Medical Error

Was it Metastatic Cancer? Four Physicians Certainly Thought So!


As the author of After You Hear It’s Cancer: A Guide to Surviving the Difficult Journey Ahead, I thought I understood the magnitude of the impact of a cancer diagnosis on patients. After all, I had written about it at length – describing that instant when one hears words so powerful that his or her world comes to a grinding halt, and future dreams dissolve in an overwhelming cloud of anxiety.

But when, earlier this week, I heard: “You have metastatic cancer,” I was completely unprepared to deal with such devastating news. At that moment, I was no longer the author who wrote about the cancer journey – I was a patient thrust into unfamiliar territory and acutely aware of the fragility of life.

Here’s my story.

After resting for several days following a minor medical procedure, I hit the gym on Saturday, intent on regaining my stamina. But after only a few minutes of exertion, I felt incredibly winded. I chalked it up to several nights of poor sleep and the after-effects of anesthesia. By Monday, I was still feeling fatigued, but there was something more…my heart felt like  it was racing.

Though I was scheduled to play tennis that afternoon, my wife convinced me that I would be far better served to stop by her office and let her listen to my heart, check my blood pressure, and measure my oxygen saturation. I reluctantly deferred to her and cancelled my game. I am glad I did.

We discovered that my blood pressure was abnormally high, as was my pulse (nearly 40 beats per minute higher than normal).  Furthermore, Lori thought she detected an abnormality in my heart’s rhythm. So off we went to the emergency department.

Because of my symptoms, I was taken back and immediately and evaluated for a heart attack. Thankfully, that was quickly ruled out…though evidence of some rhythm issue was present. The ED physician ordered a CT scan of my chest to rule out other potential problems.

Four hours after arriving at the emergency department, the results of the CT were back. As the ED physician walked into my curtain-enclosed bay, I said, “Can I go home now?”

“You are not going anywhere,” he responded, before handing a copy of the radiology report to my wife. She looked startled, as she began to read. The physician turned to address me.

“You have a number of masses in your liver. The largest is 6.4 centimeters. You appear to have metastatic cancer. Do you have any questions?”

“What?” I blurted out as a wave of uncontrollable nausea and dread enveloped my body. “I don’t feel well. I think I’m going to pass out.”

I don’t remember what happened next, but Lori said I appeared to have a seizure, then blacked out. She said she couldn’t find a pulse and shouted for the nurses. The cardiac team rushed in and prepared to resuscitate me. Fortunately, that turned out not to be necessary. When I came to, the ED doctor was nowhere in sight, nor did he come by again to check on me.

I spent the night in a hospital room that could have doubled for a broom closet. It looked as though it had not been renovated in forty years. I lay in bed trying to wrap my mind around what I had heard, and what I stood to lose. Life took on a preciousness that I had felt only a handful of times in my life. I was not ready to let go, to give up all that brought meaning to my daily existence, and I prayed to God that I would have a little more time.

I didn’t sleep much that night – between the impending diagnosis and being constantly awakened by nurses’ aides wanting to take my vitals, machines screeching in protest because there was a problem with my IV, and the simple discomfort of being far removed from my secure home.

The next morning, Lori and I impatiently awaited a liver biopsy. A transport aide showed up mid-morning and told us I was being taken to ultrasound. We presumed it was for an echocardiogram of my heart (which had also been ordered), so I told Lori to stay put and I would see her shortly. As the aide wheeled me into interventional radiology, I said: “I thought I was going to get my echo?”

“You’re here for a biopsy,” she said curtly. In a sense I was relieved that it would soon be behind me, but I felt badly that Lori had no idea where I had really been taken.

The interventional radiology team was compassionate and competent. After numbing my skin and providing some light sedation and pain relief, the radiologist used ultrasound imaging to guide a very long needle between my ribs and deep into my liver. He repeated this process four times – taking small tissue samples with each pass.

As I looked up at the monitor and saw the largest mass, I asked: “Is there a chance it’s something other than cancer?”

He responded, “There’s always a chance, but it does look like liver metastases to me.”

When the procedure ended, I was wheeled into a recovery area, where I received incredibly compassionate care from a nurse named Bailey. By then, Lori had been told what was transpiring and she was by my side. We had to stay in recovery for four hours to make sure there was no post-procedure bleeding.

Later that day, I was discharged. Now, there was nothing to do but await the results of the biopsy.

Lori and I tried to remain upbeat in the face of devastating news. When I would get weepy, she would remind me that there was always a chance that things would turn out okay. She told me that, intuitively, my condition did not make sense to her…that patients with advanced metastatic cancer to the liver were generally vastly more ill. I took comfort in those words coming from an experienced radiation oncologist, but I still struggled to have faith in a positive outcome.

