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Friday, January 12, 2007

His Handwriting Could Be on our Wall: Overdose lawsuit

On Wednesday I described the chemo overdose that took the life of Armando Castellanos. Two features of his story are especially troubling: His family wasn’t told of the error. And his story is almost untold.

In the days following Castellanos’ death, the medical center was knocked not just for the medical error but also not alerting his next of kin about the Cisplatin overdose on Aug. 12 until just before he died. Medical personnel reportedly discovered the mistake — 500 mg instead of 50 mg — but stayed mum while Castellanos’ health declined. In the end, his family was informed of the dosage before they removed him from life support. The hospital did not inform the Coroner about the overdose, though the law requires the Coroner to investigate all questionable deaths in the county.

Second, Armando’s story has been reported only in his hometown newspaper. We need to tell his story more widely, to give each victim a name, to honor him, and learn from this error to protect ourselves. The Japanese quality improvement experts say, Every defect is a treasure. We say, Amen, and each person is a treasure. If we don’t learn from his story, we’ll be condemned to repeat his experience….

Advice: Get an advocate who can help you know if an error is occurring, and help you handle it.

Tell his story.

Read Michelle Durand’s newspaper story.