Thursday, June 6, 2013

To err is human

Dear American public,

I apologize.

I accidentally cost you $470 last month, and so I owe each of you a $0.000000076.

I actually feel quite bad about this, but more in terms of the money lost and the inconvenience to the patient.

What happened, you ask? Well, I meant to order a lumbar spine CT scan. But due to a busy day and multitasking, accidentally wrote an order for a cervical spine CT. No one questioned it, and so it got done. I didn't realize the error until the report showed up on my desk. I apologized to the patient, and ordered the correct study.

The whole thing is overall harmless. The patient is elderly, and a few additional units of radiation are inconsequential. The 1 week delay in getting the proper test didn't have an adverse impact on his condition.

But still, I feel bad. I'm certainly not out to rip anyone off, especially other taxpayers.

This is, as far as I know, only the second error I've made in ordering the wrong imaging study in the last 10 years. I assume I have the same error rate as other docs for this sort of thing, and the total for mine is around $1100. Given that there are roughly 900,000 practitioners in the U.S., that comes out to $990 million dollars wasted every 10 years. That's enough to pay 20,000 school teachers for a year, or buy the Air Force eight F-35 fighters. Even by government standards it's still a decent chunk of change.

I don't have an easy answer for this. Should I be responsible? If a doc orders the wrong test, should he have to eat that cost? I guess that makes some sense, but someone is going to argue at some point that a test shouldn't be ordered. What happens if I did order a correct test, but then an insurance company claims it wasn't necessary - so should I pay for it?

Or what if the patient (after getting a test bill, of course) claims that I shouldn't have ordered a test, and wants me to pay for it? I've had that happen (I refused) and have learned it's common. I know another doctor who was threatened with a malpractice lawsuit to get her to pay for a study (she stood her ground, and they backed down).

So, I guess the only easy answer is to leave it as it is, and accept the fallible nature of humans. If ordering the wrong CT scan (at no harm to the patient) is the worst mistake I ever make in this business, I'll take it.

40 comments:

Suze said...

Dr Grumpy as an ex RN I have to tell you that mistake was harmless and inconsequential compared to some. People are humans and error does happen. If a doctor works diligently to prevent such occurrences I think they are doing the best they can.

Plastic Tolstoy said...

CT happens. Tough.

Loki said...

To put things another way - that nearly $1 billion, over ten years, is a shocking figure on an individual basis. But compared to an annual budget of $3.2 trillion, multiplied by ten years, that $1 billion suddenly gets lost, quite literally, in the rounding errors within the budget. From the standpoint of the Federal government's budget, it's just not significant.

Should efforts be made to reduce waste? Of course! But beating yourself up for this is not reasonable. Simple human error is always going to be with us - and as errors go, this one is harmless, doesn't affect an acute condition, and did the patient no real harm. Compared, just for one example, to the cost of improper sanitation in hospital settings in suffering, monetarily, and for the development of resistant strains of pathogens, I just can't get exercised about this class of error.

Anonymous said...

Electronic medical records have made making test ordering errors more common and easier than ever. All the mumbo-jumbo starts off the same. xxxxx radex ct w/wo cntrst cerv vs xxxxx radex ct w/wo cntrst lumbar.

I've been fortunate that I will put in the comment section-patient has lumbar pain radiating to leg. That way, If I do order for wrong region to be scanned, the tech will call me and ask why I want to want to obtain an image of the neck if they have low back pain?

Also, I have had patient's insurance refuse to pay for tests-even after jumping through the "prior-authorization" (prior authorization is not a guarantee of payment) bullshit hoops. I tell the patients to constact their insurance and appeal.

Packer said...

Whoa dude, careful there, I think you might have just admitted to being human. We drive ourselves to deliver, serve and have all the answers and it is hell when we recognize that we don't. Wait until you have been at it 40 years and your mental acuity wanes and your physical strength falls. Get over it, keep moving forward.

Shub said...

Everyone makes mistakes. Assigning blame for errors made in good faith is counter-productive, at best. Usually the most reasonable response is to acknowledge the error, do what's possible to correct it, and move on. Telling people they need to never make mistakes doesn't help anything.

Anonymous said...

MEDICATION MISTAKES COST THOUSANDS OF LIVES ANNUALLY. DISEASE AND LACK OF IMMUNIZATION COST MILLIONS.
HEALTH CARE PROVIDERS AS A GROUP MAKE A CONCENTRATED EFFORT TO AVOID MISTAKES = WE ARE HERE TO HELP PATIENTS NOT INJURE, MAIM, OR KILL.

PATIENTS SHOULD KNOW WHAT TEST THEY ARE HAVING, AND WHY.

AND IF THE TEST IS APPARENTLY BEING DONE FOR THE WRONG AREA OF THE BODY (LEFT VS RIGHT ARM, NECK VS LOWER BACK) THEY SHOULD SPEAK UP!!

Anonymous said...

