I can still remember waking up to that phone call. The cordless phone had been left in my room, after a long night chat with a friend before heading to bed. The last few weeks had seemed peaceful compared to the prior eight months, when my home had been filled with an air of stress, worry, and the occasional tears. Things were finally getting back to normal. My grandmother had been diagnosed with myelomonocytic leukemia. We had been through eight long months of my mother’s constant worrying, visits to the hospital, the feeling of helplessness and “what ifs?” It finally seemed as if it would be over.

After being diagnosed with leukemia my grandmother underwent chemotherapy. Slowly but surely, the cancer went into remission and, to our delight, we found out that grandma could go home. However, soon after, my grandmother also developed pneumonia. A side effect of the chemotherapy was a weakening of her body that made it harder for her to fight off infection. And as a result of the pneumonia, she was sent back to the hospital to make sure she was treated with antibiotics that would stop the infection.

Day after day she improved and finally they said she was to be released that Monday.

The phone rang very early that morning. The sun hadn’t even risen yet. The ringing startled me out of a peaceful slumber. In the darkness, without my glasses on, I fumbled for the telephone.

“Hello?” I mumbled, rubbing the sleep out of my eyes.

My grandfather’s voice came through the other end. He sounded tired, but it still hadn’t hit me how early it really was, and how odd it was that he’d be calling at this hour. It was almost a quarter till four.

“Mandy, it’s your grandpa. Can you get your mother for me?”

I slid out of bed and groped blindly for my glasses. I glanced to the clock, finally realizing the time. Suddenly I was no longer tired and a familiar feeling of fear gripped at my chest. Something was wrong, and I had a good idea what it was.

I entered my parent’s room, where my mother was still sleeping. There was no way the phone would have woken her, since she’s partially deaf, and my father was working nights at the time. I slowly nudged her awake and held out the phone as she sat up, rubbing her eyes, as groggy and half awake as I had been.

I stood in the doorway of my bedroom, the door left open a crack in order to hear the conversation my mother was about to have. I prayed it wouldn’t be what I thought it was, but as my mother finally put her hearing aids on and answered the call I knew there was no use praying anymore. My mother’s voice changed from her usual cheery tone to one of sorrow and disbelief.

“She what? She’s gone?”

As my mother made her way into the kitchen I crept down the hallway. She was in a state of shock. My father came home from work not too much later, and comforted my mother as she cried.

Later that day, after a few more restless hours in bed, I finally learned what had happened. My grandmother had suffered a severe seizure and had gone into cardiac arrest. Although she was immediately given CPR, they were not able to resuscitate her. It was just a day before we were expecting to welcome her back home as a survivor. Now she was dead. Just like that… gone. There would be no happy homecoming.

Everything had happened so fast, and none of us really knew what had gone wrong. The doctors didn’t know the cause of death, so my grandmother’s body was sent to the coroner’s office for an autopsy. Our whole family was taking things rather hard. It was one thing for grandma to lose her battle with leukemia and pass away. It was another for her to be ready to head home, and then suddenly be gone. We were confused, but we were also angry. But who were we supposed to be angry at?

When the coroner’s report finally came back, we were even more confused than before. It was the coroner’s opinion that my grandmother had died of “natural causes.” The coroner had previously thought my grandmother had an allergic reaction to the drug she was being given, Amphotericin, but ruled that out because my grandmother had been taking the medication at home. Also, no allergic reaction was demonstrated during the autopsy. The coroner then decided that the drugs, along with her pneumonia, could have caused a seizure which would make the course of events a natural process. As the report put it, “the drug alone would have been unlikely to cause a seizure without the pre-existing heart and lung diseases.” And that was that. The death was ruled a “natural process,” and we were told to bury my grandmother and go on with our lives.

You would think it would end there, but it didn’t. My aunt Beth was not satisfied. She contacted a friend of the family who was a doctor and explained to him the series of events. Alarms went off right away for him, and he was skeptical. He advised my grandfather to contact an attorney specializing in medical malpractice, and it soon became apparent that this was far from over.

Our family attorney then sent a sample of the blood from the hospital to an outside toxicology lab in Texas because none of the labs in California wanted to be involved in a lawsuit. What the lab ended up finding both shocked and angered us.

