Night Shift Nightmare
After dark is prime time for fatal hospital mistakes. How to protect yourself.

By Max Alexander
From Reader's Digest
June 2007

Something Has Gone Terribly Wrong

It's midnight in Charleston, South Carolina, and something has gone terribly wrong in room 749 of the Medical University of South Carolina Children's Hospital. The patient, Lewis Blackman, is a 15-year-old boy recovering from surgery to correct a relatively common birth defect called pectus excavatum, or sunken chest. The condition is not life-threatening and never seemed to slow Lewis down. A whiz in every school subject, he acted with the South Carolina Shakespeare Company and, at age seven, appeared in a long-running TV commercial for Sun-Drop soda with Dale Earnhardt. But a sunken chest can sometimes lead to respiratory difficulties, so Lewis and his parents decided to go for a minimally invasive surgical correction: inserting a metal strut to support the breastbone.

Three days after the surgery, Lewis should be feeling better. Instead, despite doses of a powerful painkiller called Toradol, the boy is racked with agonizing pain -- "five on a scale of five," he pantingly tells his mother, Helen Haskell, an archaeologist. Oddly, the pain seems centered in his abdomen, not his chest. Nurses are certain the boy is suffering from gas, a diagnosis reinforced earlier that evening by Dr. Craig Murray, the chief resident on call. Dr. Murray had stopped by and prescribed a suppository for what he believed was probably constipation, a common problem after surgery.

"I had no idea what to do," recalls Helen. "They're all saying it's the same thing, and they're the experts, so they must be right. But at the same time, I didn't see how they could be right."

As the night wears on, Lewis grows weaker. His heart rate climbs to 142 beats per minute (normal is 60 to 100), and his temperature drops to 95 degrees. His eyes are hollow, his skin is pale and he's sweating cold buckets. Helen is terrified, but because it's the night shift, there is not much she can do. Dr. Edward Tagge, who performed the surgery, is not available. Nor, it seems, is any other veteran doctor.

"There was no one around," she says. "It was very lonely, and almost surreal, like we were laboratory rats. I just sat there in this universe of my son's pain." Neither Lewis nor Helen sleeps all night.

Morning finally dawns, and with it the usual frenzy of the day shift, as surgeons, lab workers and administrators hustle into work, and patients with scheduled procedures file through the doors. At 8:30 a.m. nurses can't get a blood pressure reading from Lewis. They spend two hours trying different machines. By noon, Lewis is extremely pale; the color is draining from his lips. "It's... going...black," he tells his mother. Helen calls for help, and Dr. Murray, the resident, returns. "Lewis! Lewis!" he shouts.



Scary Statistics

There are many reasons to feel anxious when entering a hospital. In April, a HealthGrades study showed that some 248,000 patient deaths over a three-year period were preventable. What's less widely known, at least to the general public, is that mistakes tend to multiply on the night shift. You won't find it in any hospital brochure, but within the medical world, the dangers after dark are well known.

A 2005 study of 3.3 million births in California found that babies born late at night were 16 percent more likely to die than those born in the daytime. Other recent research found that patients going into cardiac arrest at night were more likely to die. In a review of pharmacy and patient records, significantly more medication errors were made at night. Daytime deaths can also be attributed to nighttime hospital errors: An analysis of 15 pediatric intensive care units found that kids admitted to the units at night were more likely to die within 48 hours.

Weekends can also be dangerous; a long-term study released in March showed that heart attack victims admitted to New Jersey hospitals on the weekend were less likely to receive lifesaving angioplasty treatment, and more likely to die within a month.

What's going on? Given that the vast majority of hospital workers care deeply about their patients, why has the night shift become so risky? Some reasons are statistical. Nighttime surgery, for instance, is performed only on high-risk, acute-emergency patients, whereas scheduled operations like hip replacements carry a lower risk of complications.

Another key reason: skeleton crews. You're not likely to see many top surgeons and specialists wandering around hospital hallways at four in the morning. And it's not just doctors who are home sleeping. "At night you have fewer resources in mental health, social services, directors and administrators," says Michelle Coner, a registered nurse at the Codman Square Health Center in Boston. "There are just fewer people to bounce things off."

