“I Was Horrified”: 34 Surgeons And Doctors Recall Their Worst Mistakes

Once as a tired medical resident I was called to the ER to admit someone at like 3am. This bonehead had gall bladder removal a week ago and now had a surgical-site wound infection. I asked if they'd taken their post-op antibiotics they were prescribed, and they weren't sure. I was getting more and more frustrated with this jerk preventing my sleep when I decided to use a "pregnant pause" interview technique, and just shut up. This usually results in either awkward silence and the patient saying "uhh W*F doc" or awkward silence followed by some useful deep revelation.


In this case the guy hung his head low, looked at his feet through unfocused eyes, started to sniffle while his halting voice cracked "I can't read. Never could. Didn't know the instructions they wrote down for me and didn't know I had medicine to buy. I didn't ask them because I was embarrassed."


Illiteracy haunts rural and urban places in most countries. Those folks aren't reading this, and they depend on our patience and understanding, and acceptance, to detect and bridge that vast communication gap. That's what stuck with me.

This isn't so much a medical error, but a time I feel that I failed my patient. I was on my first clinical rotation in a rural Emergency Room, and a woman came in with a miscarriage, her second one. While we were talking she mentioned she was new to town, didn't know anyone, and her husband was away for the weekend. When we told her the diagnosis, her eyes became teary, and then we left to make arrangements. The doc didn't say he was sorry for her loss or comfort her in anyway, which I instinctively wanted to do.

When I went back in her room to give her appointment time, she was in pieces. It really gets me. The five seconds it would have taken me to say those words, put a hand on her shoulder, call someone, or just offer some tissues, ugh anything but I didn't do it. Instead I let my fear of not knowing if I would be showing too much emotion or slowing down the doc, stop me from being human. The silver lining is now I do what my gut tells me. I've soothed babies from exhausted parents, picked up crying family members off the floor, and even discussed comic book heroes with kids getting stitches because that's the kind of person I am, and doctor I want to become.

This is something a little narrower to my field than a lot of these. I work in Palliative Care, and in the fall I sent a patient home to see if he could die there instead of in hospital. We weren't very hopeful, but thought it would be worth a try. To no one's great surprise (even his and his wife's), he ended up coming back a couple of days later for whatever reason.

I re-admitted him, since I knew him. I knew he wanted to be a DNR (do not resuscitate). I wrote it on my note. But I didn't re-fill out the hospital paperwork. The next day, I got to work to discover he'd been coded and was on a ventilator in the ICU. Instead of passing peacefully, his wife had to make the decision to turn off life support. My entire job at the end of life is to ensure as good a death as I can. And in one simple omission, I messed that up royally.

Pharmacy technician here. I once was much too stressed and I was rushing. Instead of prednisone 5mg, I used prednisone 50mg. The pharmacist checked it and didn't catch it, but I realized when I was putting my stock bottles away. Luckily it hadn't gone out yet so I fixed the mistake and vowed to be 100% dedicated to one task at a time. A few months later somebody made the exact same mistake but did not catch it, and the patient ended up in the hospital for a few months. (Prednisone is a steroid).

I once said "wow that's really cool" after listening to his LVAD for the first time.

That's a left ventricular assist device for heart failure that continuously circulates in a parallel circuit to the left ventricle to keep the patient alive.

He joked "it's really cool if it's not inside you" and I said "oh right, I meant the sound and the technology but yes I'm sorry about that." He was a jokester, very happy, but it did make me think twice before opening my mouth again in certain situations. It was a cool piece of technology, but the patients interpretation of your words is paramount.

I was a medic in Israel and most of the time I was on a special ambulance for extreme emergencies or dangerous runs. After an overnight shift with that one I overheard that one of the morning shift medics didn't show up for a regular ambulance so I offered to take his spot. Well I didn't realize at that moment that the driver and other medic were both very orthodox religious but when I did I said whatever and went with them. On the ambulance there's a hierarchy and in this one I was on the bottom rung mostly because I was only 18.

We get a call for an unconscious woman at a bus stop. We get there and it's a visibly homeless woman who's not breathing, has a very weak pulse, and a locked jaw. In this case you're supposed to break the jaw to open the airway but the other two refused to because they were men and she a woman and they physically stopped me from intervening beyond trying to tilt her head back. We watched her die and called the coroner and took off immediately after they arrived. I stopped working with them immediately after and went home. The next day I filled a complaint but it wasn't taken seriously other than I wasn't allowed to be on their ambulance again. I'll never forget that call.