I say a prayer every morning, and every night = God , please let me catch any errors before they happen and let no harm come to anyone in my care or from my actions. I have only a few instances when I have caught mistakes of others they have not been VERY appreciative,and am always appreciative of "the system" that looks out for patient safety first and calls any oversight of mine to task.

Jono said...

I can't even begin to calculate the cost of human imperfection.

Ivan Ilyich said...

I thought insurance companies approved these things before they were done (except for emergencies). In either case, it's between you and the insurance company, I think.

As for it being an example of waste, I don't think it's a big deal. It's a common complaint that unnecessary tests for "defensive medicine" are wasteful, but I don't see it that way. I had three CT scans (full spine), all negative. I could just as well have not had them, but was fine with having them and my insurance covered them. Is that wasteful? I don't think so.

The real problem with health-care costs is not from doctors ordering unnecessary procedures, but from the suits at the top of "not-for-profit" hospital corporations looting the system to pay their exorbitant salaries, in my opinion.

Ivan Ilyich said...

Correction — they were MRIs, not CT. Even more expensive.

Moose said...

And this is why, no offense, I have learned enough to know how to ask questions about what is ordered for me.

It's harder when I'm in the hospital, but when a doctor hands me a sheet for tests I still check it over. I recently caught my doctor checking off the WBC on a blood work form when she had verbally mentioned a few minutes before that she wanted to do a WBC with diff.

It's harder to pre-check medications these days because nobody writes prescriptions anymore, it's all done electronically. That makes it harder to say, "I think you wrote trazadone instead of tramadol."

I recently caught my pharmacy giving me the wrong medication, fortunately before I left the store. I brought it back to them and explained the problem. They apologized profusely and I said, "That's why I check. We're all human and everyone makes mistakes."

One of the pharmacy techs screamed, "You are my favorite customer EVER!"

You have to learn to be your own protection. Unlike what most people believe, doctors and nurses and pharmacists are all human, too.

Well, except for Dr G, who we all know is a humanoid from planet Xfj3kasqp. Oops, was I allowed to tell that?

OldSquid said...

What was the cost to the patient? That might have been significant.

Grumpy, M.D. said...

Don't know, sorry.

Anonymous said...

What did the lumber spinal show?

Do you think that if you explained to the patient you wanted to get a picture of her neck and the tech told her to remove her underdrawers that the patient should be responsible to ask 'what for'?

As a pharmacist, in school we were taught to ask patients when counseling, "Now, what did you doc tell you this was for?"

Piddle on the costs. What about all the mistakes that radiology techs make themselves?

bobbie said...

I agree with Packer...

Anonymous said...

One of my patients had a chiropractor order a total spine MRI (How that got approved by the insurance company I'll never know)and in the process found a couple of aymptpmatic incidentalomas, wound up have a thyroid biopsy, scan etc. and an CT guided needle biopsy of an abdominal lesion, both of which were negative. That unnecessary MRI cost probably 50,000 bucks by the time it was over.

Anonymous said...

I cannot tell you how many errors my husband has caught because he is his own advocate and will speak up if something isn't right. No matter how pissy the person who wants him to sign those forms gets.

Anonymous said...

We can't afford insurance and don't qualify for Government Medical, so we don't get tests done.

Hildy said...

If it makes you feel any better, I personally forgive you. Keep the $0.000000076. Can't speak for the 20K unhired teachers, but I suspect that even if the school systems had the extra money, all of it would go to the superintendents and their cronies anyway, so who cares if you made a small mistake?

Jedi Master Ivyan said...

Two wrong tests in 10 years is probably much better than average. Keep up the good work doc. Oh, and don't worry about paying me back. I probably owe you for how much I've enjoyed your blog.

Steeny Lou said...

I'd take the $0.000000076 if it would make you feel better, but I'm not an American citizen so I cannot be of help in the matter.

Seriously, though, I do wonder how many people have had an erroneously ordered test and it was incidentally found that something was amiss that hadn't even been considered when the erroneous order was placed.

awesomesauciness said...

As a patient, I'm the biggest pain in the ass any doctor has ever had to treat.

Why?

Because I question EVERYTHING, and demand to understand what's being ordered/done/prescribed and I won't nod my head or utter "I understand" until I really do.

One thing I don't do is ask Uncle Google about every twitch/rash/lump/pain I get. For that my Primary is very grateful...but for my questioning, she says I sometimes give her a headache.

Tough. It's my body, and no one is going to alter it - with anything - unless I know why.

On the plus side, I've gotten pretty well-versed in medical terminology over the years. Wait, that's not a plus because it means I've been to numerous doctors with various ailments over the years.

Sigh...

Anonymous said...

Several years ago I was ill and the doctor couldn't diagnose me, and ordered some special blood test. The lab ran the wrong one. She sent me back. They ran it wrong again. She sent me to the hospital and told me to meet the tech myself and explain very clearly what the test was, which I did.
They ran it wrong.
The test was never done.