There was no news on Wednesday. Late in the afternoon, we ran over to Lori’s office so she could take care of a few loose ends. As we were approaching the medical building, which is ensconced in trees and heavy grass, I thought, “What a powerful omen it would be to see deer.”

As we rounded the curve and approached the driveway, I spotted a deer standing stock still just feet from the curb. It didn’t move as our car approached. Before I could say anything, Lori turned to me and said: “That feels like an omen…a good omen!”

“You’re reading my mind,” I exclaimed…surprised that we were in such synchrony.

By the time we left, more deer had congregated a few yards from our car. The omen seemed all the more real.

What felt like a powerful omen…

Because it was Ash Wednesday, I had suggested we go to church and pray. My wife has a profound sense of faith, and I knew how much it would mean to her to attend. I’m so glad we did.

An orchestra and a choir performed, and the music took on an unusually powerful resonance. I hadn’t felt God’s presence in a long time, but I felt it strongly that night. We prayed for strength and hoped that “thy will” would be to keep me around for a while, though such an outcome was clearly out of my hands.

On Thursday, we hung out at the house until mid-day, anticipating the call that would likely determine my fate. Finally, tired of waiting, we went to run errands – including a planned stop at church to pray more.

We were just pulling up to the post office when my cell phone rang. It was my primary care physician.

“John, it’s Chris. I’m looking at your biopsy report.” He hesitated for only a moment before blurting out: “BENIGN!”

“What?” I exclaimed, as though I couldn’t possibly have heard him correctly.

“Benign. You don’t have cancer. The pathology came back indicating you have a hemangioma.”

“Oh, my God, I feel as though a death sentence has been lifted. Thank you. Thank you.”

I turned to Lori, tears welling up in my eyes: “I can’t believe it…it feels like a miracle.”

“It is a miracle,” she remarked. “I’m so grateful.”

“As am I. Now we need to go to church – to thank God for his mercy.” To which Lori quickly nodded.

There are still tests to be run and results to be confirmed, but the outlook is infinitely brighter.

The experience was a powerful reminder of how important it is to live each day fully, to honor God, and to be profoundly grateful for our loving relationships.

But it was also something more. It made me realize how truly life-altering a diagnosis of cancer is for those patients who do not receive a reprieve. As I said when I began this story, I thought I understood the impact of a cancer diagnosis. The truth is that I didn’t really have a clue – not until it was my life on the line – my future suddenly clouded by the incantation of two words:. “It’s cancer.”

In the Aftermath of Dr. Farid Fata — Straightforward Advice for Cancer Patients (and others)

Dr. Fata is an egregious example of profits over patients' well-being.

Dr. Fata is an egregious example of profits over patients’ well-being.

Dr. Farid Fata, a Michigan hematologist oncologist, is simply the latest in a long list of physicians who have betrayed the trust of their patients, bilked the federal government of millions of dollars, and caused unnecessary pain and suffering for thousands upon thousands of patients. On July 10, Fata was sentenced to 45 years in prison based upon nearly two dozen counts of health care fraud, as well as a plethora of other charges.

Rarely are we more vulnerable than when facing a devastating illness like cancer. It’s a time when we often overwhelmed with anxiety, yet have to make decisions that may impact the balance of their lives; it is a time when we would like to believe, without reservation, that our physicians have our best interests at heart. Fortunately, the majority of the time, they do. But what of the exceptions? How do we protect ourselves against the unscrupulous doctors that abuse their cultural authority and the trust bestowed upon them?

There are clear steps you can take to safeguard their health when selecting a medical specialist and undergoing treatment. First, you need to take a very hard, data-driven look at your doctor. There are some basic questions you should be asking, including:

  • Is the physician Board-certified? Though Board-certification is no guarantee of either competency or ethical behavior, it does improve the likelihood of receiving appropriate medical care.
  • How long has the physician been practicing in his or her given specialty area?
  • Have there been complaints filed about the physician with your State Medical Board or can you identify legal action taken against the physician?
  • Does your primary care physician have an opinion regarding the competency of the specialist, and upon what is this opinion based?

Next, you need to understand your purported diagnosis and recommended treatment plan. Your physician should provide and interpret all of the results from your diagnostic imaging studies, laboratory analyses, and other tests.  He or she should then explain, in terms you can understand, the best course of treatment to achieve a specific goal. In cancer care, there are three, potential goals: cure, control, or make one more comfortable.