I do HIV testing and once I showed up to work super tired because I couldn't sleep the night before. This guy comes in for a test, we go through the pre-counseling and then I tell him to step out for a few minutes while the results come up. Once he comes back to get his results, I tell him to take a sit and the first thing that came out of my mouth was "Your results are positive" and then I saw the look on his face and that's when I realized I messed up. I then said" Oh no no no, I meant to say negative." I almost gave the guy a heart attack :/

When I was a new paramedic, we were called to a house for an unknown problem. We arrived and found our patient unresponsive but breathing on a bed. A friend of his found him after he hadn't returned his phone calls- they were going out to do something that day, and he found it weird that the guy hadn't called him yet, so he had gone to his house to investigate. The patient didn't have any pill bottles laying around, and his friend didn't know anything about the patient's medical history. So, I loaded him up into the ambulance and started transporting to the hospital. Started an IV, did an ECG, drew bloodwork, the whole work up. Get him to the hospital, and the first thing the nurse asked was "what was his blood sugar level?" Oops. Forgot to check it. Turns out, it was incredibly low- which is completely treatable, and probably wouldn't have required transporting him to the hospital if corrected on scene. Every patient gets a blood sugar check now.

Edit: Got back from a call and this is no longer at the bottom of the thread apparently. Yes, the patient probably would have been transported anyway, but I still would have initiated treatment on the scene and fixed the underlying problem. But this isn't really the place for a discussion of the management of hypoglycemia in the pre-hospital setting- that's for r/ems :).

I'm a Cardiac Cath Lab Tech at another hospital, I've been in the medical field for almost 6 years.
I was being cross trained into Computed Tomography recently and was thrown into my first night shift by myself after a quick month of training. I had a script I spoke every time I would hook someone up to our power injector for a contrast study (The weird stuff that makes you feel like you pee all over yourself). The injector I used in Cath lab is a HELL of alot bigger and scarier than this little thing, but they are still dangerous as hell. I also don't worry about blowing IVs in cath lab since we normally go through a much tougher femoral or radial artery.

We do two test injections of saline, one by hand and one my the injector to make sure the IV is patent and will tolerate the injection. 99% of the time this works and everyone is hunky dory; if it blows now the body will simply absorb the saline and you might get a bruise so no big deal. This time however the IV blew RIGHT at the beginning of the Contrast injection (Your body CAN'T absorb contrast in this fashion) and the little pressure waveform on the injector remained "normal" looking. She didn't once cry out or scream as I injected 100cc of Iodinated contrast agent into her forearm and I only noticed something was off when I started my scan and saw ZERO contrast in her torso. I aborted the scan thinking the IV blew outside of the patient, walked into her quietly sobbing inside of the machine with an angry swollen arm about the diameter of a grapefruit. I pulled her out, wrapped a hot water soaked compress around her arm, held it over her head and rushed her back to the ER. I found out later she had to go to surgery for it and has long term nerve damage from the compartment syndrome she suffered. I've had people die on my table, I've been on a code team for my entire term in Cath. Lab ( I respond to Code Blue/ Cardiac Arrests) and see death and mutilation every day at my Level 1 Trauma hospital as the night tech. This one stuck with me since I felt I was directly responsible for it despite being cleared. It caused me to change my WHOLE approach when doing my contrast studies. I tell people to SCREAM if their arm does more than burn now when I inject. Insult me, throw a shoe at my window, hit the big red EMERG button on the wall, anything so I don't disfigure someone again when my safeties fail and my machine lies to me. Sorry for the runon, I'm tired after a 16 hour shift.

In 2 years of clinical rotations during med school, I had encountered a patient (we'll call him Bob) many times. Everyone knew Bob. He had spina bifida with lower body paralysis that also lead to many other problems. Despite his poor lot in life, he was always really optimistic and cool about it all. Even when cleaning out a rectal ulcer for him, one of the worst smells I've ever encountered in my life, he was still able to joke around and make the procedure no different than applying a bandaid.

Eventually, Bob had signed a DNR order, and requested no further surgeries. He was mid 20s, and just tired of all the procedures.

Anyway, I was on a 24 hour call when the nurse paged me to come check on her patient, and sure enough, it's Bob. We know each other by this point, say hi, then I see that one leg is purple and twice the size of the other. Obvious blood clot and occlusion.

I go wake up the senior resident on call, we rush to Bob, we call the surgery resident on call, and they start prepping for immediate surgery. We hurriedly talk Bob into consenting, which he reluctantly does.

What we didn't do was call his main doctor, or slow down to actually talk to Bob, or notify any of his family. And that fact haunts me years later. Bob did not wake up from the surgery.

His family and his doctor all arrived at the hospital that morning to find him not in his room, but in the OR. He died in exactly the way he had decided he did not want to go, and no one got the chance to say goodbye.

