The Cost of Medical Errors: Cases to Show How Mistakes Happen

July 28, 2017

Risk Management Program (Part 1)
8:30–10 a.m.
Saturday, July 29
Presidential D

Plenary Lecture: Risk Management Program (Part 2)
11 a.m.–Noon
Saturday, July 29
Presidential D

Medical errors are a difficult way to learn lessons, but two Saturday presentations will use real cases to demonstrate how mistakes do happen, even to conscientious health-care providers. Four of the cases involve deaths, and the fifth case is a first-person account of a podiatrist turned patient.

In the first presentation, “Till Death Do Us Part: Podiatric Case Studies,” a podiatrist and an attorney will review the details of seemingly benign scenarios that resulted in tragedy. In the second presentation, “Medical Errors: The Patient’s View,” a podiatrist faced a string of mishaps after he was seriously injured in an accident.

“We chose several death cases. The idea is to give everyone an inkling of what can happen—not to scare them but to make them aware,” said Michael J. King, DPM, a risk management speaker for PICA. “This year’s cases deal with DVT (deep vein thrombosis), a suspicious lesion that turns out to be a carcinoma, death from what appears to be a benign cyst that turns out to be an aggressive sarcoma, and a situation that is just bad patient selection for the procedure.”

Dr. King, an APMA past president who is a podiatrist at Extremity Healthcare in Atlanta, will present the medical aspects of the cases. June Baker Laird, JD, an attorney who is a panel counsel for PICA, will discuss legal aspects of the cases.

“We want to make people aware of some of these circumstances,” Dr. King said. “Even when you do things that appear to be right, these things can happen. The biggest points we will emphasize are awareness and documentation. People need to be cognizant of what they put in their medical records. We will talk a lot about documentation.

“We will do a step-by-step analysis of how each case transpired from the beginning visit to the demise of the patient. We used old records to build the cases.”

One patient died a few weeks after being treated, one died a few months after initial treatment, and the two patients with cancer died years after being treated.

“We selected these cases because these are situations you see every day. Society is so litigious that things are not always looked at that way,” Dr. King said. “The argument on the other side is, ‘The doctor should have picked this up earlier.’ If you look at these cases, you don’t see mistakes, but there are a few clues along the way, and the challenge in practice is picking up those clues.”

In his plenary lecture, Bret M. Ribotsky, DPM, of Boca Raton, FL, will recount his experiences after a 2015 boating accident left him with broken bones in both feet and ankles, as well as injuries to a knee, hip, ribs, and discs in his neck, and a concussion.

“Very quickly, I became the patient. The stories about medical errors are the ones that almost happened to me,” said Dr. Ribotsky, who is now disabled and no longer practices.

The errors Dr. Ribotsky found began shortly after his accident, when a surgery consent form said an orthopedic surgeon wanted to operate on his right calcaneus. Dr. Ribotsky knew the fracture was in his left foot.

“The orthopedist pulled up the film and the scan said, ‘right foot.’ I took the mouse and scrolled out, and I said, ‘Look where the baby toe is.’ The CT scans were mislabeled,” Dr. Ribotsky said. “This was a massive medical error that could have happened to anybody. He followed the CT scans.”

After the surgery, an oncologist who looked at scans of Dr. Ribotsky’s broken ribs mistakenly told him he had metastatic prostate cancer. At discharge, he had to ask for blood thinners and developed a pulmonary embolism because the dose was too low.

“I hope that the professionals here will see that if these problems are happening to me, they must be happening to [others],” Dr. Ribotsky said. “The essence of this lecture is that there are a lot of lessons you can learn and that maybe you are not paying enough attention. But the big one is that when the patient says something, don’t blow them off, because they might be right.”

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