Before agreeing to the recommended treatment, there are two, critical steps that will help ensure your safety. First, try to determine if the recommended treatment is considered a “standard pathway” or a generally agreed upon method for treating your disease. The National Comprehensive Cancer Network ( publishes guidelines for the treatment of most forms of cancer – including versions that are designed specifically for patients to review. If your physician’s recommendations deviate from these standards, you need to ask why.

Second, don’t hesitate to get a second opinion. If your physician balks or is not supportive of such action, find a new doctor. When seeking a second opinion, search out a specialist who has no affiliation with your current doctor. If there is a National Cancer Institute Center in your city, this may be a good place to start.

Doctors are every bit as mortal as you and I (trust me, I’m married to one…albeit a very good one). Fortunately, most physicians believe that it is a sacred responsibility to provide the best possible care.

We all know the saying about “a few bad apples.” When you find yourself faced with a serious illness, such as cancer, your job is to find the good ones!


Caduceus Medical Symbol chromePhysician Self-Evaluations

It is extraordinarily difficult for a consumer to evaluate the clinical competency of a physician. If you don’t believe me, doctors will be the first ones to tell you so! According to researchers James and Hammond, “Only another physician has the necessary knowledge and experience to judge whether a professional colleague adequately discharged his or her fiduciary trust to a particular patient.”[i]

James goes on to state that doctors are so self-protective of their cultural status that “not only do physicians resist attempts of those outside the profession to inappropriately judge medical performance, they also insist on holding one another accountable for their performance within the profession of medicine.”[ii] Evidence suggests otherwise. Though they may “insist” on holding one another accountable, they do very little to honor it.

 Policing Their Own Ranks to Protect Patients from Dangerous Doctors

If James’s statement were true, the medical community bears a clear obligation to safeguard its patients’ well-being by policing its ranks. Poor clinical performers, impaired physicians, and unethical practitioners should succumb to peer scrutiny or dramatically change their ways.

Theoretically, there are three levels at which such scrutiny should apply: (1) the peer-review committee of a hospital—which granted hospital-based privileges to the physician in the first place—(2) a state board of healing arts—responsible for ensuring the practice of safe and ethical medicine within the state—and (3) the ethics or disciplinary-action committees of national medical associations.

Unfortunately, a tremendous barrier stands in the way of effective reporting of physicians’ malfeasance: the physicians’ code of silence. Much like the mafia’s omertà, it is an inviolate code of conduct inculcated into trainees early in their education. The message is simple: Don’t attack your colleagues, or you might find yourself ostracized.

If you think I’m exaggerating, listen to what two, nationally known physician-authors have to say on the topic, beginning with Dr. Marty Makary: “Doctors and nurses know of docs who are reckless, but it takes moving a mountain to do something about it. Not reporting incompetence among peers is part of medical culture and has been for centuries. Medicine is poorly policed. Getting fired takes an action so egregious or offensive to hospital administration that I have only seen it happen twice among all the hospitals in which I’ve worked and trained.”[iii]

Dr. Otis Brawley, Chief Medical Officer for the American Cancer Society, shares Dr. Makary’s sentiment. “I know doctors who are just plain bad. Why do they continue to practice without impediment? The answer is simple: because no one is looking over their shoulders, no one files a disciplinary complaint, no tribunal of peers punishes them unless they do something spectacularly awful.”[iv]

Peer Review: A Perfect Path to Burying Problems

When the level of suffering, injury, or unnecessary death inflicted by a colleague weighs too heavily on the conscience of some physicians, they can turn to peer review. The peer-review committee provides a venue for discussing and investigating allegations of inappropriate conduct by members of the medical staff. These allegations can run the gamut from violating standards of surgical appropriateness to boundary violations with patients.

In theory, peer review provides a fair and informed method for assessing the clinical or nonclinical behavior of a physician and the resulting potential for harm to patients. The proceedings are safeguarded against legal discovery—with the intent of promoting open, honest, and corrective dialogue.

Far from being effective, “such internal peer reviews are a little like the Russian parliament under Stalin,” finds Makary. “No matter how much discussion there is, the results seems foreordained . . . any doctors who might raise probing questions are well aware that they can pay a heavy price for challenging their peers.”[v] In those rare times when action is taken, the physician is often given the opportunity to simply resign their medical-staff privileges at a hospital or health system. By so doing, their misdeeds go unrecorded and they move across town to wreak havoc elsewhere.

I’ve seen physicians who fall asleep in the midst of complex surgeries, others who open up purportedly blocked arteries with multiple interventions—despite no discernible evidence of coronary disease. Some physicians knowingly inflict pain—either because they are sadistic or, more likely, because they don’t want to waste time waiting for the effects of anesthetic agents to kick in.