Everything we did may have been medically correct. But that doesn't make it not wrong. We were all new doctors so eager to save lives that we never stopped to wonder if we were saving the person.

I wish I could tell his family I'm sorry.

I was a third year medical student on my surgery rotation at Cook County Hospital back in the mid-1990s when it was still in the old building. It was a chaotic mess. I was post-call and in clinic and saw a patient who had some type of intra-abdominal procedure and was in for follow-up. He lived in a trailer park on the far south side of the city, was poor as dirt, and clearly wasn't thriving post-op. He was dehydrated and we were concerned that he had a ileus (bowels weren't moving). I was told to admit him. I told the transporter to take him over to the surgical ward, but somehow forgot to write admission orders, so he went over with no paperwork.

He ended up getting put in a bed, and stayed there. For 3 days. With no paperwork. He got IV fluids and bed rest for 3 days, but because no admission orders went over, he never got entered into the computer system. He never showed up on our list of patients. The nurses just kept changing his IV fluids. He had no vitals, no nothing. Well, 3 days later we were on rounds, and walked past his cube (it was an open wall with cubicles at the time) and my senior resident stopped and said, "Who the hell is this guy?" The patient poked his head out, pointed at me and said, "Hi Doc! When can I go home. I feel great." He was completely better (probably because we did nothing to him). My junior resident whispered to me that I should just quickly (and quietly) write up admitting orders and discharge orders.

Two lessons: 1.) always do your paperwork/orders right away; 2.) sometimes the less we do to/for patients the better.

I am a nuclear medicine technologist working in a PET department. I deal mostly with cancer patients. Prior to exams, I'll ask the patients why they are having the test done and for any other vital information. One day, a female patient told me she found a lump, had a mammogram, a biopsy, and it turned out to be stage four invasive ductal breast cancer. Having confirmed the information I had on my sheet with the patient, I made the mistake of saying, "Sounds good." To which she replied, "No, it's actually pretty terrible," and she broke down in tears. I will never say sounds good again when a patient tells me his or her diagnosis.

If you work as a physician in any acute setting, don't dress up for Halloween. My supervising resident had to tell a family that their daughter had cancer while dressed as Cat in the Hat. (respectfully, he took off the hat.)

Myself personally, I lucked out. Considered starting medication for a young woman, gave her the script. 4 days later she found out she was pregnant. My prescription has clear teratogenic effects. I was sweating bullets. Fortunately, she decided against taking the prescription and I found out from our pharmacist that she didn't fill it. I left a message "don't take it!!" and she called me back thanking me for being such a great doctor. BETA HCG FOR EVERY GODDAMMED FEMALE WITHIN SHOUTING DISTANCE OF FERTILITY.

Edit: becsuse many people have commented on the Halloween thing, I think our hospital has it well figured out. I work in a children's hospital and what we do is take turns "trick or treating" (visiting kids and bringing treats while dressed up), for like one hour. So we get to have fun and wear costumes but we also don't do clinical work whole dressed up.

I'm a lab tech and used to work in Histology when I was new. I got a skin biopsy specimen and that day I was embedding , basically putting the fixed tissue into wax so it could be mounted on a cutting block to slice 3 micrometer sections for staining.
It's very important what side you place "down", based on how it was cut out of the body. Well I messed up and placed it sideways instead of down.
The person cutting the tissue couldn't tell and ended I'll cutting through the tissue.
This was a problem because the patient had skin cancer and they were looking at how far it had spread. Since it was cut too deep they couldn't see the edges anymore. This means the doctor had to cut a bigger piece of skin off to be sure they got it all.
That's when I found out it was a skin biopsy from the patient's nose. This patient had to have a bigger, potentially unnecessary, piece of skin from his face cut off because of me.
I was horrified and learned my lesson that day on how important it is to be certain of embedding technique.

I worked as an OR porter for a number of years to help me through school. I was cleaning up after an operation on an inmate who was Hep C & HIV+ and I was working quickly and recklessly. I stuffed the blue matting and used aprons into the garbage and as I pulled up from the garbage, blood was pouring from my hand.

Unseen and unknown to me, a doc or nurse had left a scalpel in the blue matting. It is/was so sharp that when it cut me, I didn't even feel it but I was bleeding profusely.

The nurses and docs jumped on it right away, cleaned and prepped my cut and got me on special meds right away. I had to get shots and check ups regularly for the next year.

Luckily, I was okay.

What I learned: work slowly and/or carefully especially in high risk situations. Complacency is your enemy.

