Rubber Necking

Yesterday I read this article at Salon.com about a girl who was mistakenly given one vaccine in place of another. It was hard to pass up. With the subtitle "it changed her life in an instant" it promised the sort of tragedy we all have trouble resisting. But while medical errors are serious matters and the steps hospitals and doctor's offices take to minimize them are important, the story that followed that headline was unfortunately more about a mother's overreaction and her daughter's subsequent terror than it was about the system of checks and balances in medicine that we use to keep our patients safe.

While the mistake was unfortunate, it is one most people would hopefully see as easily forgivable. No one was hurt. The girl received a vaccine she should have gotten anyway. No harm, no foul. The doctor apologized. The world should keep turning and no one should shed tears.

My reaction to the article was so filled with frustration that I almost missed the small kernel of excellent advice the author had buried beneath the sodden handkerchiefs and smelling salts. After coming to terms with the mistaken administration of the HPV vaccine (an immunization that protects against cervical cancer and should absolutely be given to every child in the country, sans drama), the author writes: "Meanwhile, she still needs to get that meningitis shot, and I'm going to make damn sure that's the shot she gets."


This is the most important sentence in the entire piece. The system of checks and balances we rely on to prevent medical errors does not only include doctors and nurses and pharmacists. It includes patients. It includes families. It includes parents. When the author speaks up in her daughter's doctor's office to double check the vaccines she is getting, she will not be doing someone else's job for them. She will be doing her own job.


Years ago, a friend had surgery on her knee. Having heard tales of surgeons operating on the left instead of the right and vice versa, she prepared by taking a marker and writing NO! in big letters on her good joint. This has now become standard practice. The surgeon marks the site intended for repair with purple marker while the patient is still awake. Memory is faulty. Sometimes even medical records can be incorrect. The surgeon performs this last review with the most important member of the checks and balances system, the patient. 


The era of paternalistic medicine has passed. But with it comes a new responsibility. Patients and their families have opportunities to be involved in health care decisions in ways that were previously not entertained. But to do this effectively, we must be informed about our health, the vaccines we receive, and the medications we are being given. We should promote safety in our medical system and, when mistakes are made, look at the underlying causes and address them. Anything else is just a distraction from the real issue at hand and a waste of Kleenex.