Medical Errors & Patient's Safety- Case Study Description: Sameer was a runner, like his dad, who is a physician. One da
Posted: Wed May 04, 2022 8:18 am
Medical Errors & Patient's Safety- Case
Study
Description: Sameer was a runner, like his dad,
who is a physician. One day, he collapsed during a run and was
hospitalized for five days. He went through lots of tests but was
given a clean bill of health. Then, a month later, he collapsed
again, fell into a deep coma, and died. His father wanted to know —
what had gone wrong? His dad tells the story of how he uncovered
the cause of his son's death.
The Case:
My son was born after my wife had three miscarriages. Sameer was
an energetic, curious little boy who went through a long phase of
asking me, "Why, Daddy?" It forced me to become creative with my
answers, but there was always another "why" waiting in my son's
mind.
Sameer grew into an active young man with a passion for running,
soon beating me in races and greeting me at the finish line with a
happy smile and the words, "Good race, Dad." Just before he turned
18, he became a computer science major at one of the Emirati
Universities.
A call that changed lives
On September 15, 2002, a call to my home changed my life
forever. It was late on a Sunday evening, and it came from a
hospital doctor. He said that Sameer had collapsed while running.
Sameer had collapsed in a similar incident a month earlier but
recovered on his own. This time, he was down for some time, and the
paramedics had to shock his heart three times to restart it. He was
in a deep, unresponsive coma. I hurried to be at my son's
bedside.
Sameer never recovered from his deep coma. Three days after I
drove to see him, He died. Words cannot capture the pain
experienced by those of us who were closest to Sameer — his Mama
and me, his little sister, and his much younger little brother. Our
relatives, neighbors and many friends held us in their hearts as we
struggled through the process of burying our firstborn son.
What had gone wrong? After his first collapse, Sameer
was hospitalized for five days. He had various cardiac
evaluations: numerous electrocardiograms, a cardiac ultrasound, an
exercise stress test, and a cardiac MRI. He was also given a
cardiac catheterization, which caused a painful hematoma, and an
electrophysiology test. During his hospital follow-up visit five
days after discharge, his doctor had given him a clean bill of
health.
A series of errors
Since there was the possibility of a genetic cause of his death,
I asked for his records. I received a quarter-inch-thick pile at
first until I pressed for his complete record, which was three
inches thick. As I examined his records and studied cardiology
literature, I discovered that his cardiologists had failed him.
After his first collapse, Sameer had three types of heart
arrhythmia (irregular heartbeat) and low potassium. Two years
earlier, a guideline from the international health research centers
called for potassium replacement in such patients. He never
received potassium replacement, even though I had told his lead
cardiologist about his low potassium. (I did not know enough at the
time to connect low potassium with heart arrhythmia).
His cardiologists had also missed a diagnosis of acquired Long
QT syndrome, a treatable heart rhythm condition that sometimes
requires patients to avoid exercise. On a scale that suggests
likely diagnosis for a score of 4 points or higher, Sameer scored
5.5 points.
A communication error was also apparent to me as I fixed
together the records. No one warned my sone not to run after the
hospitalization after his first collapse. His written discharge
instructions specified only that he does not drive for 24 hours.
There was no record of anyone warning him not to run when he had
his follow-up visit, so he didn't realize he shouldn't have resumed
running after his discharged. This was a catastrophic mistake.
In the spring after my son died, I learned of another major
mistake. A radiologist at the hospital where my son received
treatment got in touch with me. After we exchanged a number of
emails, he told me Sameer's cardiac MRI was done incorrectly
because the technicians had not been trained on new software for
the machine. Sameer or us were never told about this, and this
information was critical because the cardiac MRI was to be
performed before any invasive testing.
To be frank, my son was deceived into signing consent forms for
his cardiac catheterization and electrophysiology test. If his
cardiologists had only recognized his need for potassium
replacement, neither test would have been needed. They should have
at least repeated his cardiac MRI with technicians who were
properly trained to do the test.
Questions
Question 1: Identify at least three medical failures in
Sameer's care? (3x1= 3 Marks/15).
