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Sunday, December 31, 2006

The Machine Was the Perp: Wrong drug errors

Most American hospitals place automated drug dispensing cabinets on the patient floors, to enable nurses to give drugs to patients more promptly. Usually this is a good thing, but the convenience comes with an awful high hidden price.

The families of six premature babies, and hospital staff, have learned that grim lesson. The babies were being cared for in the neonatal intensive care unit of an Indiana hospital. The NICU was equipped with an automated drug dispensing machine--imagine a candy machine that requires a nurse's password instead of money to activate. A pharmacy technician had stocked it with the ADULT doses of heparin, a powerful blood-thinner meant to prevent blood clots that could clog intravenous tubes. Then, over time, as nurses opened the cabinet's drawer to get heparin for their preemie patients, they took the adult heparin, and gave it to six different preemies. Three of the babies died and three remain in critical condition.

Advice to hospital pharmacy directors: Store hazardous medications in the pharmacy, not in the automated dispensing machines, to prevent multiple errors.

Advice to parents: Check the label of each dose of medication your family member receives. In choosing a hospital, ascertain whether hazardous medications are stored in automated dispensing machines. A patient advocate may be useful for this purpose.

Read another of our stories about a drug error lawsuit, or read more about this one in "Family of 3rd preemie to die of overdose speaks" and "Drug Error Triple Tragedy in Indiana."

Saturday, December 30, 2006

Your Spine Can Be their Profit Center: A surgical error lawsuit

Patricia Kennedy's back hurt so much that she looked for a surgical solution. A spine surgeon in Philadelphia performed a disk replacement operation in late 2002. The surgery was not successful; indeed, Patricia says her condition is even worse now. The former competitive skater says she has gone from taking Tylenol to morphine for her pain and can no longer work for a living.

At the time she chose surgery, she did not realize that the replacement disk was experimental. She is suing both her surgeon for malpractice, and the manufacturer of the ProDisc for product liability. Her case will go to trial in March 2007. Adding insult to injury, the surgeon had not told her that he was a part owner of the device maker. This gave him--the lead researcher on a study of the ProDisc's effectiveness--an incentive to recommend and use the replacement disks, and to report favorably on them. "I'm filling out a questionnaire and saying that my pain level is an '8' on a scale of one to 10," with 10 being the worst, Kennedy says. "And my doctor is writing down that I have 'mild pain.' I don't think so," she says in Melissa Davis' TheStreet article. "I've really been guinea pigged and betrayed," she told Reed Abelson, as reported in today's New York Times.

Advice for patient advocates: Ascertain the success rate of that type of surgery, from that surgeon, before you let someone go under the knife. Ask the surgeon's office, or the vendor, whether the surgeon has a financial stake in using the device.

Friday, December 29, 2006

When No News Isn't Good News: A medical error

Heather Kubiak has finally reached a resolution of her case. Ms. Kubiak, a mother of four, lives with her husband and kids on the western coast of New Zealand. The medical error that affected her affects many others too: an urgent message in her hospital medical file was misplaced. As a result, her breast cancer was not detected for another year and a half. By that time, the cancer had grown, and she had to have both breasts removed. Now, two years later, she has received a small settlement from the hospital, whose investigation acknowledged it had been their fault.

Advice for patients: Make sure you learn whether your mammogram was positive or negative. Don’t assume that no news is good news.

Read more about Heather’s story, or read one of our recent news items about early detection.

Thursday, December 28, 2006

He'll Be Back Playing Football in the Fall: Surgical error

His mother says about her son Jimmy, "His whole life was in a team uniform," first baseball at age 4 and then football at age 7. And he was good--he'd won his local Punt, Pass and Kick competition as a child. Then at age 15 he had a bicycle accident that required outpatient knee surgery. He was told he'd be back on the football field in the fall. But he developed a staph infection, probably from a dirty surgical instrument or doctor or nurse who didn't wash their hands thoroughly enough.

MRSA (Methicillin Resistant Staphylococcus Aureus) and other bacteria had invaded his blood, bones and joints. His treatment has involved massive amounts of Vancomycin and other antibiotics, physical therapy and multiple operations. He requires bone grafts from his hip and heel to replace the lost bone damaged by infection. Now Jimmy Toolen can't go to school, and needs a cane, walker or wheelchair to get around. The hospital infection has also damaged his mother and father's health, and has wrecked them financially.

