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Showing posts with label drug error. Show all posts
Showing posts with label drug error. Show all posts

Thursday, March 5, 2009

An incentive to do the wrong thing: A Phenergan injection lawsuit

Diana Levine is a guitarist, age 63, living in Vermont. She went to a clinic, complaining of pain from migraine headaches. A doctor there chose to inject her with Phenergan, an anti-nausea drug made by Wyeth Pharmaceuticals. Though the drug label permitted the drug's intravenous injection, it stated that "extreme care" was needed to avoid hitting an artery, because "likely" complications included "gangrene requiring amputation."

Unfortunately Diana immediately developed gangrene, and the musician's right forearm had to be amputated. She sued Wyeth, and won. The U.S. Supreme Court upheld the decision in a ruling today, by a vote of 6 to 3.

Diana’s case is especially significant because the Supreme Court's ruling enhances the rights of injured patients to hold drug makers responsible.

This case also implicates our payment system. Doctors are paid well for administering injections, and are not paid for prescribing oral drugs, for example, that usually offer available alternatives. The reimbursement system provided an incentive to do the wrong thing, and Diana is suffering for it.

Advice: Consider a lawsuit if a medication error causes you significant injury.

Read a story about a migraine sufferer.

Thanks to Jess Bravin; and Joan Biskupic and Julie Appleby for the source articles in today's Wall St. Journal and USA Today, respectively.

Tuesday, September 16, 2008

She thought he was just throwing a tantrum: An IV drug error

When six-year-old Chance Pendleton came out of surgery for a wandering eye, it was obvious that something was not right. "He was crying hysterically, vomiting and kept saying, 'I wish I was dead,'" his mother said.

The boy had been through surgery before and had never reacted this way: "The nurse was quite peeved and wanted me to calm him before he disturbed anyone," his mother said, adding that Chase was denied more pain and anti-nausea medication. "She thought he was just throwing a tantrum."

After about 20 minutes, another nurse walked by, and Chance's mother beckoned her for help. The nurse checked the intravenous line in Chance's ankle and saw that it wasn't inserted correctly. He wasn't receiving any medication. She immediately fixed it, bringing relief to Chance in a matter of seconds.

Chance's mother said she had not been aggressive enough. "I wish I had been more confrontational sooner," she said. "That was the worst 20 minutes of my life."

Advice: Parents need to be the eyes, ears and advocates for their children. Dr. Steve Selbst, author of a study of malpractice suits, says, "You know your child, and if you feel something's wrong, go up the chain of command."


Read another story of a mother who saved her son.

Thanks to Laurie Tarkan for the source article in yesterday's New York Times.

Thursday, July 31, 2008

I’m sooooo beat up: An overworked nurse's medication error

I've been an LPN for a month. I made a med error this week...Gave .50 mg of Ativan instead of .25 mg. Devastating.

On top of that, I was called into the ADON's office to see how they could help me from having so much overtime on my charting.

I'm soooo beat up. I have 40 residents to care for, and I had CNA's that were gone during the 6am med pass to leave me alone with my residents taking them to the bathroom, etc...They didn't ask to break, and if they had, I would have asked them to wait until my meds were passed.

I try hard to allow as many breaks as possible. I try to help them, because I know what it was like being a CNA...needing help and not getting it...

Here I am...

Med Error, Overtime...

I feel I already take too many "short-cuts" for a new LPN to be taking, and some of the things that go on on 3rd shift...that we are "taught" to do...I won't do anymore. It's not worth it to lose my license.

I hope it is not too late for me.

Advice to people needing to go into the hospital in July or August: Bring a patient advocate, as the new crop of residents has just begun work.

Read another story of an overworked nurse.

Thanks to LookingBeyond [no name given] for the source blogpost today at allnurses.com/forums.

Tuesday, June 24, 2008

I got my mother back: Overuse of antipsychotic drugs in nursing homes

Last fall, Theresa Lamascola of the Bronx, suffering from anxiety and confusion, was put on the antipsychotic drug Risperdal. When she had trouble walking, her daughter took her to another doctor, who found that she had unrecognized hypothyroidism, a disorder that can contribute to dementia.

She was moved to a nursing home to get the problems under control. But things only got worse. She "was screaming and out of it, drooling on herself and twitching," said her daughter, a nurse. The psychiatrist in the nursing home stopped the Risperdal, which can cause twitching and vocal tics, and prescribed a sedative and two other antipsychotics.

