An Ounce Of Prevention

09/08/16 | Admin

Jackie, my nurse, sheepishly said, “I think I gave him Penicillin by mistake.”

“You think or you know you gave him Penicillin?” I questioned. Reading her face, I knew the answer before she spoke.

“I gave him Penicillin and I’m so sorry Dr. Cassatly.” I told her to call 911 and say we had a patient about to go into anaphylactic shock; the most severe life-threatening type of allergic reaction.

Will, an emergency patient bleeding from a facial laceration due to slipping on his boat, had walked into my office just as we were closing after a busy day of surgery. Now, looking him directly in the eyes, I told him straightforwardly, that my nurse had mistakenly given him Penicillin.

The EMTs arrived, rushed Will to the Emergency Department and after successfully being treated for an allergic reaction, Will was discharged home late in the evening. (To read the full story, Mistakes Happen, click here)

The day after Will’s allergic reaction, my complete office staff sat down to discuss exactly how this preventable medical mistake happened. Once we all shared our emotions about how badly we felt, it became obvious we were active participants in a preventable medical injury. A new office policy was implemented mandating that the nurse administering medication to a patient must show the drug to the doctor before the drug is given. I practiced another 18 years with three partners and our office team never experienced another medication error.

A review of preventable medical injuries and deaths reveals some frightening statistics. In 1999 there were up to 98,000 needless deaths at a cost of approximately $2 billion.1 Ten years later, in a recent government report of a sample Medicare population, 15,000 deaths per month were attributable to medical mistakes.2 From 1999 to 2008, the annual healthcare costs to treat preventable medical injuries and deaths exploded by 850%, from $2 billion to $17 billion dollars1,3 Interestingly, the majority of preventable medical injuries are not due to poor surgical technique or bad medical decision making, but as illustrated in the above true story communication mistakes! The root cause of over 50% of these mistakes is due to a lack of teamwork, most frequently caused by lack of communication.4

Provisions in the Affordable Care Act call for identification and reporting of medical mistakes allowing the Center for Medicare and Medicaid Services to deny or recoup payments for treatment related to these adverse patient events.2 Thus, the government is punishing healthcare institutions where it hurts: the pocketbook. In a recent article, I have shown that coaching of the healthcare team results in a reduction in these needless medical injuries and deaths.5 To read the full article click here.


  • Institute of Medicine, To Err is Human: Building a Safer Health System, 1998
  • Levinson D, Advesere Events in Hospitals: National Incidence Among Medicare
  • Shreve J, Van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E, Economic

Beneficiaries, Office of the Inspector General, Dept of Health & Human Services, Nov 2010

Measurement of Medical Errors, Society of Actuaries, Milliman, June 2010

4. Risser D, Rice M, Salisbury M, Simon R, Jay G, Berns S, The Potential for Improved

Teamwork to Reduce Medical Errors in the Emergency Department. The MedTeams Research

Consortium, Ann Emerg Med. 1999 Sep;34(3):370-2

  • Cassatly M, Mitsch D, The Successful Application of Business Coaching to Decrease

Preventable Medical Errors, J Med Practice Management, Sept 2011, 27(2);107-109

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