Medical Errors during the Covid Crisis

by Danielle Ofri
New York Times Op-Ed

The mean arterial pressure was well over 100 and the patient’s heart rate was racing. In an emergency room hastily converted into an I.C.U., abnormal vital signs were not unusual. Intubated coronavirus patients lined the unit, ventilators and IV pumps crammed in between their beds. The patients needed fluids, sedatives, paralytics, antibiotics. Some needed heparin (a blood thinner) for the raging blood clots that Covid-19 incited. Others whose blood pressure had plummeted were being given vasopressors.

One of the doctors, scrutinizing the armada of IV pumps, discerned the error. The patient had needed more heparin. But someone had accidentally increased the vasopressor, Levophed, instead. That’s like mixing up a blow torch and a chain saw. So now the patient was being flooded with an adrenaline-like medication, the equivalent of gunning a car engine, while the blood thinner was perilously low.

To his credit, the doctor didn’t blow a gasket. He calmly pointed out the mix-up and corrected it. The patient’s mean arterial pressure and heart rate gradually eased. Only eyes were visible amid the P.P.E., but the jagged sighs of relief from the staff members were audible. A bullet had been dodged.

This year is the 200th anniversary of the birth of Florence Nightingale, who brought to light the distinctly unpalatable truth that medicine, for all its lifesaving accomplishments, can also cause harm. Exasperated, she wrote in 1863: “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm. It is quite necessary, nevertheless, to lay down such a principle.”

The coronavirus pandemic unleashed an unprecedented wave of medical improvisation. I.C.U.s were fashioned from any corner of the hospital with a pulse. “Covid tents” were erected in parking lots. Urologists and orthopedists were drafted as medical interns. Nurses who’d been wearing administrative hats for a decade dusted off their clogs and re-entered the clinical fray, alongside traveling nurses easily identifiable by their heartland accents and pristine ID cards. Medical students were handed early diplomas to fill out the ranks.

For the better part of March and April, the entire health care system was in a sprint. Now, finally, we are catching our breath. There are still many sick patients to care for, but there is, for the first time, a moment to think.

And think we should. There’s no doubt that what went right in the hospital was far greater than what went wrong. But things did go wrong, and part of the professional commitment that has been so justly lauded entails an honest reckoning of our shortcomings. By most accounts, frank errors, such as mixing up heparin and Levophed, were uncommon, but the cascading effects of an overstretched system often led to medical care that was less than ideal.

Staff members were working well out of their comfort zones, with unfamiliar systems and equipment, caring for a career’s worth of critically ill patients in two months.

The Wall Street Journal profiled junior residents deployed to I.C.U.’s — some from family medicine and psychiatry — fumbling with ventilators while overburdened supervisors were sprinting to fires elsewhere. At least one death seemed attributable to inexperienced residents unfamiliar with ventilator management.

A nurse and I one night struggled to set up a donated vital-signs monitor. It’s not rocket science, but the interface wasn’t intuitive and we found ourselves cycling endlessly through the calibration protocols until we could hardly see straight. In the end we had to abandon it, having wasted precious time that was needed for patients.

Care suffered in other ways too. The focus on the coronavirus meant that other types of tests were less available, leading to delays in diagnosis and treatment. Patients at home suffered as their non-Covid-19 illnesses were lost in the shuffle. Prescriptions ran out. Cancer treatments were delayed. Needed surgeries were postponed. As I call my patients at home to restart their medical care, I’m discovering infections untreated, insulin rationed, domestic violence unchecked and — not infrequently — patients who have died.

My N.Y.U. colleague Art Caplan, a professor of bioethics, noted with dismay the lowering of scientific standards regarding peer review of data. Doctors were understandably desperate to help their patients, but the resultant frantic prescribing, especially of hydroxychloroquine, probably caused more harm than good.

The chaotic manner in which some hospitals ramped up was also a cause for concern. “Management panicked,” Professor Caplan observed, “and did training on the fly. They could have taken extra days to train staff better before putting them out there.” Some would argue that delays would have cost lives, but more lives might have actually been saved in the long run if staff members were better trained.

The public has been extremely forgiving, recognizing that many of these harms were ineluctable consequences of a crisis situation. But the fact that the harms were unintentional and even perhaps inevitable doesn’t mean they shouldn’t be examined.

Florence Nightingale is known primarily as a nurse, but many biographies describe her as a statistician. She was a scrupulous gatherer of data — even data that made her colleagues and the public uncomfortable. Her pioneering contribution to health care was her understanding that the only way to improve outcomes for patients is to rigorously collect data and examine it critically.

Covid-19 is still very much an active medical issue and will be so for the foreseeable future. But now that the adrenaline is receding, we need to take sober stock of how we responded before our memories fade. There are stupendous accomplishments to be justly proud of, even as they are steeped in grief for the patients and colleagues who lost their lives. We all know, however, that there are things we could do better next time. And there surely will be a next time.