Anonymous said...

Once my doctor was supposed to order 80 mg for 120 days, and wrote 120 mg for 120 days. The pharmacist caught it.

Anonymous said...

Thank you Dr. Grumpy.
What a wonderful idea and example that all parties with a stake in health might have a calm dialogue on such an important subject involving so much time, energy, and money.

Difficult? Sure. Complex? You bet. We Americans have always believed that one of our key traits we possessed was a "can do" attitude, whether it was to span the oceans or outer space. Keep up the good work.

Anonymous said...

A once in a blue moon mistake is totally forgivable. Excessive mistake making is not. Nor is over ordering tests because it's easier than using one's brain to figure out what's wrong with a patient.

I think you are doing just fine, Dr. G. Keep up the good work.

Anonymous said...

Doc, in medicine (especially emergency medicine) mistakes can be fatal. I had an instructor once say "if you haven't made a fatal error, you haven't been working very long." While I think that's a bit extreme, I agree with the idea behind it: that humans make mistakes and when it's life or death, people may die.

No need to beat yourself up over a simple mistake. You were good enough to see and correct it; IMHO that puts you ahead of a LOT of other providers.

Anonymous said...

"If a doc orders the wrong test, should he have to eat that cost?"

Yes. That's how it works in most businesses, including mine: If I make a mistake when I spec the ink color or paper stock so the job has to be reprinted, I eat the cost, not my client. This is standard business ethics.

WarmSocks said...

I agree with Anon1:52, however the patient shares some fault since I would hope that you told the patient what test you were ordering.

Packer, when someone asks which pharmacy I want my rx sent to, I say that I prefer a piece of paper in my hand. Docs will give you a hard copy of your prescriptions if you ask.

BobF said...

Doc, have you tried to buy a pencil without an eraser lately? As I told my surgeon after my scary bout with C-Diff, there is a message in the rare availability of eraserless pencils. We are expected to screw up. Welcome to the human race. Thankfully most scrwewups are painless in the end.

The Drunken Bar Owner said...

Like every business, it is factored in. In the retail business it is called shrinkage. In the bar business it is spillage, waste happens as a natural part of life and any profession.

Anonymous said...

You absolutely should eat the cost. That is the literal price you pay for making errors. As the comment above says, that is part of doing business. Why on earth should the consumer pay the cost of your error?

Grumpy, M.D. said...

Okay, but what about the scenario I suggested: I order the correct test, but afterwards an insurance company says it wasn't necessary, and refuses to pay for it. Who pays for it then? Should I? Should the patient?

Anonymous said...

In that scenario you have some options - you can appeal the insurance company's decision, you can talk to the hospital and explain the situation and perhaps get the fee reduced (since we all know hospitals inflate the crap out of any bill when dealing with insurance companies). You don't need to eat the cost on a test you felt was necessary, but you do need to advocate for your patient when they end up getting screwed by the insurance company.

Jen in Cincinnati said...

This has probably been said already ... but the patient certainly has a role in all this. When I have had fancy expensive tests done I'm aware of what body part is being tested. If I showed up for a lumbar exam and went head-first into the scanner I'd be calling time-out.

The system needs built-in redundancies such as those we use to double-check and confirm patient identity and, in the case of surgery, the side & site of the procedure. The imaging center/hospital should implement a policy where the tech does a verbal confirmation with the patient: "You are here for a [fill in blank imaging study type] on your [fill in blank for body part & side when applicable.] Does that sound right?"

Dr. Minerva said...

If you order the correct test, and the insurance company later denies it, for whatever reason, it is totally the patients responsibility.

Patient's have a responsibility to their own care. I'm sure your office makes them sign something saying they are responsible for costs not covered by insurance.

What is interesting to me, is who pays when the doctor writes the wrong prescription and the patient gets it filled at the pharmacy? Usually the pharmacist ends up eating this cost because they don't feel like dealing with the hassle. (read: complaining patient) I think in that case the doctor should refund the patient their copay.I think this happens almost NEVER.

Grumpy, M.D. said...

Dr. Minerva- I have reimbursed patients for co-pays. All were in situations where I meant to sign for DAW, and accidentally signed for generic, in epilepsy patients.

Dr. Minerva said...

Thank you Dr. Grumpy! See, that just goes to show that us pharmacists need to be more assertive sometimes. I think it was an old school pharmacist thing to just eat the cost of physician's error rather than hearing about how difficult it was going to be for the patient to go back to the doctors office.. blah blah blah.

Anonymous said...

I recently ordered an echocardiogram without stress test rather than with the stress portion --felt exactly the same way!

Similarly the patient should have known the test they were meant to go for (and didn't!).

Unfortunately, the cost to "society" is that of one extra echocardiogram and the patient's time/delay to diagnosis (fortunately the stress test was negative).

I tell myself that my penchant for attempting to avoid ordering truly unnecessary testing makes up for this in the end...you win some, you lose some. We are only human.

 
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