Memorial Day: We Remember

This weekend we recall these victims of medical errors, among many others:

Doug Bonderud


Elaine Bromiley (anesthesia error)


Armando Castellanos
(medication error)


Jasmine Gant
(medication error)


Betsy Lehman (medication error)



Brendan McDowell


Cheatum Myers
(nursing home neglect)


Naomi Press (nursing home neglect)


Jesica Santillan (transfusion error)

Handwriting on the Wall, continued: A medication error

Reader Kate Gladstone comments on Armando's Castellanos' story:

Among the hospitals that call me in to prevent medication errors (by
giving handwriting classes to the doctors), a fairly high percentage
claim to have "computerized everything" 1 or 2 or 5 or more years ago
… yet they still have handwriting problems, because of a crucial 1% to
5% of handwritten documentation that just won't go away.

Doctors in "totally computerized" hospitals still scribble Post-Its to
slap onto the walls of the nurse's station, still scrawl notes on the
cuffs of their scrubs during impromptu elevator/corridor conferences
with colleagues … and, most of all, doctors with computer systems
often have the ward clerks operate the computers, use the Net, or
whatever: working, of course, from the doctors' illegible handwriting.
Bad doctor handwriting, incorrectly deciphered by ward clerks using
the computer for any purpose, thereby enters the computerized medical
record.

And what happens when disasters like Hurricane Katrina (or tsunamis)
knock out a hospital's network? More than one hospital, during
Katrina, lost its generator, its electric power — and therefore its
computer system — for the duration. Even the computer-savviest staff
in these disaster zones had to return to handwriting. Let's hope they
wrote legibly.


Yours for better letters, Kate Gladstone -

handwritingrepair@gmail.com - telephone 518/482-6763
Handwriting Repair and the World Handwriting Contest
http://learn.to/handwrite
325 South Manning Boulevard
Albany, New York 12208-1731 USA

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.

Handwriting: A chemo overdose lawsuit

The trouble began with a doctor’s illegible handwriting, continued with clarification of the order not being recorded and a pharmacist misreading the medicine dose on the prescription, according to the report by the expert investigators at the Institute for Safe Medication Practices. Armando Castellanos’ doctor had written a prescription for 50 milligrams of Cisplatin as part of Armando’s chemotherapy. But he received 10 times that dose, causing his death several days later. The family of the middle-aged Californian man received a settlement from the medical center.

Advice: Read the doctor’s handwriting on your prescription when you get it, and ask the doctor to rewrite clearly anything you can’t read.

Read another overdose story, or read more in Michelle Durand's newspaper article last month.

Warn your friends and family.