Medical Mistakes

As a result of a medication error, the writer suffered a stroke. Could this happen to you?

Medically Reviewed by Gary D. Vogin, MD
7 min read

The migraine I'd been suffering for two weeks was nothing compared to the searing pain that suddenly shot through the left side of my head as I lay sleeping in bed one night. It was a pain as intense as any I've ever felt. It woke me from a deep sleep and left me sitting bolt upright, trembling, and holding the side of my head.

Frightened and unsure what to do, I got out of bed at 3 a.m. and drove myself to the emergency room of my HMO. I'd been at the hospital two days earlier to get some help for my migraines. The doctor at the walk-in clinic had given me a thorough exam and asked me if I was taking any medications. I'd told him about my new estrogen drug, Prempro, which I'd started taking the day before the headaches began. He'd given me a prescription for Midrin, a vasoconstrictor commonly used for migraines, and another for my blood pressure, which, he'd noted, was elevated. "The estrogen you're taking is fine," he'd told me. "You just have a migraine."

Now, just two days later, I was back at the hospital, and I was feeling scared. The ER doctor gave me a cursory exam and expressed concern about my blood pressure, which was now up to 220/100. He said he was glad I was taking blood pressure medication, assured me that all my medications were correct, and sent me on my way.

But the next day the right side of my body went numb, and I couldn't speak for over an hour, the first of three times this would happen over the next three days. I spent those days in a panic, running back and forth to the ER, where perplexed doctors continued to diagnose migraine and approve all my drugs. Finally, a CT scan of my brain revealed bleeding in one area, a sign of a hypertensive stroke.

What had caused it? My doctors couldn't tell me, but after several weeks I finally got to the bottom of it with the help of a doctor I know, a friendly pharmacist at UCLA, and a lot of time spent searching the Internet.

Here's what we think happened: Like thousands of people every year, I had been the victim of a serious medication error. Prempro had given me a headache and pushed up my usually normal blood pressure, both occasional side effects of oral estrogens. Midrin, not advised for patients with high blood pressure because it can raise blood pressure even more, had then helped trigger the stroke.

Drug errors are far from new, but with more than 12 million chemical substances now available, taking medications has become an increasingly dangerous proposition. In 1999, a report called To Err Is Human by the Institute of Medicine of the National Academy of Sciences, estimated that as many as 98,000 hospital patients die every year as a result of preventable errors, including medication mistakes. These findings prompted the Clinton administration and Congress to call for urgent reforms. Both academics and entrepreneurs are proposing an array of systems and gadgets designed to prevent errors or catch them before they can harm the patient.

Medication errors come in many forms: Patients can be given the wrong drug or dose because of an error in reading or writing a prescription. Doctors can fail to find out if a patient is allergic to a particular drug or has a condition that can be worsened by a medication. Different drugs may interact with each other to trigger a problem. Or, as in my case, two drugs with similar side effects can amplify the extent of that side effect synergistically.

These errors are costly -- in dollars as well as lives. Prescription errors are the second most frequent -- and expensive -- cause of medical malpractice claims, costing $219 million a year, according to the Physicians Insurance Association of America.

There are many reasons for the growing incidence of prescription errors. Thanks partly to pressure from managed care, doctors have little time to spend with patients, often see patients they don't know, and are forced to make snap judgments. Patients' files are frequently unavailable, especially in emergency rooms and county hospitals. And pharmacists under pressure to fill prescriptions quickly may make mistakes.

According to Michael R. Cohen, a pharmacist who serves as president of the Institute for Safe Medication Practices in Huntington Valley, Pa., nearly half of all medication errors happen because doctors lack critical information about a patient's history or about the side effects and contraindications of the medicines they are prescribing.

The good news is that, in response to this greater risk, a new approach to dealing with errors is emerging that sees mistakes as the result of flawed systems rather than bad doctors. To err is human, advocates of this "systems" approach say; accidents will always happen. The only answer is to fix the system itself by building in safeguards and double checks.

Though technology is far from the only answer, a host of new devices have cropped up that promise to help. Leapfrog Smart Products, Inc., of Maitland, Fla., offers a "smart card" the size of a credit card that patients can keep in their wallet. Loaded with a built-in computer chip, the card stores insurance, financial, and medical information, including a patient's medication history, drug allergies, vital signs, cholesterol levels, and more. The card is inserted into a computerized reader and is updated at each medical appointment.

Smart-card technology, widely used in Europe, is coming to this country too. Some Florida hospitals now use smart cards, and the U.S. Department of Defense is working on a plan to get military personnel on a smart-card system by the end of this year.

Had I walked into my HMO's clinic with such a card, the doctor on duty, whom I'd never met before, would have known instantly that hypertension and migraines were not in my history. This could have alerted him to another possible cause, such as the side effects of Prempro. True, in my case, the doctors should have found this out anyway -- if only by asking me the right questions. Where the smart card can really help is with patients who are unconscious, confused, or who don't speak the same language as the doctor.

Technology also might have warned the doctors about the possible side effects of the two medications. In 1999, a database called ePocrates was introduced by a company of the same name in Silicon Valley. The system provides information on side effects and drug interactions for more than 1,600 medications, data that can be downloaded from the Internet to a hand-held computer that a doctor can carry on rounds. The manufacturer claims that more than 80,000 doctors and nurses already use the device at teaching hospitals.

But some changes don't require new technology. Cohen says my gynecologist -- who prescribed the Prempro in the first place -- should have explained its possible side effects and invited me to call her about any problems. Had she done so, my problems might have been addressed before they got serious. As it was, I never contacted her during this episode because I didn't think my symptoms were drug-related.

One day in the near future, computerized systems may be in place at most hospitals and clinics across the country, allowing doctors to type prescriptions directly into a pharmacy-linked computer. Double checks for dosage amounts, drug interactions, and patient allergies will be automatic, and there will be no errors due to doctors' illegible handwriting. Already in use at some of the nation's hospitals -- including Brigham and Women's Hospital in Boston -- these systems have reduced medication error by as much as 81% (see the July-August 1999 issue of the Journal of the American Medical Informatics Association). They may not have helped in my case since they are not yet sophisticated enough to include warnings based on vital signs like blood pressure -- but they should be soon.

If I've learned anything from this experience, it's that medical professionals do make mistakes and that I'm ultimately in charge of my own health. As a patient, if I don't ask lots of questions and keep track of what's going on -- or have a friend or advocate who can help me do this -- I'm the one who may pay the price. And in my case, the price was pretty high -- though not as high as it could have been. Last year, I contacted a lawyer to find out about the possibility of a lawsuit to get some compensation for my months of pain and for the work time that I lost in the process. Unfortunately, my lawyer dryly explained, my injury wasn't serious enough to make a lawsuit worthwhile. Although the negligence itself was clear, I couldn't prove that I lost income because of the medical error. And I wasn't paralyzed or dead.

Still, my story does have a happy ending. I recovered fully, though I suffered brain swelling and six months of headaches after the stroke. My blood pressure is now back to normal, and I am taking a different estrogen drug, which has given me no further problems. And that makes me luckier than about 98,000 other people.