Errors became an inevitable part of medical practice that frustrates hospital staff, patients, and families. Medical error can be defined as a mistake of a healthcare worker that results in an adverse patient outcome (Mohajan, 2018). These mistakes can occur due to wrong administration of a drug, improper performance of a procedure, incorrect diagnosis, and patient misidentification (Mohajan, 2018). Unfortunately, medical error is one of the most common causes of preventable death in hospitals (Mohajan, 2018). For example, about 400,000 deaths occurred due to medical personnel’s fault in the United States in 2015 (Mohajan, 2018).
One of the examples of a severe medical error in our hospital that happened about ten years ago was the development of locked-in syndrome (LIS) in a patient whose hyponatremia was corrected too rapidly. This error could have been prevented by better communication and collaboration between medical personnel.
One of the notable examples of significant damage to patient health due to a medical error in our hospital was the case of LIS caused by rapid correction of hyponatremia. A 50-year-old male was brought to the emergency department due to severe alcoholic intoxication. The serum sodium concentration was low when his electrolytes were checked; thus, it was corrected with intravenous infusions over the next 16 hours by the team of residents.
The patient developed bilateral paralysis of the upper and lower limbs after five days. Brain MRI showed central pontine myelinolysis, which occurs because of cell death, damage to the brain-blood barrier, and demyelination of neurons (Palamalai et al., 2018). The patient had to undergo almost one year of rehabilitation to restore his functions minimally. According to my older colleagues, it did not result in a court case, but the hospital administration introduced stringent policies. Specifically, all electrolyte and metabolic disturbances undergo careful evaluation by physicians, nurses, and pharmacists to prevent similar cases in the future.
To sum up, medical errors are one of the most common causes of preventable damage to patients. Mistakes can be caused by the wrong dosage of a drug or an incorrectly performed procedure. The case of the patient who developed locked-in syndrome due to rapid correction of hyponatremia demonstrated to medical personnel and hospital administrators the importance of interdisciplinary communication and collaboration to avoid harm to patients.
References
Mohajan, H. (2018). Medical errors must be reduced for the welfare of the global health sector. International Journal of Public Health and Health Systems, 3(5), 91-101.
Palamalai, V., Olson, A. P., Hogg, J. P., & Killeen, A. A. (2018). Osmotic demyelination syndrome after correction of hyponatremia: A case report. The Journal of Applied Laboratory Medicine, 2(6), 965-969. Web.