His mother Lisa Toolen has worked hard to support a state law requiring the disclosure of hospital infection rates in South Carolina. Efforts like hers have persuaded 16 states to pass some form of public reporting law. She has told her story to the Consumer Reports organization, which is collecting these stories.

Advice for parents: Tell your story loud and long, here and elsewhere. Join with other victims' families to get laws passed to reduce hospital infection rates.

Read more in articles by Robert Kittle and David Hutchins.

Tuesday, December 26, 2006

The 10-Week Medication Error, continued: A look-alike drug error

To prevent look-alike drug errors like the one that afflicted Donna Ulliman, pharmacies should make similar drug names look different. For example: meTHIMazole and meTOLAzone look very different. Compare that to the CVS computer screen, where METHIMAZOLE and METOLAZONE look somewhat similar. Pharmacies could also use different typefaces for different syllables of the drug name, e.g., by using the Tallman font.

Read our earlier posting on this.

Monday, December 25, 2006

Lawsuit on Look-Alike Drug Error

In June, 2005, Donna Ulliman presented to the CVS pharmacy in Xenia, Ohio, a prescription for the drug Methimazole (used for thyroid conditions), as she had done regularly for almost a year. This time, instead of Methimazole, the pharmacist dispensed the drug Metolazone. Metolazone is a powerful diuretic (that is, it makes you pee). Ms. Ulliman didn't notice the error and took the meds for ten weeks, causing her potassium and electrolytes to drop to dangerously low levels. The effect of low potassium and electrolytes led her to experience heart problems. The medication error was discovered at an emergency visit to her physician. Although Ms. Ulliman did not die as a result of the error, it was a very close thing.

How it happens:
To save pharmacists time, the pharmacy computer has been programmed with a feature called AutoComplete. When the pharmacist types the first few letters of the drug name, the names of several similar drugs appear on the computer screen, and the pharmacist clicks one of them. Here, the pharmacist clicked on the wrong drug.

Advice to pharmacy customers: Read the drug name closely when you pick up your prescription!

In a post soon, we'll describe a way pharmacies can prevent most errors like this one.

Read the lawyer's brief (the source of this story) or the thoughtful blog posting by Ms. Ulliman's lawyer about CVS' standard operating procedure for handling their medication errors.

Sunday, December 24, 2006

Teens Raiding Medicine Cabinet: The wrong drugs

Many teenagers are abusing prescription drugs like Vicodin, oxycontin, and others, according to the recent annual "Monitoring the Future" survey.

Advice to parents of teens: Go to your medicine cabinet, and discard the prescription meds that you're no longer using, down the garbage disposal. This might even save the life of a younger child like Saleem.

Thanks to John Walters of the Office of National Drug Control Policy for this tip. For more, see Christopher Lee's story reprinted in the Boston Globe on Dec. 22.

Saturday, December 23, 2006

A Medical Student Victim: A surgical error

When I was in the first semester of my freshman year of college, I had laser hair removal done on my upper lip by my dermatologist, and the laser severely burnt my skin. I stupidly trusted my doctor, who told me that my skin may be a little pink after the procedure, but it should fade by that evening. Of course the fine print said "scarring, death, etc." as it always does. So of course I was aware of the "risks". But every release form warns of the worst, doesn't it? And I didn't fail to disclose the use of photosensitizing agents, tanning, or medical conditions; nor did I fail to disclose a propensity to develop keloids (a special type of scar which results in an overgrowth of tissue). I had no idea I had such a propensity. What upsets me is not that I was burnt (which probably was faulty laser settings, due to the fact that the procedure hurt BADLY. And I have hereditary pancreatitis, so I know pain. This laser HURT. I almost asked her not to do the other side!)

The wound healed as a keloid scar, and my dermatologist paid for cortisone injections, which were administered by a local plastic surgeon, and then for removal of the keloid. I had to treat the scar night after night after night, had to endure painful injections and more than one surgery.

Advice to patients: Be sure to research the risks of surgery yourself, beforehand. And try to find a doctor like the one Blogger Kim hopes to be—-one who knows how patients feel, perhaps from their own experience as a victim.

