They stopped me from saving her life: Patient partnership and E.R. treatment

Lee's story:
I live here in Arlington, Massachusetts. For several years I was dating a woman named Elizabeth. She was a Type 1 diabetic from when she was 12 years old. She hadn't taken good care with her insulin when she was young because she was angry and felt adults didn't understand her. Her mom was divorced several times during her childhood, and that added to what she rebelled against by eating sugar when she shouldn't. She also feared gaining weight if she took as much insulin as she should. Most type 1 diabetics became diabetics as children, and have inner psychological battles. There's a very private inner painful world – they could die if they don't do what they're supposed to do. Some kids rebel….

When I met her, Elizabeth's condition had advanced to the point where both of her kidneys had failed, and she had received a transplanted kidney from her mother. She had had five eye operations, and was legally blind in one eye. She had neuropathy [a nerve problem] in her feet and hands, and couldn't balance well. She was an adorable, absolutely lovely and loving person, the most amazing person I ever met.

Due to side-effects of the immunosuppressive drugs she was on to prevent rejection of her transplanted kidney, her vascular condition had degenerated to that of a typical 95-year old woman (though she was only 43). At the time of her kidney transplant, the immunosuppressive drugs used caused calcium to leach out of bones and deposit in the walls of her arteries, so she had atherosclerosis, and plaque deposits in her arteries.

During 2008 she had four minor strokes, and recovered completely from each. She also developed arterial spasm events in her brain which could give stroke-like symptoms. She'd have to go the E.R. when a brain artery spasm happened, and the spasm could be immediately relieved with Compazine.

On New Year's Eve Day last year, she called me at 6 am in the middle of one of these brain arterial spasms; I rushed to her house and drove her to the E.R.

She had been through the same situation in that E.R. four or five times before, so it was all in her records what needed to be done, including a letter with specific directions from her stroke specialist; all they had to do was give her a short I.V. [intravenous, i.e., into the vein] of Compazine. But the E.R. doctor decided to review her whole case first. So she continued retching, and her retching caused a cerebral hemorrhage. Because of the cerebral hemorrhage she was taken off Plavix in the ICU [intensive care unit]. Before she completed her recovery from the hemorrhage in the ICU, she had a severe stroke – because she'd been taken off the Plavix - and she died.

During the whole time in the E.R., I was telling the nurse, "You need to give her the Compazine! Here's a letter about that from the stroke [physician] specialist!" I asked the nurse, "Can't you just give the IV?" She said, Not without a doctor's order. The letter from the stroke specialist wasn't good enough.

So she didn't get the Compazine in time. That review by the E.R. doctor effectively killed her – because of the time he spent on it.

I knew more about her condition, much more, than the E.R. doctor because I'd read hundreds of pages of information about it. The nurse asked him to come into the room and talk to me, but he did not come in until after her hemorrhage, and by then it was too late.. Doctors assume that someone who's not an M.D. is an idiot; it's not the case. Sometimes we are better educated about a condition than the doctor.

With the computer system at that hospital, there's no way for a standing order to be placed in the system to dictate what to do during an E.R. visit with a particular problem. So someone with a recurring condition (as most stroke patients have), cannot take advantage of their stroke specialist's prior knowledge of what has to be done.

I've called every major vendor of healthcare software in the U.S. No system has a feature allowing it to hold a standing order for the E.R. If such a feature existed, Elizabeth would be alive.

Back up four months: When we learned first about the brain arterial spasm problem that Elizabeth had, and how critically she'd need Compazine, I asked if I could have a vial of Compazine and a syringe to use in an emergency. Their answer: the standard dose is by I.V. and not syringe injection. Our policy is that we don't allow people to have Compazine at home. I had specifically tried to be responsible in a way to save her life, and they stopped me, like they did later in the E.R. too.

I'd tried to save her another way, too. When we were in the car on the way to the E.R., I called ahead, and asked them to please get the Compazine ready. They answered, "No, you’re not an ambulance."

I don't want to pursue a legal case unless that is necessary to change their system. Not every doctor will be good; the guy that was on duty in the E.R. was horrible. I want a capability so a person can prevent damage from the stupidity of an inadequate doctor by acting ahead of time.

This business of preventing people who are highly responsible for their health from helping themselves and the ones they love is insane!

The hospital wouldn't let us have a Compazine for an emergency they knew would predictably occur. What do you mean, she can't have a syringe?! She gave herself insulin about four times a day!

I could be trained. I'm a very competent person. I taught at MIT and I designed medical equipment for years at Hewlett Packard. If I'd known a spasm could kill her, I'd have done whatever it took to have that Compazine at home. If I had to, I would have stolen the stuff.

Lee's Advice: If you or someone you love has a recurring condition that needs to be treated at the E.R., write a letter to the hospital urging them to put in place a standing order at the E.R. for how to treat your condition. Urge them also to put in place a policy of preparing for your arrival based on a phone call from you. If there is a treatment you should be trained to give at home, push to be trained to administer that treatment.

Please feel free to send a copy of this along with your request, and please let the writer of this blog know what response you get.


Thanks to Lee Weinstein for sharing Elizabeth's story.