Fewer people, and less experience. Since workers with seniority tend to get first dibs on the daytime positions, the night shift is often staffed with newbies -- right down to the nursing assistants and lab technicians. You have to learn sometime, and more often than not, on-the-job training happens in the middle of the night.

When you add to this mix same-day surgeries and tightwad insurance plans that have driven the not-so-sick out of overnight stays, who's left? The really sick.

"It used to be, people could stay a few days after they felt relatively well," says Barbara Williams, a nurse at Dominican Hospital in Santa Cruz, California, with 15 years' experience on the night shift. "Now they are sick the whole time, and they require a lot more pain management, IVs and other assistance. Patients have called 911 from their beds because they thought nobody was there."



"Falling Asleep at Every Traffic Light"

Less-than-conscientious workers find it easier to go unnoticed at night. Cornell Morton, a mechanic who suffered disfiguring burns over 35 percent of his body in 2003, spent more than three months in a burn unit at a Houston hospital. He remembers one night nurse roughly waking him, which was especially painful because of his excruciating condition. Adding to his anxiety was the burn unit's policy of no overnight visitors, so he could not be comforted and protected by his wife. "I was totally paranoid every evening, dreading that nurse would walk through the door."

Another factor contributing to night shift errors is the military-style hierarchy of the medical establishment, which discourages advocacy by underlings. Night staff are often loath to wake up a senior physician if they have a concern about a patient. Helen Haskell says it was her impression that as Lewis's condition clearly worsened, "residents and nurses were hesitant, to put it mildly, to disturb anyone who was not at the hospital. This included the so-called chief resident, of whom the intern was clearly terrified. The chief resident, actually a senior resident on his pediatric rotation, was apparently equally determined not to disturb the attending physician."

Says Nurse Williams: "I would never have a problem calling someone. I figure it's the patient that matters. But some people are more timid by nature, and more hesitant. And if they have less experience, they often don't know when they should be calling."

Finally, fatigue is a major contributor to night shift errors. Hospital staffers work notoriously long hours -- 24-hour shifts and 80-hour work-weeks are common for residents and interns -- and fatigue tends to be worse at night. Last September, for example, a Harvard Medical School study showed that interns on the night shift injured themselves twice as often as those working during the day.

Researchers also found that people who had worked 24-hour shifts had the equivalent performance level of someone with a blood alcohol content of .10 -- legally drunk.

A retired obstetrician who did not want his name used remembers harrowing commutes after long hospital shifts: "I recall falling asleep at every traffic light on the way home. The cars behind me would honk to wake me up. My feeling is that no one in hospitals, including administration staff, should work long hours that will in any way compromise the health of patients. I believe the health industry is behind other industries in this respect."



A Frightening Place

Even in the finest hospitals, with topnotch surgeons, the night shift can be a lonely and frightening place. In late 2003 journalist Melinda Henneberger was recovering from breast cancer surgery in a special ICU ward at UCLA Medical Center. "My husband wanted to come with me, but I finally persuaded him to stay home, thinking how much scarier it would be for our two kids if we were both gone," she remembers.

"But my best friend, Mary, did fly in from Oregon, and thank God she did. I was on the table for 12 hours, and when I came out, they put me on a morphine drip. Nauseated, I'd start to vomit, then choke. I was thirstier than I'd ever been, but I couldn't drink anything. Mary was there to feed me ice chips and hold me up when I choked. A few times, we pushed the button for help, but no one responded for quite a while. Sometimes they never came at all. If I'd been on my own and choking, I'm not sure how I would have made it through the night."

A spokesperson for UCLA says that the hospital "assigns one nurse for at least every two patients in the ICU both night and day."

Melinda says that the night shift staffers at UCLA were kind and caring but appeared to be overwhelmed by patients needing attention. "I could hear other patients crying out for help that didn't seem to come," she recalls. "It was horrible listening to them."