Question 2: highlight two medical errors/ medical
negligence happened in UAE's hospitals (reported in the media or
any relevant study or personal experience)? (2x1= 2
Marks/15)
Study
Description: Sameer was a runner, like his dad,
who is a physician. One day, he collapsed during a run and was
hospitalized for five days. He went through lots of tests but was
given a clean bill of health. Then, a month later, he collapsed
again, fell into a deep coma, and died. His father wanted to know —
what had gone wrong? His dad tells the story of how he uncovered
the cause of his son's death.
The Case:
My son was born after my wife had three miscarriages. Sameer was
an energetic, curious little boy who went through a long phase of
asking me, "Why, Daddy?" It forced me to become creative with my
answers, but there was always another "why" waiting in my son's
mind.
Sameer grew into an active young man with a passion for running,
soon beating me in races and greeting me at the finish line with a
happy smile and the words, "Good race, Dad." Just before he turned
18, he became a computer science major at one of the Emirati
Universities.
A call that changed lives
On September 15, 2002, a call to my home changed my life
forever. It was late on a Sunday evening, and it came from a
hospital doctor. He said that Sameer had collapsed while running.
Sameer had collapsed in a similar incident a month earlier but
recovered on his own. This time, he was down for some time, and the
paramedics had to shock his heart three times to restart it. He was
in a deep, unresponsive coma. I hurried to be at my son's
bedside.
Sameer never recovered from his deep coma. Three days after I
drove to see him, He died. Words cannot capture the pain
experienced by those of us who were closest to Sameer — his Mama
and me, his little sister, and his much younger little brother. Our
relatives, neighbors and many friends held us in their hearts as we
struggled through the process of burying our firstborn son.
What had gone wrong? After his first collapse, Sameer
was hospitalized for five days. He had various cardiac
evaluations: numerous electrocardiograms, a cardiac ultrasound, an
exercise stress test, and a cardiac MRI. He was also given a
cardiac catheterization, which caused a painful hematoma, and an
electrophysiology test. During his hospital follow-up visit five
days after discharge, his doctor had given him a clean bill of
health.
A series of errors
Since there was the possibility of a genetic cause of his death,
I asked for his records. I received a quarter-inch-thick pile at
first until I pressed for his complete record, which was three
inches thick. As I examined his records and studied cardiology
literature, I discovered that his cardiologists had failed him.
After his first collapse, Sameer had three types of heart
arrhythmia (irregular heartbeat) and low potassium. Two years
earlier, a guideline from the international health research centers
called for potassium replacement in such patients. He never
received potassium replacement, even though I had told his lead
cardiologist about his low potassium. (I did not know enough at the
time to connect low potassium with heart arrhythmia).
His cardiologists had also missed a diagnosis of acquired Long
QT syndrome, a treatable heart rhythm condition that sometimes
requires patients to avoid exercise. On a scale that suggests
likely diagnosis for a score of 4 points or higher, Sameer scored
5.5 points.
A communication error was also apparent to me as I fixed
together the records. No one warned my sone not to run after the
hospitalization after his first collapse. His written discharge
instructions specified only that he does not drive for 24 hours.
There was no record of anyone warning him not to run when he had
his follow-up visit, so he didn't realize he shouldn't have resumed
running after his discharged. This was a catastrophic mistake.
In the spring after my son died, I learned of another major
mistake. A radiologist at the hospital where my son received
treatment got in touch with me. After we exchanged a number of
emails, he told me Sameer's cardiac MRI was done incorrectly
because the technicians had not been trained on new software for
the machine. Sameer or us were never told about this, and this
information was critical because the cardiac MRI was to be
performed before any invasive testing.
To be frank, my son was deceived into signing consent forms for
his cardiac catheterization and electrophysiology test. If his
cardiologists had only recognized his need for potassium
replacement, neither test would have been needed. They should have
at least repeated his cardiac MRI with technicians who were
properly trained to do the test.
Questions
Question 1: Identify at least three medical failures in
Sameer's care? (3x1= 3 Marks/15).
Question 2: highlight two medical errors/ medical
negligence happened in UAE's hospitals (reported in the media or
any relevant study or personal experience)? (2x1= 2
Marks/15)