The most outrageous case I know of  involved a physician performing a circumcision on a two-year-old. The parents, waiting in a nearby room, heard their child screaming in pain. When later they asked the physician what had caused such a violent reaction in their child, he responded, “the injection of an anesthetic.” In reality, he provided the child with no anesthetic—after all, it was a simple, quick procedure. In my mind there is a fitting punishment for such behavior on the part of the physician . . . and it is no mere slap on the wrist.

Finally, there are those who are blind drunk when operating. Such behavior is tolerated day in and day out in American medicine. To do otherwise would be to break the code of silence.

There are physicians who hold themselves to a higher code—one that demands owning responsibility for their actions. One such physician, Dr. Peter Elias, writing in the New York Times’ Sunday Dialogue, offered this advice to his colleagues regarding medical error: “As a practicing family physician for thirty-six years, I have come to believe in the seven essential Rs of an apology: it should be Rapid (as in right away when the error is discovered), show true Remorse, Recognize explicitly the error, accept Responsibility, acknowledge the Repercussions for the patient, offer Restitution or repair, and close with a Repetition of the opening words: I’m sorry.”[vi]

State Medical Boards Receive an F for Failing to Protect Us

A second “safeguard” against dangerous physicians should be state medical boards, which oversee licensure and disciplinary action. But they are not, according to Alan Levine, who provides oversight of the medical boards on behalf of the United States. Inspector General Levine indicates that many of these boards serve the vested interest of physicians to a far greater extent than they serve the public good.[vii]

Though the accounts are anecdotal, I’ve heard many physicians suggest that these boards are partly populated by dangerous physicians. It’s a case of the fox guarding the hen house. If there’s bad news coming down the pike regarding a physician’s practice, a position on the board will ensure that the physician will be first to hear it and attempt to squelch it.

In a recent review of state medical boards conducted by the consumer advocacy group Public Citizen, only two states were given an A rating. The vast majority received a Fs. What was particularly disturbing was the variance seen among these boards. “The most recent three-year average state disciplinary rates (2009–2011) ranged from 1.33 serious actions per thousand physicians (South Carolina) to 6.79 actions per thousand physicians (Wyoming), a 5:1–fold difference in the rate of discipline between the best and worst state doctor disciplinary boards.”[viii]

Sidney Wolfe, MD, founder of Public Citizen, noted that there was no evidence to suggest that the rates of inappropriate behavior by physicians vary dramatically between states. Therefore, the variations observed by Public Citizen can only be attributable to the manner in which individual boards manage physician disciplinary issues. He goes on to state that “there is considerable evidence that most boards are underdisciplining physicians.”[ix]

Wolfe’s research concludes that the average serious disciplinary rate, for any cause, is only 3.06 per one thousand . . . or 0.3 percent. Yet we know that there are a tremendous number of impaired physicians wreaking havoc on patients every day—physicians who obviously go either undetected or unpunished.

As Dr. Marty Makary points out in his book, Unaccountable, “There are also grossly impaired physicians [and] doctors with horrible skills, hazardous judgment, [and] ulterior motives or who suffer from substance abuse or other problems that make them dangerous. Society ought to be able to deal with this better, not sweep it all under the rug.”[x]

Do such physicians represent the proverbial needle in the haystack and thus only affect an infinitesimally small portion of the population? Makary asks us to consider what it would look like if 2 percent of our doctors had a major impairment due to drugs, alcohol, or other causes. He then calculates that there would be twenty thousand impaired physicians in America treating up to ten million people per year.[xi]

That’s a lot of needles and haystacks.

If Makary’s estimates sound absurdly high, consider the conclusions reached by researchers Eugene Boisaubin, MD, and Ruth Levine, MD, as published in the American Journal of Medical Sciences. “Approximately 15 percent of physicians,” they find, “will be impaired at some point in their careers.”[xii]That’s not to suggest that these physicians will, de facto, endanger their patients, but it certainly indicates a higher level of risk than might be suggested by the rate of disciplinary actions taken by state medical boards.