Amazingly, later in the week, when Melinda was able to move around, she stayed up at night feeding ice chips to another patient. "It took me half an hour just to get across the room. I was still in a great deal of pain and moving pretty slowly," she recalls. "The whole thing was Dante-esque. My advice to anyone going in for surgery anywhere would be, By all means, get somebody to stay with you through the night."

"Lewis! Lewis!" Back in room 749, Lewis is "coding" -- medical slang for going into cardiopulmonary arrest. Finally, the hospital responds with its full resources. Staffers flood the room, and 11 physicians descend on Lewis, frantically trying to stabilize him. Helen, joined by her husband LaBarre Blackman, a retired teacher, and their young daughter, Eliza, "stand in the hall in disbelief, watching this scene as if from a bad TV movie," Helen later writes in her diary.

Helen is terrified that Lewis has suffered brain damage, but she is utterly unprepared when lead surgeon William Adamson calls her into a room. It is 1:30 in the afternoon on November 6, 2000. Dr. Adamson introduces himself and says simply, "We lost him."

"I had no idea he was near death," says Helen. "We brought in a perfectly healthy child." An autopsy revealed that Lewis had bled to death internally from a perforated ulcer, which was likely caused by the painkiller Toradol. By the end, much of his blood had drained into his peritoneal cavity. A more experienced doctor -- especially one familiar with the dangerous side effects of Toradol -- might have recognized the symptoms early enough during the night to save him.



Promoting Teamwork and Communication

The Medical University settled for $950,000 without a lawsuit. A portion of the money was plowed into Mothers Against Medical Error, an activist group founded by Helen, who now works full-time as a patient advocate. Her efforts led to the passage, in 2005, of the Lewis Blackman Hospital Patient Safety Act, which requires all physicians in South Carolina to wear identification describing their rank. Hospital staffers must also call an attending physician if a patient asks. "It would be hard to do anything else," says Helen of her ongoing patient activism. "You're sort of driven by the Furies."

Fatal hospital mistakes on the night shift cost lives, careers and millions of dollars in legal fees, boosting health care costs at a time when many Americans can barely afford to get a cavity filled, let alone pay for necessary surgery. So several schools, including those at Villanova University and the University of Florida, are developing computer analysis programs that allocate nursing staff where they're needed most. Other experts are grappling with the medical establishment's lumbering hierarchy, considered by many to be outdated in a time when life-and-death decisions must be made with lightning speed.

Instilling the value of teamwork begins in medical school. At the University of Minnesota, the schools of medicine, nursing and pharmacology are all on one campus to facilitate interaction. The students participate in simulated high-risk scenarios set up like contests. "To succeed, they have to know what the other people on the team are doing, and how to communicate," says Dr. Carol Ley, chairman of the University of Minnesota Medical Center's board and director of occupational medicine at 3M Company. Dr. Ley has firsthand experience with medical error: Her seven-year-old daughter, Jacquelyn, could have died after a morphine pump was mistakenly set too high. It happened during the night shift, following surgery for a shattered elbow; fortunately, Dr. Ley, spending the night in her daughter's room, noticed Jacquelyn was barely breathing. She puts it bluntly: "The night shift, with its hand-offs and staffing issues, is prime time for medical error."

In South Carolina, the Medical University recently endowed a professorship called the Lewis Blackman Chair of Patient Safety. The first Lewis Blackman professor is an expert in simulation training who will oversee a center at Greenville Memorial Hospital, where Lewis was born, as well as six others. Dr. Jerry Reves, dean of the college of medicine at MUSC, says the new program is a bold statewide initiative that will train medical students and nurses to manage simulated crises. "It's a fundamentally different way of approaching medical education," he says. "The old way was, See one, do one, teach one. This way, you don't get out of it until you've proven you can actually manage it, even if it takes a hundred times."

In Houston, burn victim Cornell Morton is making slow progress. "But my balance is still off, and I feel like an arthritic person," he says. Four years after his accident, he continues to live the nightmare of the hospital night shift. "I'm in bed at nine and up by midnight, usually for three or four hours," he says. "I haven't slept five hours straight since 2003."