Read another story of surgical error.

Friday, December 22, 2006

Dr. Speedy: A surgical infection

On Dec. 6, I had ankle ligament reconstruction surgery. Two days post-op, I returned to the doctor and had dressings changed and was told -- in my 45-second consult -- that all looked well. In the proceeding days, the pain in my ankle became more intense. I contacted the physician and was told to keep it elevated and continue on the pain medication. When I returned to the doctor nine days post-op, the ankle was red and swollen. The doctor said that I had cellulitis. I said, "Oh, it's infected." His response, "No, cellulitis." Now, I'm no doctor but isn't cellulitis an infection caused by bacteria? In my drug-induced euphoria, I didn't argue. Now the doctor isn't too concerned, except about his good name, I'm sure. I, however, am coming up on two weeks off work, which has implications for me. So I sit here with my foot above my heart taking an extended course of antibiotics.... - Julie's story, Dec. 20.

Advice to patients: Slow down Dr. Speedy by asking some prepared questions: How would we know if this wasn't healing well? What is the most common complication after this kind of surgery?

Wednesday, December 20, 2006

A Tired Nurse’s Fatal Medication Error

Jasmine Gant was a teenager, about to give birth in a Milwaukee hospital’s Labor and Delivery unit during the July 4 holiday. Her nurse had worked at the hospital for 13 years, receiving good performance reviews. The nurse worked two eight-hour shifts back to back the night before, ending at midnight, and then slept at the hospital for a few hours before starting work at 7 am.

She took several medications from a storage area, including an epidural, though the doctor had not yet ordered it. She placed the medications on a counter, where another nurse placed a bag of penicillin ordered from the pharmacy. Both medications were in clear plastic mini-bags, with the name of the drug printed on each bag. The epidural medication also had a bright pink label. The nurse spiked the bag she thought contained penicillin into an IV line into Jasmine's arm. However, it was the epidural medication, which is to be administered into the spine, not intravenously. Jasmine had a seizure—a severe adverse reaction. The nurse pulled the medication tube out of the IV and a Code Blue was called. Efforts to revise Jasmine failed, and an emergency cesarean section delivered the baby, who survived.

Type of Errror: Wrong drug, and wrong route

Lesson for Patients & Advocates: Check the label yourself before allowing anyone to give you medicine.

We’ll revisit this later this week. Or you can read more now from the newspaper story or at the AtYourCervix blog posting of Nov. 25.

Readers: Do you have a story to tell?

Monday, December 18, 2006

Advice from a Pilot-Widower - Choosing your surgical team: An anesthesia error

Martin Bromiley is an airplane pilot, the father of two young children. His deceased wife Elaine had long suffered from chronic sinusitis, an inflammation of the nasal passages. Then, early in 2005, one of her eye sockets had become infected. The threat of permanent damage to the optic nerve led her surgeon to recommend a minor operation to straighten the inside of the nose - a possible contributory factor.

Unfortunately, during the operation, she was deprived of oxygen. It appears that moments after being sedated, Elaine's airway collapsed, preventing adequate levels of oxygen from reaching her brain. Though potentially an emergency, the event is a recognised risk during an anaesthetic and, as such, should be manageable. Surgeons and anaesthetists are drilled to follow a series of steps at this point - beginning with a non-invasive attempt to get the patient breathing normally, and ending, as a last resort, with an emergency surgical procedure. This is usually a tracheotomy - where the surgeon cuts through the windpipe, inserting a tube directly into the airway through the throat.

At first the drill was followed impeccably. But then a problem arose: the surgical team tried to get a tube into the airway to help Elaine breathe, but encountered some kind of blockage. According to the drill, this was the time to consider doing a tracheotomy. But the three physicians appear to have made the sort of human error that is horribly common in crisis situations. They became fixated on what they were doing. They also appear to have ignored the junior staff and remained intent on finding a way to insert a tube into the airway. More than a half hour passed before adequate oxygen levels to the brain were restored. Significant brain damage resulted, and she died less than two weeks later, soon after life support was withdrawn.

