Resistance to change: a basis for error in Medicine
Most of the time humans are not happy to change a routine. There is also a feeling of safety when we work with electronic database thinking that, because computer are fast and efficient, we are going to be able to avoid errors. But, even with the best computer tool for data storage and retrieval the human factor is always present.
I have been in the medical world for over 30 years, most of them in the field of Medical Oncology. I try to remember some of the mistakes I have made throughout this time and one of them had a real influence in my search of improving diagnosis. This is the story… Continue reading My story: error in the midst→
An 80-year-old man had a diagnosis of heart failure, atrial fibrilation and diabetes. He was taking digoxin and warfarin. He went to the Emergency Department with nausea, vomiting and pain on his upper right quadrant. No bleeding was present but the hemoglobin level value was 7,9 g/dl. Digoxin level was higher than normal. The initial diagnosis was digoxin overdose and anemic syndrome.