"I knew the drugs were doing this to her," said her daughter. "I told him to stop the medications and stay away from Mom."

Not until another doctor took her off the drugs did she begin to improve. He prescribed Aricept. "It's not clear whether it was getting her hypothyroid and other medical issues finally under control or getting rid of the offending medications. But she had a miraculous turnaround," said the new doctor.

She still has dementia but she went from confinement in a wheelchair – unable to sit still and screaming out in fear – to being able to walk with help, sit peacefully, have some memory and ability to communicate, understand subtleties of conversation and even make jokes.

Or, as her daughter put it, "I got my mother back."

Researchers estimate that one third of all nursing home patients have been given antipsychotic drugs.

Advice to people with elderly relatives in a nursing home: Ask the doctor about alternatives to antipsychotic medicines.

Read another story about drug side-effects in the elderly.

Thanks to Laurie Tarkan for the source article in today's NY Times.

Tuesday, May 27, 2008

I should be an indignant patient-plaintiff: Apology for drug interactions and other medical errors

Amy Silverstein’s story:
For the many errors that I have witnessed as a heart transplant patient at a well-regarded New York City hospital over the last 20 years, there has been only one doctor with the courage and character to say "I'm sorry."

I should be one of the "indignant" patient-plaintiffs who send legal costs and insurance rates soaring, but I am not. Money cannot heal the ways that I – and many other patients – have been damaged.

It does not take the surgical removal of the wrong kidney or arm – the stuff of lawsuits – to bring about the kind of injury worthy of a hospital's attention. A patient fills a prescription written by her doctor, only to be warned by the package insert that the drug interacts dangerously with another medication prescribed by this same doctor, and there is error, destruction of trust and near loss of life. And no one pays attention.

Even without the threat of lawsuit, a wronged patient deserves some long, hard thought among doctors and hospital administrators.

The writer is the author of "Sick Girl," a memoir.

Advice: Read the package insert after you pick up your prescription.

Read a celebrity’s fatal drug interaction story.

Thanks to Amy for her source letter to the editor, printed in the May 26 issue of the New York Times.

Sunday, May 25, 2008

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)

Thursday, January 31, 2008

As if it never occurred: Pain medication errors affecting a nurse patient

Laura's Story
I herniated a disc in my back when I was very young and, although I was diligent with my physical therapy exercises and had tried many healing modalities, nothing helped my chronic and debilitating back pain. Still in my twenties, I was told to have breast reduction surgery to help my back. Although I didn't particularly care about the cosmetic effects, overall I was hopeful that the surgery would help and thus increase my enjoyment of my life. The health insurance I had at the time of the initial recommendation would not cover the surgery, but I was finally able to have it a few years later when I changed companies and the new one was willing to cover it.

Because of restrictions imposed by my health insurance, I was required to go to a hospital that, even then, I could not strongly recommend even though it is a major Boston teaching hospital (I worked in healthcare so have some knowledge). I did not have anyone to stay with me because my father had recently died, my mother was dying, and my friends were busy during the day with work or children. Still, I was reassured that I would be ok because I trusted and liked my surgeon, I would only be in the hospital one night, and my surgeon had come up with a strict pain management plan for after the surgery. I would have strong pain medication available to me every two hours, as well as Tylenol in case I needed it in between.

Unfortunately my trust was misplaced. Still sedated, disoriented, and numb immediately after four hours under general anesthesia, I was allowed by the orderlies and nurses to lift my entire body weight from the gurney to the hospital bed, despite orders that I not use my arms or lift heavy weights for a month. As a result, by the next morning, I was in agony. I had had my chest spliced open, very tender body parts were stitched back together. Yet my nurse refused me any pain medication at a time I should have been able to get it, and said I was not allowed Tylenol. She left and did not return, despite repeated calls from me, through the floor secretary, to her (which I overheard through the intercom). I was left crying, sweating from pain, my heart pounding, frightened. I felt trapped and vulnerable because I could not get out of the bed due to the pain. I was helpless.

