part of the chain but usually the error cause something that causes the death. An untreated appendix that ruptures is death by a ruptured appendix, not death by the emergency room physician who did not treat the appendicitis but instead treated a “tummy ache”. Given these complexities death as a result of medical error is not counted as a cause of death. If they were, estimates are that it would be would be between the third and sixth leading cause of death in the United States. Medical errors are costly because they include the costs for the care associated with the error and the costs of loss of productivity associated with the ill health or death of the person who was the victim of medical error. In 2008, medical errors are estimated to cost $17 billion USD.
In medical care a “sentinel event” is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Between 1995 and 2005 wrong site or wrong person surgery is the second most common “sentinel event.” Wrong site or wrong person surgery is known as a “never event” or one that should never happen. One of the most common strategies implemented to prevent wrong site surgery or even wrong person surgery is surgery check lists. Part of the purpose of check lists is to take time out to regroup between surgeries or for any particular surgery. Because surgery check lists are often implemented as part of a comprehensive strategy to prevent wrong site or wrong person surgery it is not clear if they themselves reduce medical error but they are quality improvements in surgeries where they are used.
When I experienced my sentinel event of wrong site surgery the surgeon was distraught and we decided that his taking responsibility for the error and paying for all of the healthcare related to the surgery and implants was appropriate. Unlike many, we chose not to pursue legal action.
I do not regret choosing not to pursue legal action but I do have a healthy respect and some trepidation in regard to oral surgery. I knew I needed to deal with my broken and sick tooth. I was determined to be positive about the whole situation. I told my new dentist that I was happy to see him. He laughed and said he did not hear that often. I told him I was serious, I was happy to see him because I needed his help and I was looking forward to having healthier teeth. He took one look at my tooth and agreed that it needed to come out immediately. He referred me to an oral surgeon who used a general anesthesia rather than the sedation method I had previously had difficulty with. Although I had some disquiet going into the surgery, particularly about being told that it could take me about a week to recover, everyone at the office was very kind. They commiserated with me about needing to finish my floors but still said I would probably need to wait a bit before returning to them. They took time out to answer questions for us and they used surgery checklist mounted on the wall that they and I could see. Together we confirmed which tooth was being removed. Before the surgery began I told the surgeon I was happy to be there. Like my dentist he laughed and said he did not hear that often. When I woke up from the anesthesia I was happy. I slept the rest of the afternoon and then ate chocolate cake soaked in milk. It was a good day!
Today I thought I was ready to get back to my floors since I was not in pain. I thought rather than dive right into sanding floors I would to put a simple table together. If it had not been so sad it would have been hilarious. Twelve screws and I could not put the table together. I dropped tools, I misplaced them, I screwed things in wrong, I got a table leg upside down. I went back to bed.
I woke up in time to see the snow today. Today was a good day too.
Thank you to my friend, NFP for teaching me about the importance of medical error.