I was a hospice nurse for 10 years. I admitted a patient with cancer who had intractable bone pain, with what I expected to be a week or two before he died, based on my assessment. In his case, the only medication that gave him any relief was morphine. His wife did a great job taking care of him and giving him his meds as we planned. It was very effective and the he was comfortable.

As he came closer to his death he was sleeping more, which is normal and expected, and a daughter flew in to be with him at the end. She went crazy that "daddy was on morphine" and raised so much hell that his wife freaked out and caved to her demands, revoked hospice and called the ambulance. When he got to the hospital, the daughter told them that he had taken too much morphine and the ER room doctor gave him Narcan. He came out of it screaming in pain, and didnt stop. He stayed in the hospital until he died, and he really suffered. It's been years since this happened and it's still the worst nightmare of my nursing career. There really wasn't anything I could have done because I spent alot of time teaching his wife what to do and what to expect, but I still feel bad about it.

A couple. I'll tell two - a funny one, and a non-funny one.

I was working as a pre-registration pharmacist in a community pharmacy based in a supermarket. A boy and a girl come in, nervous as hell, and step up to the counter. They're teenagers, probably 17-18 or so (in the UK age of consent is 16).

The boy asks "Can I have some condoms, please?"

I'm serving, and we keep the condoms at the counter. They come in packs of threes, tens, twenties. So I smile, try to be reassuring, but I need to know what they want.

"Sure," I say. "What size?"

The boy turns bright red, but his girlfriend nudges him. He starts estimating with his hands. "Uh... about...this long?"

---

Second story I'll never forget. I was in a cancer clinic, doing follow-ups. I'd just messed up a medicine choice (I was under supervision, so it was fine), and wanted to try and ask something smart to the oncologist. So we're in a consultation with a woman who'd had a mastectomy, and I asked the probability of recurrence of the cancer.

That was stupid. Because the oncologist then had to answer, and probably be very conservative, and scare the hell out of the patient. That really destroyed me. I felt like a total jerk.

I'm a Hospitalist - an internal medicine doctor that specializes in Hospital (inpatient) medicine.


I had a lovely but truly unfortunate lady. She was in her late 40's and had metastatic breast cancer. It had spread to her brain and actually to her intestine causing persistent bleeding. She was in an out of the hospital for about 2 months.


I knew she was dying. Her oncologist knew. I began talks about what to do if she got sicker and was nearing death. She wanted "everything". I was off and my partner took over. She eventually got sicker (which I 100% expected) was bleeding again from her tumor essentially coded, was placed on a ventilator and sent to icu.


It should never have gone that far. I should have made her DNR. She had no hope of survival. She should have had a peaceful death. Instead she was intubated and died in the ICU.


Families and patients get mad at me when I try and discuss "end of life goals" but this is the reason I do it. Despite patients getting ridiculously pissed at me for trying to address this important issue.

Med student here. A few years ago, when I was working as a medical assistant in an interventional pain management clinic, I was asked by the doctor to place a grounding pad (a sticky pad like they use for EKGs) on the patient's leg during a radiofrequency (RF) nerve ablation procedure. The patient had some lotion or something on her leg that was keeping the pad from sticking properly, but it seemed to be mostly well attached and I didn't want to hold up the procedure to get another pad or clean off the patient's leg. The pad ended up partially coming off right as the high-voltage RF was being applied, causing a small burn on her leg. There was no lasting damage done and the patient was very understanding, but I still felt horrible. It was the first time I had caused harm to a patient, and it could easily have been avoided had I just spoken up. Now I never hesitate to say something if I have even a slight feeling that something is off. Nothing is more important than a patient's well-being.

Pharmacist here. I was working alone on a Saturday. Just before closing, a woman brought in 19 prescriptions for her husband who was just discharged from the hospital. Then a swarm of people came in after her and I kept getting interrupted by people who refused to wait until the next day for their Xanax. One of the prescriptions was isosorbide mononitrate, a heart/blood pressure pill. It was written for half a tab daily, and I filled it with instructions for one and a half. It was a normal dose that I saw often and was well within the dosing guidelines, but it was too much for him. Several days later he was re-admitted for low blood pressure and the prescribing physician caught my error. I called his wife to apologize from my personal number as soon as I found out. She was so understanding. She saw how crazy things were for me and understood how stressful the situation was. I offered to pay for the out of pocket costs of the additional hospitalization, but she would not accept. Unfortunately he was a very sick man and died two weeks later of issues not related to my error. It could have been much worse, but it really made me realize that I hated retail pharmacy and the lack of help that puts so much strain on pharmacists. I quit as soon as I found another type of pharmacist job and I am so much happier. It haunted me for a while, but I was able to get over it.