At least two hours elapsed with me in this difficult state. Towards the end, growing desperate, I attempted to page my surgeon from my bedside phone but was told by the operator it was not allowed, and I should ask my nurse to page him (!). Later I called back and, explaining my plight to the operator, was connected with a helpful hospital employee who then reached various nursing supervisors, resulting in a parade of nurses of various levels coming to my bedside. My nurse told me she had not come because I wasn't due for my medication; I said she should have come to see me anyway, because I had a right to know why no one was responding to me. She and her supervisors seemed angry and hostile to varying degrees, which I found upsetting at that vulnerable time. No one took responsibility; in fact my nurse blamed the innocent secretary for not relaying my pleas for help. She did not tell the truth, which I found alarming in itself.

I was discharged home without my pain under control and thus suffered from severe side effects from taking the maximum dose of oral pain medication; I almost landed in the emergency room. I was in too much pain to change my bandages as required so I had to have a visiting nurse come to my home to help me, which I am told is very unusual after this procedure. A year later, I had to have my scars re-excised because they were so severe; my surgeon thought that could be due to having lifted myself after surgery. At that time, along with a kind outpatient surgical nurse, I reread the medical chart from that hospitalization. It was clear to that nurse that the medication orders in the chart, readily available to my nurse on the day after my first surgery called for strong pain medication every two hours if I needed it. The Tylenol order was also spelled out in black and white; all just as my surgeon had stated to me beforehand. My nurse the day of surgery seemingly had lied to protect herself and had not bothered to even re-check the orders as they were clear even to me. There was no notation at all in the medical record of me lifting myself or my multiple calls for help, or my severe pain that morning. It was as if it never occurred.

Worse than the physical scars are the emotional ones for me. Something happened in my soul when that nurse left me so vulnerable and helpless. To this day I have trouble with trusting healthcare providers and hospitals, which is unfortunate for me because I have some minor but chronic health problems that require regular visits to such places. Additionally, I used to work in healthcare and find that I am less interested in working in such settings due to the unpleasant feelings that come up. It is remarkable how one person's unprofessional behavior can impact your life when you are a patient and thus intrinsically more helpless, vulnerable, and reliant on others.

Advice: Even nurses need a patient advocate when they are hospital patients themselves.

Browse for similar stories in our index at the very bottom of this page, or read a pain management story.

Sunday, January 6, 2008

The blunderer must bear the cost: A drug error

Question:
When my husband developed a leg infection, his physician prescribed the wrong antibiotic. The insurance company, recognizing the mistake, refused to cover the prescription's $573 cost. But I had already filled it, and my husband had taken a dose. I think our doctor should reimburse us. (The correct treatment for this common infection was immediately prescribed by two other doctors.) My husband demurs. You?
-Name withheld, Los Angeles.

Answer by Randy Cohen, the NY Times Magazine Ethicist:

The doctor should take responsibility, including financial responsibility, for his error. This is not to demand omniscient physicians or mistake-proof medicine. Everyone is fallible on the job. But acknowledging human fallibility does not mean abandoning all professional standards. It this was, as it seems, a genuine blunder, then it is the blunderer who must bear its cost.

Update: Acknowledging his error, the doctor agreed to waive all future fees up to the amount of the erroneous prescription.

Advice to victims of a medical error: Insist that the doctor bear the cost of the error.

Browse for related stories in the index at the very bottom of this page, or read an insurance company denial story.

Thanks to Randy Cohen for the source article in today's New York Times Magazine.

Wednesday, January 2, 2008

He was found dead at his computer: A Fentanyl overdose

Adam Hendelson had been in a car accident as a teenager. For years, on his right arm he had worn a Duragesic patch, containing Fentanyl gel, to manage his chronic hip pain. In December 2003, at age 28, he was found dead at his computer. The cause was traced to a leak in the patch that had given him a fatal overdose. In June 2007, a Florida jury awarded his family $5.5 million.

Last week, noticing that hundreds of people had died from similar accidents, the Food and Drug Administration issued a warning about the use of Fentanyl. The FDA warned doctors against prescribing Fentanyl patches to anyone new to opioids, the family of painkillers that includes morphine. The drug is only to be used for chronic pain in people who are used to using narcotics, such as cancer patients. Fentanyl can cause other people to have trouble breathing.

Advice to those with family members using Fentanyl patches: Read the FDA warning.

Browse for related stories in the index at the very bottom of this page, or read a less harmful story about conscious sedation.

Thanks to Lauran Neergaard of the Associated Press and Kenneth Reid for the source stories in the Dec. 22 issue of the Boston Globe and the June 18 issue of Adverse Event Reporting News, respectively.

