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All medical mistakes are problematic. A few are truly tragic. But every now and then, a medical error comes along that is downright hilarious. From AHRQ WebM&M, the case-based Web journal I edit for the federal government, here are two of the latter kind. They are a hoot. We published the first about three years ago and called it “Allergy to Holter”:
A 52-year-old man was admitted for palpitations and chest pain. As part of the evaluation, on hospital day 4 the patient was sent to the cardiac clinic to start a continuous recording of his electrocardiogram via Holter monitor.
Since the patient was ambulatory and had gone for other tests on his own, he was told to go to the cardiology clinic for a check-up of his heart rhythm. He was handed a "Request for Consultation" form, on which there was only one word: "Holter." The form did not state the patient's name or the department.
The patient had been told the clinic was on the fifth floor of the ambulatory building, so he took the elevator to that floor. He presented himself to the reception desk of the first clinic he saw—the allergy clinic (which is on the same floor as the cardiology clinic)—where the nurse took his consultation form, and told him, "Mr. Holter, you are in the right place." She then proceeded to conduct a complete pinprick skin sensitivity test on his back, which showed no evidence of allergies. Armed with a form that showed his "Holter" test was negative, the patient walked back to his ward.
Upon his return, the patient told his ward nurse, "I've just finished the Holter test."
—"And where is the Holter device?" asked the nurse.
—"It is on my back and does not hurt at all!"
The nurse looked at the patient's back and realized that he had had an allergy test. She then escorted him to the cardiac clinic to have an actual Holter monitor placed. There was no harm (fortunately) to the patient, other than an unnecessary test and a brief delay in the ECG recording.
Additional investigation revealed that the patient was able to read and there was no language barrier. The workload for the allergy clinic nurse was light. She had merely glanced at, but did not read, the consultation form. Since it was not the first time a patient had received an unnecessary allergy test, the hospital published the event in their incident report newsletter and changed the signs to clinics on that floor. The nurse retired from practice (as previously scheduled) the following month. Years later, I still get a chuckle over "Mr. Holter." We published the second case a few months ago, and Medscape picked it up this month, where it quickly garnered a bemused following. We called the case, “Code Blue – Where To?": An 80-year-old man with a history of coronary artery disease, hypertension, and schizophrenia was admitted to an inpatient psychiatry service for hallucinations and anxiety. On hospital day 2, he had sudden onset of confusion, bradycardia, and hypotension. He lost consciousness, and a "code blue" was called.
The inpatient psychiatry facility is adjacent to a major academic medical center. Thus, the "code team" (comprised of a senior medical resident, medical intern, anesthesia resident, anesthesia attending, and critical care nurse) within the main hospital was activated. The message blared through the overhead speaker system, "Code blue, fourth floor psychiatry. Code blue, fourth floor psychiatry."
The senior resident and intern had never been to the psychiatry facility. "How do we get to psych?" the senior resident asked a few other residents in a panic. "I don't know how to get there except to go outside and through the front door," a colleague answered. So the senior resident and intern ran down numerous flights of stairs, outside the front of the hospital, down the block, into the psychiatry facility, and up four flights of stairs (the two buildings are actually connected on the fourth floor).
Upon arrival minutes later, they found the patient apneic and pulseless. The nurses on the inpatient psychiatry ward had placed an oxygen mask on the patient, but the patient was not receiving ventilatory support or chest compressions. The resident and intern began basic life support (CPR with chest compressions) with the bag-valve-mask. When the critical care nurse and the rest of the code team arrived, they attempted to hook the patient up to their portable monitor. Unfortunately, the leads on the monitor were incompatible with the stickers on the patient, which were from the psychiatry floor (the stickers were more than 10 years old). The team did not have appropriate leads to connect the monitor and sent a nurse back to the main hospital to obtain compatible stickers. In the meantime, the patient remained pulseless with an uncertain rhythm. Moreover, despite ventilation with the bag-valve-mask, the patient's saturations remained less than 80%. After minutes of trying to determine the cause, it was discovered that the mask had been attached to the oxygen nozzle on the wall, but the oxygen had not initially been turned on by the nursing staff. The oxygen was turned on, the patient's saturations started to rise, and the anesthesiologist prepared to intubate the patient. Chest compressions continued.
At this point, a staff nurse on the psychiatry floor came into the room, recognized the patient, and shouted, "Stop! Stop! He's a no code!" Confusion ensued—some team members stopped while others continued the resuscitation. Although a review of the chart showed no documentation of a "Do Not Resuscitate" order, the resuscitation continued. The intern on the team called the patient's son, who confirmed the patient's desire to not be resuscitated. The efforts were stopped, and the patient died moments later. The case generated a wonderful series of posts on one of Medscape’s physician forums. A few choice samples: This made me laugh so hard… because this is EXACTLY the way a real hospital code goes down.***
Well that’s just atrocious, if highly amusing. It is scandalous that there wasn’t even a damn AED on the ward… [see my prior post on this topic] *** Sounds like a job for the Keystone Cops:  *** The term “Chinese fire drill” also comes to mind…*** And, my favorite comment, referring to the erudite discussion of quality problems in off-site cardiac arrests by Dr. Bruce Adams, Chief of the Department of Clinical Investigation of the William Beaumont Army Medical Center, that accompanied the case on AHRQ WebM&M:The juxtaposition of the stooge-worthy hijinx of the case followed by the dry academic deconstruction – that’s literature, my friends. Worthy of Ezra Pound or PD Wodehouse [sic]. Fabulous. You can’t make this up…I couldn’t agree more. Sometimes, even when the subject is medical errors, you just gotta laugh.
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