As a pilot, Martin Bromiley had received the standard training in open communication in the cockpit. Indeed, he is a specialist in this "Human Factors" field. He realizes that "Fixation is a normal reaction to stress. Human Factors training teaches people that it's normal to carry on trying to take the usual action, even when it's clearly not working. But at some point, a decision has to be made to break out of that pattern of behaviour. The way to ensure that happens is for all members of the team to see it as their duty to speak out to keep the patient safe." There was no comfort in knowing that two of the nurses knew how to save his wife's life. "What they didn't know - and what Human Factors [also called in the U.S., Crew Resource Management or Crisis Resource Management] would have taught them - is how to broach the subject with their bosses."

Lesson for Caregivers: Before surgery, verify that the surgical team has been trained so that the surgeon will open-mindedly consider urgent input from nurses and junior doctors. Do this in advance by asking the Risk Manager of the hospital whether the surgical team has been trained in Crisis Resource Management, Crew Resource Management or similar candid team communication techniques. If not, consider scheduling the surgery at a different hospital.

The whole story is told by blogger John Ray, and by Jane Feinmann in the newspaper article "Blunder that Killed my Wife."

Loving Intentions: A Medication Error

Saleem (not his real name) was a Syrian-born toddler, brought to the hospital with a viral infection, feverish, and bleeding from the nose on October 29. His mother, an X-ray technologist at the hospital, had given medicine to her two-year old son when he first became ill. Then, when Saleem started bleeding, she took him to the hospital.

The boy died soon afterward. Based on a liver biopsy, the physician in charge of the investigation into Saleem’s death found necrosis (tissue that had died from a lack of oxygen) and fatty tissue in his liver. He, the pathologist, and the government’s health department investigators are 98% sure the cause was a drug interaction or drug sensitivity.

Type of error:
This was a preventable adverse drug reaction, from the wrong drug, or perhaps from an overdose of the right drug.

Apparently, Saleem’s mother had inadvertently caused her son’s death by giving him the wrong medication or dosage.

Ways to prevent similar tragedies:
Parents and grandparents should avoid giving one child’s prescribed medication to another young child; an infant’s organs may not be able to metabolize (break down and use) the medicine.

Readers: Is it ever acceptable for a parent or grandparent to give one child’s prescribed medication to a different child? When? Do you know of similar errors?

Read more in Nina Muslim's article, “Toddler’s death due to adverse drug reaction” GulfNews.com, Nov. 6, 2006.

Saturday, December 16, 2006

A Survivor's Best Friend

Ed Bradley lived for years with leukemia, after his quintuple bypass, as we discussed earlier this week. Hopefully he had the help of friends and family when he needed them. Patients like him, with cancer or other difficult chronic diseases, can benefit greatly from help with meals, shopping, etc.

Advice for caregivers: Use an excellent free resource to organize and coordinate help from friends and neighbors: lotsahelpinghands.com . I don't get any money for recommending this. The founder is an old high school friend who developed it for a friend with cancer. Check it out!

Thursday, December 14, 2006

Don't Let Haste In your Waist Make Waste: Colon cancer screening

Colonoscopy (examination by a doctor of your large intestine via a flexible scope) can detect and snip out cancerous and pre-cancerous polyps before they become harmful, and is recommended for 50-year olds. However, some doctors perform it more carefully and thorougly than others, and detect more polyps. Hasty doctors may catch only one-tenth as many as more careful ones! Doctors who take more time looking find more of them. On average, about a fifth of colonoscopy procedures detect one or more pre-cancerous polyps.

Lesson for Caregivers: If your doctor, or spouse's doctor, has a very low rate of detection of polyps, that may be a sign that their haste in doing the procedure has been causing them to miss many cancerous and pre-cancerous growths. Ask beforehand! If the doctor's detection rate is low, or unknown, find another doctor. Otherwise, you may find after your colonoscopy that you're left with the discomfort, the bill, AND. still, the polyps.

Share this with your friends who are about to have the big 5-0 birthday.

Read more in Gina Kolata's New York Times article: "Study Questions Colonoscopy's Effectiveness," Dec. 14, 2006, page A23.

Wednesday, December 13, 2006

Ed Bradley's Fatal Infection

The CBS reporter Ed Bradley died last month at age 65 from complications of chronic lymphocytic leukemia. Bradley, who underwent a quintuple bypass operation on his heart in 2003, had been diagnosed with leukemia "many years ago,” said Bradley's cardiologist, Dr. Valentin Fuster, but it had not posed a threat to his life until he got an infection. It is not publicly known whether the fatal infection came from home, a hospital, or somewhere else.