Caveat emptor to all patients: as Dr. Wolfe has demonstrated, “most states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner.”[xiii]

The Abdication of Responsibility by Professional Societies

The final level of protection from malevolent, incompetent, or impaired physicians resides in their professional associations—most prominently the AMA. The AMA’s Code of Ethics states that “a physician shall deal honestly with patients and colleagues and strive to expose those physicians deficient in character or competence or who engage in fraud or deception.”[xiv] The question becomes whether such standards are ever enforced. “After asking around,” Makary found, “it became clear that the only time that a doctors’ association would ever consider taking action against a doctor was if a state medical board had already done so.”[xv]

Professional societies exist not merely for the benefit of their members but to uphold the standards of the profession. Yet Otis Brawley, MD, questioned whether medicine even conforms to the definition of a profession. “A profession,” he notes, “is a group of people who police themselves and put the welfare of their clients above their own. In many respects, people within medicine have forgotten what the word profession means.”[xvi]

One can seek comfort in the belief that problematic physicians are few and far between, but the comfort will be short-lived. “An average American’s combined exposure to quality failure from providers’ underuse, overuse, and misuse of services is roughly 50 percent for preventive, acute, and chronic care services.”[xvii]

It’s Time to Step Up to the Plate: The Need for Physician-Defined Standards of Competency and Reporting Requirements

It is abundantly clear that there is a crying need to restore the fundamental trust between patients and physicians. A good starting point would be for the medical community to define criteria on which physicians’ performances would be evaluated, as well as the degree to which such information would be transparent to the public. Right now, “there is no agreed-upon definition of competence that encompasses all important domains of professional medical practice.”[xviii]

Doctors Epstein and Hundert, in an article published in JAMA, suggested a definition that, on the surface, appears quite cogent: “We propose that professional competence is the habitual and judicious use of communication, knowledge, technical skills, clinical reason, emotions, values, and reflection in daily practice for the benefit of the individual and community being served. Competence builds on a foundation of basic clinical skills, scientific knowledge, and moral development.”[xix]

The authors go on to discuss the importance of the following measures of competency:

  • Acquisition and use of knowledge
  • Integrative aspects of care: “It is defined by the ability to manage ambiguous problems, tolerate uncertainty, and make decisions with limited information.”[xx]
  • Building therapeutic relationships: “The quality of patient-physician relationship affects health and the recovery from illness, costs, and outcomes of chronic diseases by altering patients’ understanding of their illnesses and reduction patient anxiety.”[xxi]
  • Affective and moral dimensions: “Moral and affective domains of practice may be evaluated more accurately by patients and peers than by licensing bodies or superiors.”[xxii]

Epstein and Hundert also point out deficiencies in current methods for assessing competency: “Few assessments use measures such as participatory decision making that predict clinical outcomes in real practice. Few reliably assess clinical reasoning, system-based care, technology, and the patient-physician relationship.”[xxiii]</indent>

Finally, they point out, “Standardized test scores have been inversely correlated with empathy, responsibility, and tolerance.”[xxiv] Perhaps you should disregard what I said about MCAT scores.

In an interview in September 1997, I asked one of the physicians I revere the most how one finds a great doctor. Elisabeth Kübler-Ross, never shy of opinions, offered thoughts about why it is difficult to find a good doctor: “You have to be an A student. That eliminates 90 percent of the good people. Then you have to have lots of money—that eliminates the other few percent. That means it is pure coincidence if you get one good apple in the whole basket. Then you train them to cure, you don’t train them how to be physicians.”[xxv]



The Myths of Modern Medicine: The Alarming Truth About American Health Care. It is available on or directly from the publisher, Rowman & Littlefield.

[i] James and Hammond, “The Challenge of Variation,” 1001.

[ii] Ibid., 1001.

[iii] Makary, Unaccountable: What Hospitals Won’t Tell You, 102.

[iv] Brawley, How We Do Harm, 125.

[v] Makary, Unaccountable: What Hospitals Won’t Tell You, 100.

[vi]Peter Elias, “Sunday Dialogue: Handling Medical Errors,” New York Times, October 18, 2013,

[vii] Makary, Unaccountable: What Hospitals Won’t Tell You, 103–104.

[viii]Sidney M. Wolfe,Cynthia Williams, and Alex Zaslow, “Public Citizen’s Health Research Group Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2009–2011,” Public Citizen, last modified May 17, 2012,

[ix] Ibid.

[x] Makary, Unaccountable: What Hospitals Won’t Tell You, 97.

[xi] Ibid., 96.

[xii]E. V. Boisaubin and R. E. Levine,Identifying and Assisting the Impaired Physician,American Journal of Medical Sciences322, no. 1 (July 2001): 31–6,

[xiii] Wolfe, Williams, and Zaslow, “Public Citizen’s Health Research Group.”

[xiv] Lundberg, Severed Trust, 10.

[xv] Makary, Unaccountable: What Hospitals Won’t Tell You, 102.

[xvi] Otis Brawley, MD, chief medical and scientific officer of the American Cancer Society, in discussion with the author, August 16, 2013.