Saturday, December 8, 2007

It's not who he is: Misdiagnosis of autism

Jeremy is a 20-year-old young man who lives in Columbia, Missouri, and works on the "Mizzou" college campus as a volunteer, cleaning classrooms.

From the looks of him, you can't tell Jeremy has autism. He has a high functioning form called Aspergers. Doctors didn't diagnose him until he was 16. Before then, Jeremy said he had complications stacked up against him from doctors not knowing much about autism.

"They put me on several drugs and misdiagnosed me several times," said Jeremy. "Those were probably the most catastrophic years of my life, being misdiagnosed, being on those drugs, being treated poorly by the school, of their ignorance of autism, of my condition."

Now "his autism does play a part in his life, plays a big part, but it is not who he is," said his mother, Robin. "He is someone who has dreams and aspirations, who has many skills, who has a kind heart, who likes to volunteer, likes to help people... that is who Jeremy is."

Despite the difficulties he faces, Jeremy has no tolerance for those who want to "cure" autism.

"It's insulting to me because it is saying, you know, when people say, 'I am not going to try to understand this, I just want to cure it.' When it is actually something neurological. It is hard-wired into your brain. There is nothing you can do about it. That is just the way it is. They just want a cure, they don't want to understand it. They don't need to treat it. They don't want to deal with it. It is a lifelong thing," said Jeremy.

Advice to people whose drugs aren't helping: Find other people in your situation; they might help you learn a more accurate diagnosis.

Browse for similar stories in our index at the very bottom of this page, or read another delayed diagnosis story.

Thanks to Ashley Reynolds for the source story.

Friday, November 23, 2007

They brushed off my questions: Incorrect medical decision-making for a thyroid problem

I spent months being treated for acid reflux-like symptoms, and I found myself seeing doctor after doctor. They all treated me for acid reflux – a commonly diagnosed problem of stomach acid flowing backward from the stomach into the esophagus – and brushed off my questions asking if my problem couldn't be related to a thyroid condition. There is a history of thyroid problems in my family and my instincts kept telling me my problems were related to my thyroid gland. The doctors continued to tell me I just had acid reflux and I should keep taking the "little purple pill." I couldn't understand how I could so suddenly develop acid reflux. After all, I had always been able to eat anything I wanted and now even eating cereal and drinking water made me hurt.

After seeing several different local specialists and undergoing many, many tests, I referred myself to an endocrinologist (someone who specializes in thyroid diseases) at a large medical center for another opinion. Within five minutes of meeting this endocrinologist, he was convinced all of my symptoms were related to being hyperthyroid (too much thyroid hormone). He explained to me that when you are hyperthyroid all the systems in your body are hyper (overworking) and can give you symptoms I was experiencing like acid reflux! I was never so relieved – I had finally found someone who believed that my symptoms were related to a thyroid problem. Further testing confirmed his diagnosis, and surgery was scheduled to remove my thyroid gland. It seems my instincts were right after all. Since having surgery (I now need daily thyroid hormone replacement) my symptoms have disappeared and I no longer need "the little purple pill" for acid reflux.

My only regret is not finding the right doctor sooner. I could have avoided many unnecessary tests and months of suffering.

Dr. Pikula's Advice: Sometimes you have to keep asking and pursuing answers until a situation makes sense.

Browse for related stories in the index at the very bottom of this page, or read a thyroid story.

Thanks to Donna Pikula, DDS, for the source, “After the Diagnosis: How to Look Out for Yourself or a Loved One.”

Wednesday, September 19, 2007

Before he raced off to work: Perceptive listening about ventricular tachycardia

Dr. Bernard Lown describes how he found "The Hidden Clue:"

A college president consulted doctors over a decade for ventricular tachycardia, a very serious heart-rhythm disorder. He had been hospitalized in many of this country's leading centers and more than a dozen different medications had been tried, all to no avail. On his first visit, I asked at what time of day the arrhythmia occurred. He responded that it was almost consistently in the morning, before he raced off to work. When questioned further, he stated that it happened between about 7:30 and 8:30 am.

After gathering more information, I told the patient that his problem would be solved if he set an alarm clock to 5:30 am and as soon as he awoke, took a double dose of an anti-arrhythmic medication before going back to sleep. Following this counsel for the next eight years, he was totally free of arrhythmia.

