$52,000 for headaches: Multiple wrong-drug errors

In his fine essay in the New Yorker magazine this week, Dr. Atul Gawande described one woman as an example of a high-cost patient. She is a young migraine sufferer with diabetes, age 25. She had visited the E.R. about every ten days, i.e., 29 times, in a ten-month period, compiling bills of $52,000. She had faithfully filled her prescriptions, not missing a single renewal.

She'd take her medicine, but it wasn't working. When the headaches got bad, she'd go to the E.R. or to Urgent Care. The doctors would order CT scans and MRIs to ensure she didn't have a brain tumor or aneurysm (a blood-filled balloon-like bulge in a blood vessel), give her a narcotic injection to temporarily stop the headache, renew her prescription for imipramine if needed, and send her home. The next time she had a migraine, she'd go to the E.R. again and see the doctor then on duty, repeating the pattern. She wasn't having a primary care physician try different medications systematically to figure out how to prevent or limit her migraines.

She is an employee of a company that pays for her health care. At that company, like most, a very small fraction of patients consume a very disproportionate share of all healthcare expenses. The E.R. is the wrong place to treat people with a chronic condition like hers.

Three kinds of people could help her escape this agonizing pattern: medical providers, her employer, and she herself. First, the E.R. doctors might well have recognized her as one of their "frequent flyers." It's a shame none of them helped her get a primary care provider. (That would have gotten her better care, reducing costs by cutting the hospital’s E.R. revenue.) Second, the employer might have recognized that her medical care was poor. Indeed, the employer had hired Verisk Health to analyze their costliest patients' care, and Verisk’s research director discovered the problem in the woman’s pattern of care. It's not clear from Gawande's essay whether the unfortunate woman eventually received better care as a result of the data analysis. Third, the woman herself, or a friend, family member, or other patient advocate might have realized that her medical care was poor. Lacking that, the woman apparently took for granted that suffering in this way was her lot in life. She didn't think to advocate for herself.

Advice: If you're limited by poor health, ask an advocate if anything can be done to make your life easier.

Read another story on migraines. Thanks to Dr. Atul Gawande for the source essay in the New Yorker of January 24.

The magician, not the wand: Wise use of the electronic medical record

Dr. Matthew Heller's comment:
Having been in solo practice for rheumatology for 34 years, I know that it's the magician, not the wand, that provides better health care. Although I use electronic medical records in my office, I do it in a way that does not interfere with listening to patients, making eye contact and practicing medicine in the way that I was taught 40 years ago.

It's not just privacy that’s at stake. More often than not electronic records spit out boilerplate data (often laden with errors) that get transmitted from one doctor to another completely devoid of any semblance of human interaction.

My vote is for the better practice of medicine, not the better use of computers.

Advice: Find a doctor who uses an electronic medical record as a useful tool, while preserving rapport and attention with you while in the exam room.

Read one patient’s observations on this.

Thanks to Dr. Heller for his letter to the editor, published in today’s New York Times.

Is it better to bring 8,000 individual cases?: Pathology errors in breast and prostate cancer biopsies

Patients impacted by a misdiagnosis and the quality of service at the Miramichi Regional Hospital will file a class-action suit on Tuesday.

Halifax lawyer Raymond Wagner will file the proposed lawsuit in Miramichi on Tuesday. It is available to any patients who had a biopsy or other procedure at the Miramichi Regional Hospital between 1995 and February 2007, regardless of their test results.

"They suffered great mental distress, frustration, and needless anxiety while awaiting confirmation that the original results were correct," he said.

The province is reviewing more than 23,700 cases from the hospital dating from 1995 to 2007 while a public commission is examining the rate of breast and prostate cancer misdiagnoses.

An independent audit of 227 cases of breast and prostate cancer biopsies from 2004-05 found 18% had incomplete results and 3% had been misdiagnosed at the health authority in northeastern New Brunswick, which was being served by a now-suspended pathologist.

Filing a lawsuit will hold the system accountable, Wagner said, adding that arguments revolve around allegations of negligent hiring and poor quality control at the pathology department.

"The suit of course is to assist the people in the community surrounding the Miramichi with respect to their health care," he said. "It is to bring to account the hospital administration with respect to oversight and quality control and to assure the community that their health care is of sufficient quality for them to have confidence in that health care."

A judge will have to decide if the suit will go ahead, which will involve testing whether the lawsuit is the most efficient way to proceed, Wagner said.

"Is it more appropriate and more efficient to have the case determined in one case, or is it better for everybody to bring their own individual cases, in other words 8,000 cases?" he said.

The Halifax law firm, Wagners, is working in co-operation with Newfoundland and Labrador firm Ches Crosbie Barristers.

Advice: Pathologists have to use very subjective judgments in assessing biopsies. Ask the pathologist how certain s/he is about the findings of your biopsy.

Read another Pathology error story.

The source article comes from a posting today on the Canadian Broadcasting Corporation's website.

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.

The Machine was the Perp, Part 2: A drug dispensing error

Earlier
I described what happened after nurses opened the drug drawer of a mis-stocked automated dispensing machine and gave adult doses of Heparin to three newborns.

That hospital unit usually only received doses of Heparin for newborns, and the vials of adult and baby doses are of similar size and color. If the hospital had consistently used vials of a distinct size or color for babies or youths, the errors would have been far less likely. The pharmacy technician would not have stocked the drug wrongly, and the nurses would not have given it to the babies.

Safeguards like this distinctive repackaging are a form of error-proofing ("pokayoke," in Japanese)--an effort to make errors impossible, or at least highly unlikely. Of course, such distinctive packaging costs hospitals time and money. Since the powerful blood-thinner Heparin is known as a hazardous medication, it's probably money well-spent.

Advice to patients and advocates: Be especially vigilant when hazardous medications are being given.

Advice to pharmacy directors: Repackage hazardous medications to consistently distinguish adult from infant doses with distinctive colors or vial sizes.

Read Nurse Mary Bylone's blog posting for more.

In Her Second Trimester: Medical device and overdose lawsuit

Sylvia Lane was 17 weeks pregnant. Diabetic, she lay in her bed in her Lynnwood, Washington apartment, comatose and alone, her blood and brain in desperate need of sugar. But the medical device she'd just received instead kept pumping insulin into her body, starving her brain. Her husband was on an aircraft carrier, halfway round the world. The small pump had a safety feature designed to stop the insulin flow in emergencies like this. But the feature had never been turned on. The pump had been shipped to her with the option turned off, and she hadn't known about the "auto-off" safety feature. She suffered severe and permanent brain damage. And her doctors determined that her growing fetus had suffered irreparable harm; she was not able to have the baby. Her family sued Medtronic Inc. — the parent company of the pump's manufacturer — claiming the pump was unsafe. Her family reached a settlement with Medtronic whose details have only now come to light. This riveting story is reported by Ken Armstrong and Justin Mayo.

Advice to patients: Before you use any pump, make sure you know what safeguards in the pump's design might prevent an overdose.

For another story of multiple errors caused by a machine, see The Machine Was the Perp.

The Machine Was the Perp: Wrong drug errors

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

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

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

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

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