[xvii]Arnold Milstein and Nancy E. Adler, “Out of Sight, Out of Mind: Why Doesn’t Widespread Clinical Quality Failure Command Our Attention?Health Affairs22, no. 2 (2003): 119–27,

[xviii]Ronald M. Epstein and Edward M. Hundert, “Defining and Assessing Professional Competence,” Journal of the American Medical Association287, no. 2 (January 9, 2002): 226–35, doi:10.1001/jama.287.2.226.

[xix] Ibid., 226.

[xx] Ibid., 227.

[xxi] Ibid., 228.

[xxii] Ibid., 228.

[xxiii] Ibid., 230.

[xxiv] Ibid.

[xxv] Elisabeth Kübler-Ross, MD, author of On Death and Dying, in discussion with the author, September 4, 1997, Carefree, Ariz.

The Danger Lurking in American Hospitals


Underlying their glistening facades, hospitals are home to a grievous level of medical error.

Underlying their glistening facades, hospitals are home to a grievous level of medical error.

The following post is an excerpt from John Leifer’s recently published book, The Myths of Modern Medicine: The Alarming Truth About American Health Care, now available on

The Danger Lurking in America’s Hospitals

Perhaps the most startling revelation about hospitals is the degree to which they imperil patient safety. Allow me to share a few tales—including one that I personally witnessed.

Tragedy Strikes at One of America’s Finest Hospitals: Downing a Rising Star

Harvard-affiliated teaching hospitals symbolize the strength of American medicine.[i] Among these giants, one in particular stands out—Massachusetts General Hospital. It was here, in 1846, that the public witnessed the miracle of the first painless surgery performed under anesthesia.

There have been many firsts at Mass General—often bringing renewed promises of life where before there had been little hope for desperately ill patients. But like all hospitals, Mass General has witnessed its share of tragedies, including ones that were avoidable.

In the tough world of television production, there are also giants, and Trevor Nelson was well on his way to becoming one. Though only thirty-four years old, he had already made his mark in the industry as a producer of the award-winning program 60 Minutes. Though his job was demanding, he always found time for what was most precious—his family.

While on vacation with his wife, Maggie, and sons, George and Conrad, Nelson became ill. Though he tried to ignore it, he couldn’t shake the headache that accompanied his general sense of malaise, driving him to seek treatment at a local hospital. A short battery of test revealed little about Nelson’s condition, and he was discharged with medication. The medicine, however, proved to be of little help in ameliorating Nelson’s wracking headache. So, three days later, Trevor and Maggie drove to the Mass General’s ER.[ii]

With more than eighty-five thousand visits per year, Mass General’s ER bustles like a small city. The seasoned staff, who are accustomed to treating major trauma, not “mere” headaches, saw no reason for undue alarm. In fact, after a number of hours had passed, they suggested that Maggie return home to care for the boys. Reluctant to leave, Maggie finally acquiesced, accepting the staff’s promises that her husband would be fine.

But Trevor was not fine. Diagnosed with non-life-threatening viral meningitis, Nelson was admitted to the hospital. During the course of his visit, he was given a plethora of powerful drugs to alleviate his intractable headache—purportedly including more than twelve doses of narcotics in fifteen hours.[iii] Early the next morning, when nurses came to check on him, they discovered he had no vital signs. Though placed on life support, Trevor Nelson would never recover . . . and nor would his family from their epic loss. Was his death attributable to a fatal combination of drugs that suppressed the central nervous system, as the family alleges . . . and was thus avoidable? That question would be determined by a jury.

The Case of the Blazing Patient

There’s nothing esoteric about an electrocautery. The device has been a fixture of virtually all operating rooms for nearly a century. As its name implies, electrocautery can be used to stem the flow of blood during surgery through cauterization of tissues and blood vessels. It can also be used to make an incision. In most situations it is both safe and invaluable.

There are exceptions, however, as “Mary,” an eighteen-year-old patient undergoing emergency surgery for a ruptured appendix, was about to find out. As Mary was being prepared for surgery, her skin was treated first with iodine and then with an alcohol compound known as spirit. The initial incisions were made, and as the operation progressed, the surgeon began to cauterize the surgical site. Following is an account of what happened next.