It is astonishing that no doctor had tried to identify the precise time the arrhythmia occurred. Taking a much larger total dose of the same drug at intervals around the clock, as he had been told to do, provoked many adverse symptoms without containing the arrhythmia. The reason for the failure was straightforward. His evening dose had dissipated by early morning. The morning dose was taken too close to the onset of the disordered heart rhythm for the drug to have reached an effective therapeutic blood level. Furthermore, he needed a higher dose at that time to prevent the arrhythmia from breaking through. No amount of technical wizardry could have resolved his difficult problem. The solution would never have been unearthed without the information the patient provided.

Frequently a patient not only tells what is wrong but provides information suggesting how best to manage the problem.

Advice to patient and patient advocates: Be sure you have a doctor who asks you enough questions to perceptively diagnose your condition.

Read more from Dr. Lown's essay, "The Hidden Clue," in The Lost Art of Healing.

Saturday, September 15, 2007

Not “just the way it has to be:” Treatment of Hirschsprung’s disease

Matthew Swan is a third-grader with a rare and serious congenital condition called Hirschsprung's disease. It limits the ability of his large intestine to process food. Doctors near his Idaho home had told him to eat a high-fiber diet and use laxatives, which hadn't helped.

Matthew's mother couldn't find specialists near their home, and so had been taking him to a children's hospital in Michigan. But Matthew still got chronic intestinal infections that required frequent visits to the Emergency Room, and prevented him from attending full days of school.

"We were told that this was just the way it has to be," said his mother. She researched colorectal programs, spoke to other parents, and chose to come to Cincinnati Children's Hospital. Doctors there realized Matthew has an exceptionally rare form of the disease, and stopped the high-fiber diet and laxatives. They performed surgery and gave Matthew other forms of help to better control his bowel movements.

Staff at Cincinnati Children's Hospital see part of their job as helping each patient to live as normal a life as possible. That means helping patients like Matthew to remain continent. Not doing so would be a "glaring deficiency," in the words of Dr. Marc Levitt at CCH.

Advice to mothers: Matthew's mother was unwilling to accept the conclusion that nothing could be done. As a patient advocate, you should research alternative places to get treatment, and ask other parents, as she did.

Read more from Reed Abelson’s article in today's New York Times.

Sunday, July 22, 2007

One more day: A wrong drug error

In early November, Dean Baggett had his prescription for a common painkiller refilled. Three painful weeks later he was close to death, said his wife, Laura Baggett.

"You are so careful and think you're doing everything right ... and then something so preventable like this happens," said Laura, an emergency medical technician who runs a cardiopulmonary resuscitation training business and coordinates the CPR program for city employees in Fremont, California.

A prescription for painkillers was mistakenly filled with an antibiotic. On the bottle for the painkiller that Baggett was given, the label reads: Carisoprodol: generic for SOMA/white, round tablet/MP 58. But the oblong, white pills inside Baggett's bottle are marked "MP 85." Dean said he noticed the discrepancy immediately.

However, an employee at Haller's Pharmacies in Fremont, which filled the prescription, explained that the numbers were different because the refill was a generic version of Soma, Laura said.

The Haller's manager and Dean's doctor both refused to comment.

Taking the antibiotic for nearly three weeks made Dean's immune system attack itself, nearly wiping out his body's platelets.

"Just touching his arms raised blood blisters, and he would bleed from the mouth and even his cuticles," Laura said. "He was so sick."

The antibiotic contained sulfa, to which Dean is highly allergic. In addition, his wife said he was having withdrawals from Soma, which Drugs.com warns should not be stopped suddenly without first talking to a doctor.

"I just felt like curling up," Dean said. "One more day and I would have probably woken up cold."

By the afternoon of Dec. 1, Dean was rushed to the emergency room in a Fremont, California hospital. He was given multiple blood transfusions, and by the following Monday he was stable enough to return to his home.

A week later, his hands and arms still were swollen and bruised.

Now the reality of mounting medical bills is setting in for the former New United Motor Manufacturing Inc. employee.

"He is still very sick," Laura said. "He has a long recovery ahead."

Advice: Carefully inspect the medication label and pills for possible transposed numbers.

Read one of our wrong drug stories, or read more from the source article in the Oakland Tribune of Dec. 12, 2006 by Angela Woodall.

