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| Shapiro, Washburn & Sharp

A doctor’s preventable mistake at Tufts Medical Center spotlights a lesser-known cause of potential deadly hospital errors: cognitive bias.

The Boston Globe recently reported the story of a woman who died at Tufts after a procedure to relieve pain from back injury. A report filed by Medicare investigators determined the woman died because she was injected with a dye that was not intended to be used inside the spine.

The doctor ordered one dye, but the pharmacy didn’t have it so it substituted it with another dye. Despite a label on the substitute dye clearly stating that it should not be injected into the spine, the doctor used it.

The patient suffered severe pain and seizures and ultimately died the next day. The doctor admitted the mistake immediately, telling the woman’s sons he injected the wrong dye. Although he said the nurse handed the dye to him and he used it without checking the label, hospital executives paint a slightly different picture. They say he did look at the dye, but instead of seeing what it actually was, he saw what he expected to see: the dye he ordered. Of course, this does not excuse his mistake, but it does explain it. This doctor’s mistake is what researchers refer to as “cognitive bias” or “confirmation bias”, and it causes more hospital mistakes than those outside the research field realize.

Cognitive bias and confirmation bias contribute to medication errors and surgical mistakes, but they contribute even more so to diagnostic error, which is the primary cause of preventable patient deaths. Our brains have created cognitive bias as an adaptive technique to quicken our decision-making ability in familiar situations. The obvious problem when applying this normal part of brain functioning to the medical field is that many cases that seem familiar may in fact be distinct. Failing to thoroughly assess a situation, putting aside what a doctor suspects or even assumes is the problem, medication, or procedure, would reduce medical errors and save lives.

Researchers believe the best way to reduce cognitive bias is to employ safeguards against doctors’ misperceptions. Diagnostic errors could be reduced through enhanced requirements for second opinions and decision-making protocol to make sure the diagnosis is based on facts and not assumptions. Medication errors could be avoided by following protocol already in place at most hospitals to have more than one person check a medication before administering it – both for accuracy and potential adverse reactions – will reduce these preventable mistakes.

Our firm has successfully represented clients who were seriously injured by medication errors, so we know that reducing preventable medical errors is in every patient’s interest. We may never eradicate cognitive bias in medicine, but if we were capable of creating this useful cognitive tool, surely we are also capable of creating new tools to override bias when it is potentially harmful to others.

Unbelievably, the doctor’s immediate apology did not prompt the hospital to act quickly to provide compensation for the woman’s family. Eight months after the death, Tuft’s malpractice insurer sent the family a letter denying that the hospital or its staff was negligent.

It is a shame that the hospital has not admitted fault, and then it can pursue an action over against the pharmacy for the egregious error outlined above. It is preventable malpractice errors like the one, that require the civil justice system to kick in as a sanitizer. We wish the best of success to the family who expected more of the medical care system and was extraordinarily let down.



  1. Gravatar for Barbara A. Cross
    Barbara A. Cross

    If you were the Attorney for this clients' family how would you proceed? If the institution does not admit blame, what is the legal recourse?

    1. Gravatar for Rick Shapiro
      Rick Shapiro

      Interesting question. Suit would be filed against the doctor, the hospital and possibly the pharmacy also.

      Evidence would be developed that the medical standard of care was violated by the physician, and the hospital may be liable if the hospital personnel ordered the dye and failed to detect that it was the wrong one. And, last the pharmacy may or may not have liability, but details would need to be developed on the labeling and whether it was in a position that hospital staff or a doctor should have appreciated the substituted dye.

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