As soon as the cautery was used, the cotton wound towels applied on the two sides of the incision caught fire due to a flame arising from the undersurface of the towel. It was extinguished using another sponge but not before producing deep dermal burns on two sides of the skin incision. The cautery was checked and found to be correctly installed. On careful examination, it was observed that the skin was still wet with the last coating of spirit, which was not dried up properly. The residual spirit film on the skin caught fire from the spark of the cautery leading to burns involving the lower part of the anterior abdominal wall. It took three weeks for the deep dermal burns to heal with residual scarring.[iv]

 A research study published in the May 2013 issue of Anesthesiology examined the cause of OR fires using insurance-claims data. The researchers determined that the electrocautery was the source of ignition 90 percent of the time.[v] The most frequent cause was the ignition of oxygen being administered to anesthetized patients, though “alcohol-containing prep solutions and volatile compounds were present in . . . 15 percent of OR fires during monitored anesthesia.”[vi]

The Tragedy of Multiple Deaths Due to a Single Avoidable Error

Heparin is an extremely potent drug used to thin a patient’s blood as a preventative for strokes and other adverse events. It is commonly used in neonatal intensive-care units (NICUs) to keep the IV lines open in premature babies. The drug can be lifesaving when properly administered and lethal when given in the wrong dose.

On September 16, 2006, tragedy struck the NICU at Indianapolis-based Methodist Hospital, part of the Clarian health system (now IU Health). It began with a silent but deadly error—when vials of heparin containing adult doses of the drug were delivered inadvertently to the NICU by an experienced pharmacy tech.[vii] With tens of thousands of prescriptions being filled each day by Clarian pharmacists, it simply slipped through the cracks. Though there were numerous times when the error might have been identified, no one caught it before the drugs were administered.

As a result, six babies received a dose of heparin that was one thousand times more powerful than prescribed.[viii] Three of the babies died. Three were injured. As a consultant to the organization, I witnessed this tragedy unfold, albeit at some distance. I saw the ensuing anguish that cascaded through the organization. Everyone was heart-broken, as, of course, were the families of those tiny children.

The children were gone, and there was nothing the team at Clarian could do to change that fact. But, much to the credit of Clarian’s administrative and physician leadership, they immediately went public with the painful truth behind the tragedy, promising that these tiny lives would not be sacrificed in vain. The team then devoted themselves to identifying and fixing the systemic breakdowns within their hospitals so that such tragedies would not be repeated.

A Mother Loses Her Precious Daughter

Desiree Wade was full of life. As a four-year-old girl, she dreamed of being a ballerina—dreams that helped shield her from the difficult reality of life in Harlem and brought joy into her life. When doctors suggested to her mother, Beverly, that Desiree needed a tonsillectomy, she assumed it was a minor operation with few risks. And she was right, in terms of statistical averages, but not in terms of the one outcome that mattered most to her—her precious daughter’s health.

Desiree began to show symptoms of a problem the day after what appeared to have been an unremarkable surgery. Seventy-two hours later, Desiree was hemorrhaging massive amounts of blood from her mouth, dying shortly thereafter in her mother’s arms.[ix] A beautiful life, a mother’s hopes and dreams, cut tragically short by a surgical complication arguably due to a poorly trained provider.

A Kidney Goes Missing

In August 2013, CNN broke a story regarding the University of Toledo Medical Center.[x] According to reporter John Bonifield, patient Sarah Fudzcz was hospitalized for a kidney transplant. Her brother, Paul, was a perfect match. So on August 10 of 2012, Paul underwent surgery to remove one of his kidneys so that it could be transplanted into his sister.

The surgery went swimmingly. Unfortunately, though, a nurse inadvertently threw the kidney away. Hard to believe? It really happened. Dr. Jeffrey Gold, chancellor and executive vice president for Health Affairs at the university, offered a profound apology. The matter is now in the courts.[xi]

These Cases Are Not Isolated Examples

As outlined in chapter 1, hospital-induced injuries, illness, and death are a major problem in the United States. The extent of health care’s dirty laundry was fully exposed in 2000, when the Institute of Medicine (IOM) published, To Err Is Human: Building a Safer Health Care System. Headlines across the nation proclaimed that medical errors were now one of the leading causes of death in our nation.

The report was groundbreaking. The fact that such sensational findings came out of a methodical study conducted by the IOM made it difficult to refute, though plenty of pundits tried. Most importantly, though, “the report called for a fundamental transformation in the delivery of health care, emphasizing the culpability of the entire medical system rather than individual physicians.”[xii]

This report was akin to Upton Sinclair’s 1906 book, The Jungle, which exposed the ills of the meat-packing industry, resulting in dramatic industry changes over time. Sinclair was a muckraking journalist. The IOM is a distinguished scientific body. If Sinclair could catalyze wholesale change across an industry, could not the IOM?

Despite the concussive effects of its initial publication, the IOM report does not appear to be having a dramatic impact on the safety of American hospitals. High rates of errors continue to plague our hospitals, based on the current research.