Friday, July 13, 2007

Satisfied users of medication reminder watches: Patient compliance

These three testimonials appeared on a vendor’s web site, so take them with a grain of salt:

C.C.’s Testimonial:
Your company was very helpful in finding a good electronic reminder for my Mother. She is Diabetic and needed help in trying to remember to take her Insulin at the right time. Before she had the watch that we eventually bought from epill.com, we had experienced a couple of spells where her blood sugar required us to call 911 in the middle of the night. Needless to say, this caused my Father and the rest of our family great stress. Since then, she hasn't forgotten to take her Insulin and actually enjoys the vibrating watch that we got for her. With her hearing problems, she never would have had the same degree of success with an audible alarm. Your complete and informative website directed us to the right alarm for her.

Thanks so much! We will enjoy the watch and having my Mom around for hopefully many years to come.

K.P.’s Testimonial
The watch (e-pill MeDose) is a godsend. Prior to using the watch my grandson had approximately 64 seizures in a 2-month period. Since using the watch he has had only 2 seizures in a 2-month period.

T.M.’s Testimonial
Thank you for creating this product (MD.2). My mother is able to stay at home and take her medication thanks to this pill machine. She was recently declared cognitively unable to take her medications from a traditional pill box.

The visiting nurses have commented on how much better she is doing now that she is getting the correct medication at the correct time. Prior to having your specialized pill machine, my mother was inadvertently taking medication from the wrong day or time or getting confused and trying to put the medication back into the regular pill bottles and fill the pill boxes herself.

This machine has eliminated all of that confusion for her and allows her to live at home and take her medication without supervision.

Thank you for giving my mother additional days/months/years of independence. I know at some point her Parkinsons will get the best of her, but for today, the machine [e-pill Monitored Automatic Pill Dispenser] allows her greater independence. Thank you.


Advice to family members with a forgetful loved one on medication: Consider buying a device like the ones described above.

Read one of our patient compliance stories.

Monday, July 9, 2007

I did not want to scare her: Misdiagnosis, medication errors, and patient privacy

Susan Stern’s story:
Two years ago, I drove myself to a hospital Emergency Room with only moderate pain in my right and left shoulder. Since I am over 70, I was immediately given nitroglycerine, and the dose was repeated three times during my Emergency Room stay.

I was brought two more times to the E.R., each time with more severe pains. I was then correctly diagnosed with pericarditis. The last hospital wanted to admit me, but I signed myself out against doctor’s advice.

When my daughter called at my request, the doctor told her I might die unless I stayed at the hospital. I needed my daughter’s involvement, since I could not drive myself to see my doctor, but I did not want to scare her, as she was the mother of a toddler and pregnant with her second child.

I told my doctor that I did not want anyone telling my family that I might die. I was told that my only choice was to prohibit the doctor from giving any information to my family or having no control whatever over what was said.

I am now enjoying excellent health. I put a letter in my file instructing the doctor to share all dire warnings only with me.

Details of a person’s illness should be kept private from kin if the patient is conscious and does not want certain details revealed.

Advice: Write a letter about your preferences and have your doctor put it in your medical record.

Read one of our patient privacy stories.

Source: Susan’s letter to the Editor appeared in the July 9 New York Times.

Friday, June 29, 2007

She turned her life around: Drug-free years and a medication error

Sandra Kenley worked for 11 years in a newspaper mailroom as a legal permanent resident of the U.S., having come from Barbados more than 30 years ago. But then drug addiction derailed her life. She was convicted of drug possession in 1984, and in 2002 for trying to buy a small amount of cocaine—another misdemeanor.

But then she turned her life around, after probation and treatment. She completed a nursing course, and got legal custody of her baby granddaughter, Nakita.

She returned to visit Barbados in 2005 to show off her grand-daughter, then one year old. On returning with Nakita, at Washington’s Dulles Airport, an airport database showed the convictions, and she was ordered to meet with an immigration inspector.

At the meeting, she told her story, and showed she was taking blood pressure medication and was scheduled for surgery. The inspector arrested her, as her two convictions made her subject to exclusion from the U.S.

She was imprisoned in Pamunkey Regional Jail in rural Hanover, Virginia. She died there a few weeks later, having complained that she had not been receiving her blood pressure medication. An autopsy attributed her death to an enlarged heart from chronic high blood pressure ("hypertensive disease").

Sandra was one of 62 immigrants to die in administrative custody since 2004, according to Immigration and Customs Enforcement. Immigration detention is the fastest growing form of incarceration.

