Health Care’s Hidden Secret: Preventable Medical Errors

It’s been 21 years since 29-year-old Cathy Shine tried to bolt out of Massachusetts General Hospital to avoid being intubated during an asthma attack.

Shine didn’t make it out the door. She was stopped by a physician and a security guard and returned to her room, where she was placed in four-point restraints and forcibly intubated, a measure the attending physician deemed necessary to save her life.

Two years later, in July 1992, Shine remained so traumatized by the forcible intubation that she refused to go to the hospital during a severe asthma attack. She died two days later. The Shine family sued Massachusetts General Hospital and the physician who had intubated Shine against her will. The Massachusetts Supreme Judicial Court, citing “the right of a competent individual to refuse medical treatment,” even life-saving treatment, found in their favor.

An annual lecture series named for Shine and endowed by a $100,000 gift from her family launches today, March 3, at the School of Public Health. The series is dedicated to advancing the rights of patients, a focus of Shine’s advocacy work before her death. Noted bioethicist, legal activist, and author Lori Andrews will deliver the inaugural lecture, titled Studying Medical Malpractice at the Bedside.

The creation of the lecture series resulted from a bond formed between the Shine family and George Annas, William Fairfield Warren Distinguished Professor and chair of the SPH health law, bioethics, and human rights department. Annas used Cathy Shine’s case to argue for the rights of patients to refuse restraints in a highly cited article in the New England Journal of Medicine.

BU Today spoke with Andrews, a Distinguished Professor of Law at the Illinois Institute of Technology’s Chicago-Kent College of Law and director of the its Institute for Science, Law and Technology, about today’s lecture. Andrews’ work as a bioethicist and lawyer has had a major impact on changing laws to better protect patients.

BU Today: What will you talk about in your lecture Studying Medical Malpractice at the Bedside?
Andrews: I’ll be discussing a hidden secret of the health care system: that many patients die of easily preventable medical errors.

You led a team of researchers who closely followed medical staff at a teaching hospital to determine why medical errors were being made. What did you discover?
We discovered that 46 percent of patients had at least one error in their care and that 18 percent of patients had an error in their care that caused serious harm. By shadowing surgeons, nurses, medical residents, hospital administrators, and others, we found a much higher rate of errors than other researchers have found in medical records. For example, the Harvard Medical Practice Study found a 3.7 percent error rate by reviewing medical records after patients’ stays in New York hospitals. This disparity is understandable, since one would not expect that doctors would admit their errors in a record. In fact, some physicians in our study indicated that they did not include information about errors in the patient’s chart because they wanted to avoid litigation.

What surprised you most in your research?
It surprised me that the hospital made little attempt to learn from its errors and prevent future errors.

What message do you hope the audience gets from your lecture?
People need to become activists to make hospitals safe for all of us. If each day a 747 airplane crashed, killing all 500 people aboard, we’d be outraged. But more than that many people die of medical errors each day and society ignores it.

You are known largely for your work as a bioethicist in the field of reproductive and genetic technologies. How did you become interested in this field?
Soon after graduating from law school, I was invited to speak about informed consent at the first international meeting in Germany about in vitro fertilization and other reproductive technologies. Only three test tube babies had been born in the world at that time. The doctors and scientists I met there began calling me with questions: does the child of a sperm donor have a right to know the identity of the donor? If a couple with a frozen embryo divorce, could they split the embryo in half and each get a baby from it? What happens if a surrogate mother changes her mind? Figuring out the answers launched me into the field.

Have ethics failed to keep up with technology?
The law always looks backward, while science always looks forward. If there is a legal case involving the Space Shuttle, courts look to precedents involving the horse and buggy. But some scientific issues have no precedents. If there is a fight over a frozen embryo, should the embryo be treated like a person or like property? I’m thrilled to be speaking at BU because George Annas has been a leader in creating legal policies that are forward-looking.

You’ve been critical of a new breed of biological scientists and the role of venture capital in medical research. What’s your biggest concern?
That medical researchers are putting profits before patients. Rather than sharing information, such as the discovery of a gene related to cancer, for example, some researchers are keeping the information secret so that they can patent the gene, claim they now ‘own’ the disease, and forbid other scientists and doctors from even looking at the gene in their own patients or doing research on the gene.

What’s the strangest case you’ve encountered in your work as a bioethicist?
A Middle Eastern country wanted me to help develop a legal system so that they could clone men. For example, if a man cloned himself, would he be creating his child or his brother? If someone stole a lock of a rich man’s hair, could the thief clone the rich man from the DNA in the hair follicle and sue the rich man for child support?

The inaugural Cathy Shine Lecture is today, March 3, at noon in Room L-110, BU School of Medicine Instructional Building, 72 East Concord St. The event is free and open to the public and will be followed by a reception.

Lisa Chedekel can be reached at chedekel@bu.edu. John O’Rourke can be reached at orourkej@bu.edu.