Read about a near-miss in matching a patient’s home medications with hospital medications [“medication reconciliation”].

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.

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.

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.

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.

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)

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.

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.

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.

Nine years of HIV treatment, but no HIV: A lawsuit about misdiagnosis

Testimony has begun in a lawsuit brought by a Fitchburg, Massachusetts woman who received nine years of HIV treatment after being misdiagnosed with the virus. Audrey Serrano is seeking unspecified damages from several doctors and clinics that were involved in her treatment.

One of those doctors told a Worcester Superior Court jury Tuesday she began treating Audrey in 1994, about 18 months after another doctor had diagnosed her with HIV. The doctor testified she had no reason to question the original diagnosis because Audrey convinced her she had the virus that causes AIDS.

Audrey claims in her suit that she suffered a variety of physical ailments because of AZT and other harsh medicines she took daily because of the diagnosis. She says the emotional distress led to depression.

Advice to those receiving a diagnosis based on a lab test for a dread disease: Verify the diagnosis. Many lab tests have high false-positive rates.

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

Thanks to the Associated Press for the source story on Dec. 4.

You don't have any questions for the pharmacist, do you?: A fatal methadone overdose

Terry Paul Smith, a 46-year-old roofer, suffered from a disorder of the peripheral nerves (neuropathy) in his back and legs, which kept him in chronic pain. He took Oxycontin and Neurontin, but he disliked the way it made him feel, e.g., making him sometimes "drop out" in the middle of a conversation. After he mentioned the pain meds' side effects, his doctor changed the prescription to methadone, a narcotic pain reliever. The doctor wrote a prescription for Terry to take four 10-milligram pills, twice a day.

Terry filled the prescription at a local Walgreen's pharmacy in Jacksonville, Florida. In handing over the pills, the pharmacy employee asked, "You don’t have any questions for the pharmacist, do you?" They didn’t.

Though Terry didn’t know it, the label on the medication vial was incorrect; it directed him to take four tablets "as needed for chronic pain," and did not mention any limits on the frequency. Terry took the pills for the first time on July 23-24, 2001.

Within 36 hours, he was dead. An autopsy that his widow insisted found toxic levels of methadone in his blood.

The pharmacist had mislabeled the pills as "take as needed" rather than take "twice a day."

Now Terry's widow, Pearl Smith, is pursuing a lawsuit against Walgreen's. Next week, the jury will begin considering the case.

A company spokesman says Walgreen's has spent $1 billion over the last decade on pharmacy safety systems, safety training and technology. Walgreen's filled more than half a billion prescriptions in the last fiscal year.

Advice: Read the doctor's prescription and check it carefully against the label, especially for a new medicine.

Read an informed consent story, or read more from the source article by Kevin McCoy in the USA Today of Nov. 2.

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.

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.

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.

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.

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.

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.

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.

Somehow he's still an optimist: Leukemia patient after medical errors

Before his first trip here, John Kunka was near death — a place he's been many times, before and since. But this morning, the 28-year-old Alberta, Canada, resident is nearly ready to get married here, at an annual event called the Plunge for Patients. These money-raising races, hosted every summer by Morey's Piers, are a big event in his life, which would explain his wedding here — two years after he got engaged at the races.

Here's how important: As Kunka sees it, he may well be alive today and able to marry the love of his fragile life because of the Plunge for Patients and the cause it benefits.

At 13, Kunka's world was built around soccer and school. Then leukemia came along and blew up his world, and his body.

But at first, he appeared to be lucky. The recommended treatment for his rare form of the blood cancer was a bone-marrow transplant, and Kunka's doctors found a good match without having to go far — his sister, Sabrina. Six months after he was diagnosed, he got the transplant and his cancer went into remission. But now he knows his health troubles — which would send him "through hell and back several times," in the words of a woman who knows his history — were just starting.

He developed graft-vs-host disease, or GVHD — his body was rejecting the new bone marrow and attacking his own organs. His skin, for example, grew so tight on his body that "it's like glass," he says.

Early in the fight, he got to go on a trip with a group that sends sick children on dream vacations. His trip was to Disneyland but his dream was interrupted with a rude dose of reality when he bumped into a table in a hotel room — and his crisp-textured skin burst like a glass shattering, sending him to the local emergency room. "That gave me an idea of what to expect for years to come," John says, showing off legs carrying the scars of many such war stories in his 15-year battle within his own body.

His treatments for the condition made his joints deteriorate. He has had three knee replacements and two hip replacements — again, at age 28 — and he expects to need more surgery to replace his shoulders and his ankles and even his knuckles, all because of complications from his disease.

He has shattered a hip and been plagued with blood clots in his lungs. He has had more than 40 operations, and will have even more.

“I've almost died after my last few surgeries,” he says, from overdoses of anesthesia and morphine.

Still, somehow after all that, John Kunka is an optimist.

He hasn't been able to play since he got sick, but he never lost his passion for soccer, and he coaches on crutches if he has to.

Advice to people with chronic illness: Optimism and love might be powerful forces for you.

Read another of our leukemia patient stories, or read Martin DeAngelis’ source story.

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.