Hospital-induced errors were the key focus of To Err Is Human, but such errors are pervasive throughout the delivery system—from the physician’s office to the ambulatory surgery center. Just how pervasive are errors within our health-care system? A 2002 study revealed that “35 percent of physicians and 42 percent of the public reported errors in their own or a family member’s care.”[xiii]

According to Walshe and Shortell, hospitals have a long history of sweeping problems under the rug, thus preventing improvement in processes across the system. “It is striking,” they say, “that major failures are not usually brought to light by the systems for quality assurance or improvement that are now found in most health-care organization in developed countries.”[xiv]

Walshe and Shortell reinforce their point by citing a somewhat dated but glaring example of this issue. “At Vermillion County Hospital in Indiana, where Orville Lynn Majors worked in intensive care and murdered patients, there were twenty-four deaths in the intensive care unit (ICU) in 1991, twenty-five in 1992, thirty-one in 1993, and 101 in 1994, but the quality-management systems did not identify a problem.”[xv]

Despite incredible pressure on hospitals to clean up their act, mistakes are still happening at an alarming rate. The May 5, 2013, online edition of the St. Louis Post-Dispatch reported the case of a fifty-three-year-old paralegal named Regina Turner.

Apparently, a neurosurgeon operating at St. Clare Health Center in Fenton, Missouri, operated on the wrong side of Ms. Turner’s brain. As a result, according to Ms. Turner’s attorney, the patient “now requires around-the-clock care and cannot speak intelligibly.”[xvi]

A less malignant but nonetheless damaging form of error is the system’s failure to provide the requisite services for its patients. The IOM published a subsequent book on quality and error, entitled Crossing the Quality Chasm. In it, Sarah Bleich concludes that “the average patient receives only 55 percent of the services that would benefit that individual,” according to an IOM Report in 2001.[xvii]

In the automotive industry, there are extensive warranties on the product you are purchasing in order to provide a safeguard. In health care, not only are there no warranties, but providers stand to profit from the very problems they create through poor quality delivery.


[i] “Mass General Hospital Ranked No. 1,” Harvard Medical School, July 17, 2012,

[ii] Olivia Victoria Andrzejczak, “Lawsuit: TV Producer Pumped Full of Drugs,”, August 9, 2009,[AU: The URL you offer is restricted and so shouldn’t be used as a citation for your readers. Is the following story perchance the same text?]YES

[iii] Olivia VictoriaAndrzejczak, “60 Minutes’ Ace’s Death Echoes of His Own Investigations,” Houston Chronicle, July 30, 2009,

[iv] Sanjay Marwah and Sham Lal Singla, “Spirit-Induced Cautery Burns: An Unusual Iatrogenic Injury,” Internet Journal of Surgery 22, no. 2 (2010): 1,

[v] Sonya P. Mehta, Sanjay M. Bhananker, Karen L. Posner, and Karen B. Domino, “Operating Room Fires: A Closed Claims Analysis,” Anesthesiology 118, no. 5: 1133-39, doi: 10.1097/ALN.0b013e31828afa7b.

[vi] Mehta et al., “Operating Room Fires,” 17[AU: Please provide page number.]

[vii] Theodore Kim and Tammy Webber, “Third Baby Dies after Error at Indiana Hospital,” USA Today, September 20, 2006,

[viii] Ibid.

[ix] Laura A. Fahrenthold, “4-yr.-old Dies after Surgery,” New York Daily News, March 23, 1995,

[x] John Bonifield, “Ohio Family: Hospital ‘Botched’ Transplant, Threw Out Kidney,” CNN, August 30, 2013,

[xi] Susan Donaldson James, “Toledo Hospital Threw Out Donor Kidney, Now Denies Negligence,” ABCNews, August 29, 2013,

[xii] Sara Bleich, “Medical Errors: Five Years after the IOM Report,” Commonwealth Fund, last modified July2005,

[xiii] Ibid., 9.

[xiv] KiernanWalsheand Stephen M. Shortell, “When Things Go Wrong: How Health Care Organizations Deal with Major Failures,” Health Affairs23, no. 3 (May 2004): [AU: Please provide specific page number.]107,

[xv] Ibid., [AU: Please provide page number.]107

[xvi] Jim Doyle, Blunders: Botched Brain Surgery Prompts Extensive Review at SSM Health Care,” St. Louis Post Dispatch,May 5, 2013,

[xvii] Bleich, “Medical Errors,” 9.[AU: Your citation is for Bleich, “Medical Errors: Five Years after the IOM Report,” but your paragraph text indicates it ought to be Committee on Quality of Health Care in America and Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century (Washington, D.C.: National Academy Press, 2001). Please reconcile the seeming discrepancy The source is an Issue Brief from The Commonwealt Foundation (pub #830) published July 2005. The author is Sara Bleich).]