Hospital-acquired infections can come from germs on the hands of doctors or nurses, or unclean medical or surgical devices or instruments. Urinary tract infections are the most common infections for hospitalized medical (i.e., non-surgical) patients like Bradley, according to an article offering an overview of the topic in a microbiology journal, based on 26,000 infections in the National Nosocomial Infections Surveillance system. Though some safety experts recommend that a patient routinely ask each doctor, nurse and phlebotomist (person who draws blood) whether they have washed their hands, this may be embarrassing or impractical for the patient.

Lesson for caregivers: It may be easier for the patient or advocate to post a sign on the door or hospital bed saying, “Please wash your hands, and tell me you’ve done so. Thanks.”

Readers: Do you know of errors like these?

Bradley news source: “Admirers to Pay Final Respects to Bradley,” from BET.com News Staff & Wire Services, Updated Nov. 21, 2006.

Tuesday, December 12, 2006

Too Much of a Good Thing: Lesson Two

Mrs. A. is a heroine of the story, for providing the hospital resident the key information about her husband's vitamin and mineral supplements. She could have acted even sooner--when the mineral supplement was first prescribed. At that point, she could have asked the surgeon how and when the mineral supplement would be effective. If the answer was, "It should help the wound heal within two weeks," Mrs. A. could then ask, when the wound hadn't healed two weeks later, whether the mineral supplement should be continued. The lesson: When receiving a prescription, ask when and how the prescribed drug will likely be effective. If it has not been effective, follow up with the prescribing doctor.

Readers: Has something similar happened to someone you know?

Monday, December 11, 2006

Medical Error of the Week: Too Much of a Good Thing

Mr. A., a bearded, pleasant-looking married man of 47 with three children, loved to eat. His weight had become alarming, and he had gotten diabetes. Four years ago, he had had gastric bypass surgery to reduce his weight; he lost more than 100 pounds--and his diabetes. Two years ago, he developed a hernia (a protrusion through the abdominal wall), which was repaired surgically. To speed the healing of the surgical site, his surgeon prescribed multi-vitamins, with a zinc supplement. However, the four-inch wound didn’t heal, even after intravenous antibiotics in the hospital. Indeed, he became anemic—tired, and lacking red blood cells, achy, and neutropenic (having lost most of his bacteria-killing white blood cells), along with a fever. A young hospital resident [physician] determined that both his anemia and neutropenic fever had been caused by too much zinc. The doctor told him to stop taking the zinc supplement, and he recovered fully within two months.

What was the error?
A preventable adverse drug event/adverse drug reaction to zinc. The dosage may have been too high (wrong dose). The patient might have been instructed to take the zinc for too long (wrong time).

Why did the error occur?
The surgeon had prescribed the high doses of vitamins and zinc because of evidence that they can speed healing after surgery, especially early on. However, the surgeon, the hospital doctors who treated him later, and his primary care physician did not link the complications of anemia and neutropenic fever to the zinc supplement.

Lessons for Caregivers:
Mr. A.'s wife had shown the hospital resident the list of Mr. A.'s home medications, enabling the resident to learn of and look into the role of zinc. Mrs. A had included vitamins and minerals in the list--not only medicines. She both wrote the list and brought it in to the attention of the doctor at the right time. Bravo! Please do the same for your family members.

Later this week we'll discuss more about Mr. A.; stay tuned.

This summary is drawn from Dr. Lisa Sanders’ article, “The Healing Problem,” in The New York Times Magazine, Nov. 12, 2006.

Our Purpose

Our family members need us to help them get the best possible medical care. When they're ill, we and they need to know how to advocate most effectively, and work best, with doctors, nurses, and other health professionals. In focusing on the needs of family caregivers and their patients, this blog provides advice to keep our parents, children and other loved ones with acute or chronic illnesses healthy and safe from medical errors.

We provide a place for readers to tell and hear stories about the medical care they have seen and experienced, to give advice and get advice.

We help patients and advocates to be knowledgeable, pro-active, and empowered partners with their doctors and nurses.