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Friday, September 30, 2011

What We Can All Learn From Michael Jackson's Doctor

Michael Jackson had what most of us think we want:  utterly personal attention from a dedicated doctor, on call all the time for him alone. 

Dr. Conrad Murray is now on trial for manslaughter, though no one thinks Michael's death was deliberate. What went wrong, and what can we learn from it?

Much remains unclear about exactly what happened, but I see three key lessons: Don't assume information about your medications has been communicated from one doctor to another. Keep an updated medication list. Get a family member or professional patient advocate.  

This story, among those of other celebrities, is explored in my book, Getting Your Best Health Care:  Real-World Stories of Patient Empowerment. There, I examine more fully the role of the medical team. This week, more information has been made public, though the conflicting accounts by the prosecutor, defense lawyer, and early witnesses make it hard to know the truth at this time. Still, some useful lessons are already emerging. 

Poor communication among medical personnel

    Michael’s primary care provider communicated some critical information poorly. When emergency medical technicians arrived to try to revive Michael, his primary care doctor did not inform them that he had given Propofol to Michael [according to the prosecutor].  That may have affected the way the EMTs tried to revive him.  Flumazenil was used to reverse the effects of benzodiazepines like the Lorazepam that Michael had been taking.  Miscommunication may have led the EMTs to administer the Flumazenil in a misdirected effort to counteract the effects of the Lorazepam, though it seems that the biggest immediate problem was actually the Propofol. 

The patient's role

Michael himself seems to have played a role in at least two miscommunications. First, Michael had become addicted to another sedative, Demerol, which he regularly received from his Beverly Hills dermatologist, without telling his primary care provider.  The addiction allegedly left Michael unable to sleep, sometimes for days, leading him to beg for Propofol [according to the defense lawyer].  Second, Michael had swallowed an extra dose of the anesthetic, Propofol, while the doctor was in the restroom, unbeknownst to the doctor [according to the defense lawyer].  

The risk of hand-offs

     Such miscommunications of information during medical “hand-offs” among medical personnel like these are common, so patients need to be on guard.  Keeping an updated medication list of each drug, its dose, and the reason you’re taking the drug can prevent errors like this.  During crises, a patient advocate – either a trained family member or professional advocate – can also catch and correct the miscommunication before the patient suffers for it.  

     It’s most likely that a chain of errors on the part of both Michael and his primary care provider, and perhaps another physician, were responsible for his death.  Given the many drugs Michael was taking and they way he received them, it seems there were several wrong-drug, wrong-dose, and wrong-time errors.

Michael Jackson's death also raises two other issues that patients should consider: 

-Behavioral health and substance abuse issues
Michael was relying on many drugs, at least one of which was habit-forming. Ideally, a concerned family member, or even Michael himself, would ask his primary care physician about his dependency, and the doctor would have some training in detecting and dealing with substance abuse. In the absence of that, lacking full knowledge about Michael’s habits, the doctor was flying blind, though neither Michael nor he seemed aware of that. (Michael called the propofol his “milk;” indeed, the drug’s nickname is “milk of amnesia.”)

-Did Michael Jackson choose the wrong doctor?  
In hindsight, it’s easy to say, Yes. Beforehand, it was less clear-cut. If Michael had looked up the doctor’s public quality information in Health Grades, for example, he would have seen the doctor had received only two or three stars on a five-star scale, as rated by a small number of patients on each of ten different dimensions of care, including trustworthiness, communication skills, listening skills, whether they would recommend him to someone else, etc. At that time, the doctor had neither any malpractice activity, nor any actions by the state’s medical board, nor any formal sanctions.

Ken Farbstein, MPP, President of Patient AdvoCare, is a professional patient advocate who advises people on staying safe through healthcare crises.

Read another miscommunication story.

Thanks to Ian Lovett and Timothy Williams of the New York Times, and Anthony McCartney and Linda Deutsch of the Boston Globe, for their source articles this week.

Thursday, September 15, 2011

57 American children: The flu vaccine

Today is the birthday of my beloved father, may he rest in peace. It brings to mind his long work with Rotary International to raise money to eradicate polio through vaccinations.

I read just now that 57 American children who had not received the flu vaccine during the last flu season died from the flu, according to figures compiled by the U.S. Centers for Disease Control. Their deaths were easily preventable.

Advice: Pass this on to your friends with young children, who are particularly susceptible to the flu.

Read another vaccination story here. Thanks to the writers of Infection Control Today for their source story today.