Advice to family members of medical error victims: Tell your story to journalists and bloggers to help warn others.

Read another of our detainee stories, or read Nina Bernstein’s source story on the front page of Tuesday’s New York Times.

Thursday, June 28, 2007

Gitmos across America: Drug error death of a detainee

Abdoulai Sall, 50, a Guinea-born taxi cab mechanic in Washington, DC, with no criminal record, died in detention last December.

Abdoulai, whose boss of 17 years had sponsored him for a green card, was at an immigration interview with a lawyer, Paul S. Allen, when he was unexpectedly arrested on an old deportation order — part of a legal tangle left when another lawyer abandoned his case in the 1990s, the lawyer said.

The case file shows that Mr. Allen’s office urged medical intervention for Abdoulai, who had been taking medication for a serious kidney ailment at the time of his arrest. While in detention at the Piedmont Regional Jail in Farmville, Va. he complained that he was not getting his medication and that his symptoms were worsening in a barracks-style unit.

Fellow detainees described him as huddling next to the unit dryer for warmth, barely able to walk. "The medical staff told him they don’t have what he needs because Immigration don’t pay enough money," one detainee wrote.

The accusation was denied by Lou Barlow, the jail’s superintendent, who said Abdoulai had received good care, including a visit to the local emergency room. "We’ve never done anything unethical, illegal or immoral," Mr. Barlow said.

Autopsy results are still pending.

Abdoulai was one of 62 immigrants to die in administrative custody since 2004, according to a new tally by Immigration and Customs Enforcement that counted many more deaths than the 20 previously known.


This is not my America!

I’ve emailed the warden. Let’s see what he suggests families can do to prevent similar tragedies in the future.

Read another of our stories about poor access for our outcasts, or read Nina Bernstein’s source story.

Saturday, June 9, 2007

Prime time for medical error: The doctor’s daughter in the night shift

Seven-year-old Jacquelyn Ley was in the hospital for surgery for her shattered elbow. After surgery, night nurses gave her morphine via a pump, inadvertently setting the dose much too high. Luckily, her mother was there, spending the night in her daughter’s room. She noticed that Jacquelyn was barely breathing, and could have died.

Jacquelyn was lucky because her mother was there and because she knew her stuff: Dr. Carol Ley is Chairman of the Board of the University of Minnesota Medical Center and director of occupational medicine at 3M Company. Dr. Ley says, "the night shift, with its hand-offs and staffing issues, is prime time for medical error."

Advice: Get a patient advocate to be with you in the hospital.

Read another of our night-time stories, or read Max Alexander’s source story in the June 2007 Readers Digest.

Thursday, June 7, 2007

The pharmacist-daughter’s mantra: Drug side effects in the elderly

Phylliss Hunt Moret’s story:

Being my parents’ primary caregiver had never crossed my mind until a critical event six years ago when my dad fell and broke his hip a week prior to my mom’s shoulder surgery. Diabetes, high blood pressure, and heart disease evolved to heart attacks, strokes, an amputation, cognitive decline, and 12+ daily medications each.

Our country "gets it" that babies and toddlers can’t take the same drugs as adults. But seniors have their own unique medication-related challenges. As a pharmacist committed to seniors’ care, I know the mantra by heart: All symptoms in a senior should be considered a drug side-effect until proven otherwise.

A common scenario: A senior gets a new prescription to treat something, say depression. Then a new symptom presents itself: confusion. The senior gets another prescription to treat the confusion, when all along the confusion was a side effect of the medicine used to treat the depression.

Why does this happen? Because seniors are at greater risk for medication-related problems due to multiple illnesses, multiple physicians, multiple medications, and multiple pharmacies.

Because studies repeatedly show that one in five seniors takes at least one medication considered potentially inappropriate, when instead there are alternatives with less risky side effects for seniors.

And because medication-related problems all too often look like common geriatric problems an d syndromes, e.g., confusion, depression, insomnia, tremors, incontinence, weakness, loss of appetite, fainting, loss of balance, falls, and more.

Because there is a scarcity of expertise among health care professionals about geriatric pharmacotherapy and the unique medication-related needs of seniors. Which means that too few health professionals know the mantra….

Advice to people with elderly parents or spouses: Remember Phyliss’ mantra: All symptoms in a senior should be considered a drug side effect until proven otherwise.

Read another of our drug-drug interaction stories, or learn more about medications that are potentially inappropriate for your parents.