Medical errors that have happened to me – 1

I had an appointment with a urologist as a routine follow up to having been treated for prostate cancer two years ago. My treating doctor was in another state and this local urologist had been recommended.

After checking in, the receptionist told me I would be seeing “L”. I assumed L. was going to take my vital signs – he never did – but when he introduced himself as a physician’s assistant, I asked if I was indeed going to see Dr. F, with whom I had made the appointment. He said no, Dr. F. wouldn’t be back until the afternoon. He was surprised because he said it was their policy for new patients (like me) to be seen initially by the doctor.

I have written before about error cascades. There is the initial error (scheduling me when Dr. F was not there), the possibility to detect the error (both the receptionist and L. detected the error) and the recovery – to tell me to come back in the afternoon when Dr. F would be there! The recovery failed.

Things got worse. They wanted to increase the frequency of PSA testing and also test me for testosterone. It just so happened they have their own physician’s office immunoassay analyzer – with a limited menu – but does include assays for PSA and testosterone. I didn’t let them draw my blood and I won’t be back.


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