Monday, September 12, 2011

She experienced relief sooner: Effects of a patient portal

A story from Debbie Scammon, PhD:
I continue to be impressed with the fervor of MyChart (our patient portal) users regarding the benefits to patients of on-line access to their medical records. In one recent focus group with patients with longevity with our clinics (visits over several years), 5 of 6 participants were avid users and the other one was an admitted technophobe. The 5 users repeatedly asked how they could help the other patient “get up” on MyChart so he could start seeing the benefits. One patient dealing with migraines was excited that as she and her provider experimented with alternative medications to treat her headaches she could report after each dose how she was feeling and how the new medication was working. With this ability to share her experiences with her provider in real-time, adjustments in dosage could be made quickly and the patient experienced relief sooner. Another patient pointed out to the group that he (at home), and his provider (during a visit), could see graphs of his health status over time (back years) and thus have a better idea of how he was progressing. Yet another patient was elated that when she tried to schedule a routine preventive screening, she found by looking at her records in MyChart that it wasn’t yet time for that exam and thus she was able to avoid an unnecessary test, one that would not have been covered by her insurance. Access to her medical record on-line gave her more control over her healthcare and a feeling of enhanced self-management.

These are exactly the sorts of benefits hoped for from the implementation of our patient portal. I’ve definitely seen that patients want to help each other gain access to the portal so that they can begin to take more control over their health.

See another of Debbie's stories, on seniors' use of social media.

Thanks to Debbie Scammon for this, based on her research project, “Transformed Primary Care - Care by Design,” funded by AHRQ (U.S. Agency for Healthcare Research and Quality) Grant # 1 R18 HS19136, and led by Principal Investigator Michael Magill, MD.

Sunday, September 11, 2011

Accomplishments of Massachusetts hospitals' Patient/Family Advisory Councils

The Patient/Family Advisory Councils of Massachusetts hospitals have made some innovative changes. Here are a baker's dozen of them.

Developed a program in which all medical house officers now rotate through our Simulation Center, receiving didactic and high-fidelity simulation sessions on conducting family meetings. (Beth Israel Deaconess Medical Center)

Launched “Patients as Educators” program to share experiences with small groups of nurses and doctors (Dana-Farber Cancer Institute)

Reviewed quality dashboards and publicly reported quality measures (Health Alliance)

Reviewed quality outcomes and patient satisfaction data (Heywood Hospital)

Helped residents plan family participation in Chief of Service Rounds (Children’s Hospital)

Helped plan an “Appointment Buddy" program that provides volunteer assistance to families of children with special needs (Children’s Hospital)

Participated in training sessions with oncology fellows and residents, so physicians could learn directly from patients and families about the human experience of living with cancer (Children's Hospital)

Installed a Portuguese channel on inpatient televisions (Morton Hospital and Medical Center)

PFAC member became a "secret shopper" to go through the registration process, three members working with hospital staff on the registration, flow and patient handout information (Nantucket Cottage Hospital)

Re-vamped a discharge medication tool to be more patient friendly and easier to understand for patients. (New England Rehabilitation Hospital)

Developed the “Crisis in the Classroom” program, which reinforced the need for mental health services for the community. This program brings experts in child psychiatry and development together with parents and first-responders (teachers, principals, guidance counselors, school nurses, and law enforcement. (Newton Wellesley Hospital)

Helped to design 'the Joanie'- an improved hospital gown that is more comfortable. (Newton Wellesley Hospital)

Developed a process for families who wish to stay overnight to request a cot be brought up to a patient's room (Caritas Norwood Hospital)

Read another story about innovative efforts by patient/family advisory councils.

Thanks to Amelia Russo for compiling the master list, and to Linda Burgess, Nicola Truppin, Deb Wachenheim, and Alec Ziss as our Patient/Family Advisory Council work group members at Health Care for All’s Consumer Health Quality Council.

Friday, September 9, 2011

Nine months after the 2010 IHI Forum

It's now nine months after the Leadership Summit at the IHI Forum in December 2010, and time to take stock again of our progress. At the IHI Forum we agreed as a group that our mission is to continually and measurably reduce medical errors, building an ever-growing coalition.

My previous updates about our progress have focused on our accomplishments as individuals; this one, for the first time, discusses our accomplishments as a group.

In the last week, a clear majority of our original group of activists/advocates (35 of the 54 of us) have signed a petition promoting transparency of hospitals' JCAHO reviews. Consumers Union and the Leapfrog Group, among other effective advocacy organizations, have joined us on the petition.

Our joint political agenda is emerging, as significant numbers of our members have also come together to spread the use of pulse oximetry among newborns, ban the use of gag clauses in medical settlements, and propose an Ad Council campaign to raise awareness.

Our Facebook group has quadrupled in size since its launch, to 197 participants.

This comes in the shadow of the tenth anniversary of 9/11. The math of our yearly toll from medical errors is grim: a 9/11 every eleven days. We have to get much better at working together. Our challenge is to plan together and collaborate with powerful organizations.