Dr. Howard Cohen spent nearly 30 years as an infectious disease physician in Atlanta.
He treated people with everything from the flu to malaria.
He was a highly respected doctor, recognized in his field. But about a decade ago, Cohen made a mistake that he has never forgotten. And he doesn’t want to forget.
At the time it happened, he was far from a rookie. He was a seasoned professional at the top of his game.
As Atul Gawande — a Boston surgeon and bestselling author — put forth in a 1999 article in the New Yorker magazine, “When Doctors Make Mistakes,” many medical mistakes are made by good, highly regarded doctors, not by the habitually negligent.
And critical mistakes occur often. A recent study in the Journal of Patient Safety said that 210,000 to 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death.
Cohen’s mistake was simply a mix-up, but a troubling one. It all started when two of his patients, whom he calls A. Jones and B. Jones, visited his private practice office at about the same time.
The two women had the same last name, but different first names and very different prognoses.
A. Jones was a patient of Cohen’s with a known blood abnormality, and Cohen ordered laboratory tests to determine whether her condition had worsened.
B. Jones, on the other hand, was a healthy woman who had come in for a periodic check-up. Cohen found nothing out of the ordinary during an examination, but as matter of routine, he had a sample of her blood drawn and sent to a lab for testing.
In the rush of a busy practice, mix-ups can happen.
Numerous lab reports arrived at the office every day and were stuffed into patients’ charts, where doctors read them and acted on them. In the hurried atmosphere, most doctors never questioned whether a particular lab report was in the right folder.
When Cohen looked at the test results in B. Jones’ folder, they showed significant abnormalities suggesting leukemia, even though she had seemed healthy a few days earlier. He immediately reached out to her and asked her to come in for a face-to-face consultation.
B. Jones came in the next day and got the totally unexpected news that she appeared to have a serious illness.
“I feel fine,” she said, but she was also stunned and frightened.
But then her gaze focused on the chart in Cohen’s hand, and she saw that something was amiss on the lab paperwork. The birth date was not hers.
As it happened, the worrisome test result actually belonged to A. Jones, the patient with a history of blood abnormalities. The result had mistakenly been put into B. Jones’ folder.
A wave of relief swept over B. Jones as she realized she was healthy after all and that her doctor had mistaken her for another patient. Cohen was quick to apologize for the blunder.
“I said, ‘I’m so sorry. I’m so sorry I made you feel so stressed for 24 hours,’ ” Cohen recalls. “I said we made a mistake.”
Within 24 hours, Cohen notified A. Jones of her test result. It signaled a turn for the worse in her condition. But given her previous problems, she was disturbed by the news but not overwhelmed by it.
Apologizing may go a long way
Cohen felt horrible for the false alarm he had given B. Jones.
“For a night there, I’m sure this lady didn’t sleep,” he says today.
To his surprise, the woman was so relieved when she was told about the mix-up that she gave him a big hug.
This is not as surprising as it seems. A 2010 study from researchers at the University of Michigan and Brigham and Women’s Hospital showed that when doctors apologize for their mistakes, it can actually prevent malpractice lawsuits.
In fact, there are entire organizations devoted to this philosophy.
Sorry Works! Consulting, a company in Glen Carbon, Ill., provides training and resources to health care professionals to teach them to disclose when they have committed an error and apologize to patients and their families.
The company was started in 2005 by consultant Doug Wojcieszak. He had lost a brother to medical errors in 1998, and his goal was to reduce malpractice lawsuits as well as medical errors.
“It’s often not bad individuals, it’s poor systems that get in the way,” says Dr. Scott Richardson, campus associate dean for curriculum at the GRU-UGA Medical Partnership in Athens.
Richardson mentions systems redesign, an approach to health care championed by the Agency for Healthcare Research and Quality (AHRQ), as an important factor in reducing medical errors.
It includes mechanisms like electronic health records and checklists to limit the potential for human error. This strategy has been used to reduce medication errors, delays in performing surgery, and paperwork mix-ups like Cohen’s, says Richardson.
In the New Yorker piece, Gawande described an error he made as a surgical resident in an emergency room. A car crash victim came into the ER with a blockage in her airway, and after Gawande and his medical team made repeated attempts at intubating her, she was no closer to breathing on her own.
She needed a tracheotomy to have the breathing tube inserted through her windpipe rather than orally.
Gawande, who blamed himself for the mistake, said he should have been preparing the patient for a tracheotomy, and instead let the emergency medicine attending physician continue attempting to intubate the patient.
This made her vocal cords swell, and her airway shut down. Eventually, the intubation was successful, but the long period of time she went without oxygen made it unclear how much brain function she would have when she regained consciousness.
In August 2012, Cohen put down his stethoscope to become a full-time medical school professor in Athens at the GRU-UGA Medical Partnership.
Immediately after the mix-up in his office a few years ago, he met with the office manager and the staff to go over their policy for handling abnormal test results and verifying information before calling patients. A clearly defined procedure for notifying patients of lab results can prevent patients from being alarmed unnecessarily.
And ever since that day, says Cohen, he has been more careful himself. He always double-checks in any situation where an error might occur.
He believes that electronic health records — which are increasingly being used in the United States and will become even more widespread under the Affordable Care Act — will reduce the likelihood of medical mistakes. But they will not eliminate them completely.
There is still the human factor.
“Computers may be infallible, but the data put into the computer may not be,” he says.