The hospital had been administering two different antibiotics to combat my grandmother’s pneumonia. The lab found that for my grandmother’s weight the maximum safe dosage for the antibiotic Abelcet would have been 350 mgs at a time. This would have shown a blood level of 5 mgms/kg. For the second antibiotic, the Amphotericin, the maximum dose recommended as a “desperation dose” would have been 88 mgs, which would have left a blood level for that drug at 1.25 mg/kg. The blood analysis showed that the hospital had administered 350 mgs of the second antibiotic. The tox-scan revealed that the blood level found in my grandmother was 5mg/kg– over four times the safe dose for that antibiotic.

It was not my grandmother’s frail state combined with antibiotics that had killed her. My grandmother’s death was not of “natural causes.” They made a mistake, and my grandmother paid for that mistake with her life.

There are many people who think that something like this could never happen to them or their family. I was one of those people, but I was mistaken. It can happen, and it does happen, more often than people may think.

According to the Institute of Medicine, nearly 44,000 Americans die each year as the result of medical errors. In two large studies, one conducted in Colorado and Utah and the other in New York, findings showed that “adverse events,” or medical errors, occurred in 2.9 and 3.7 percent of all hospitalizations. In Colorado and Utah, 6.6 percent of these mistakes led to death. The number was even higher in New York, where it rose to 13.6 percent.

Therefore, according to this information, more people die as a result of medical error than motor vehicle accidents (43,458), breast cancer (42,297), or even AIDS (16,516).

This doesn’t mean that all of these mistakes could have been prevented. In fact, in both of the studies it was found that only half of the deaths from medical errors could have been prevented.

Medication errors may be the hardest to detect, as they were in my grandmother’s case. The effects that medication overdoses and improper prescriptions can cause may often look like natural causes of death. Medications account for one out of 131 outpatient deaths and one out of 854 inpatient deaths. These errors occur often in hospitals, and though not all errors may result in harm or death, those that do are costly.

One recent study at two acclaimed teaching hospitals found that 2 percent of patients experienced a preventable medicine-related error. These mistakes resulted in the average hospital costs increasing by as much as $4,700 per patient, or about $2.8 million each year for a hospital with at least 700 beds. If you apply this finding to the rest of the country, the costs of medicine errors alone run about $2 billion per year nationwide.

But of course there are other severe costs to these mistakes that can’t be gauged in dollars. Many people, as I did shortly after my grandmother’s death, lose their trust in the medical field. People grow up learning to believe in their doctor’s opinions. They are taught that doctors know best, and that they are safe in the hands of medical professionals. However, people need to know it is not always the incompetence of their doctor that is to blame for these mistakes. Doctors and health care professionals are also frustrated with the lack of coordination that leads to these accidents in the health care system.

The current health care system is very decentralized, which makes it difficult for different doctors and sections of the system to communicate with each other. Many people received medical care from a group of loosely affiliated health care organizations and providers. The lack of efficient communication between them prevents access to complete information about a patient’s current treatment and needs. This miscommunication results in mistakes, and also hampers efforts to improve the safety of patients. You can improve the flow of important information in one section of the system, but that improvement will never reach the other providers. Uncoordinated care makes it easier for something to go wrong. It also blurs the lines of accountability. The Institute of Medicine believes sufficient pressures must be made to make preventable errors costly to health care organizations and providers, compelling them to make efforts to improve safety. In California there is a $250,000 limit on malpractice claims, which hospitals usually settle out of court. Though it may seem like a lot of money, that is the maximum penalty a hospital can be charged, with most malpractice suits bringing in much less. With malpractice insurance and other safety nets, that’s chump change.

The internal problems of the health care system are not unknown to those inside the system, yet very little has been done to change it. Many people who have been involved in a malpractice suit continue to blame the individual instead of the system, and must begin to realize that blaming a single person does nothing. More needs to be done to make the system as a whole function better so that communication of how mistakes happen becomes easier, making it easier to prevent repeating those mistakes. Individuals must still be held responsible for their carelessness, but heath care providers need the resources to learn from the mistakes of others.

My grandfather stood over my grandmother’s casket during the viewing, looking down on her. He slowly removed her glasses from her face, folded them, and tucked them into the pocket of her dress.

“She doesn’t sleep with her glasses on.” I don’t remember much about the funeral itself. It was the first time in my life I’d ever hated the sun. The brightness of the sky didn’t match the darkness inside my heart.

Since my grandmother’s death, my feelings toward hospitals have still not quite recovered. But it is no longer a feeling of blame and hatred, but more of a loss of innocence. I often wonder if there are other people out there who don’t know mistakes were made. Sometimes I wish that we would have never found out, but I know it’s better that we did. I hope that improvements will be made, that mistakes will be prevented, and that no one else has to wake up to that phone call.