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.

A matter of iron: Patient compliance

Dr. Larry Kirkland's story:

What I've come to think of as "the ferrous sulfate affair" may seem trivial but it was representative of the conflicts that occurred during my stay. Because of anemia from a chronic infection secondary to a pressure ulcer, I was placed on ferrous sulfate three times a day. That is not a prescription drug [as it can be bought over the counter]. Since I knew that ferrous sulfate can irritate the stomach, I requested that the pill be left on the table and told the nurse that I would take it during my meal, which had just arrived. The nurse said, "I can’t do that." I thought she was kidding, so I explained my concern and assured her that I'd take the pill 10 or 15 minutes later, adding jokingly, "I promise not to try to sell it." Her response was to pick up the pill cup and say, "I'll wait until you're ready." When I told her it might be a few minutes, she repeated that she'd wait. Rather than prolonging this demeaning and unnecessary charade, I told her to cancel the medication order.

Although I knew it would mean that the attending physicians wouldn't know all the medications I was taking, I had my wife bring some ferrous sulfate tables from home. The fact that I needed the iron was never mentioned in the negotiation over when I took it. Instead of honoring the patient's right to be involved in decisions, the nurse was practicing a form of "directly observed therapy," an approach usually reserved for patients who won't comply with antituberculosis therapy, drug addicts in methadone programs, prisoners, and mentally incapacitated patients.

It's possible that such a rigid approach had evolved at this hospital out of dealing regularly with emotionally fragile patients….But if the patient is a physician…conflicts will arise if he is treated in the same manner as, for example, a patient with brain damage….

I'd never before come across so many staff members seemingly fearful of using their own experience, common sense, and judgment in making a decision, nor so many who cited "policy” or "regulations" to explain a particular action. I could single out individuals, but it seems likely that a share of the blame for the pervasive disrespectful treatment I encountered at this hospital should be assigned to the hospital administration and the priorities it transmits to the staff through training, example and regulations….

I remember a time when the patient, not regulations or the "bottom line," was the central driving force in the system. Maybe this is naïve, but I fail to see how a return to more personal and compassionate attitudes would reduce safety or be economically unsound.

Advice to hospitalized patients on taking their home medications: Stick up for yourself, and discuss this with nurses and doctors in the hospital.

Read our Hospital Patient Bill of Rights story, or read Dr. Kirkland's source story in the June 2007 issue of the American Journal of Nursing.

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.

Parkinson’s Treatment - Off and On: A medication error

Raul, a very nice elderly man who has had Parkinson’s Disease for 15 years, had frozen in place, seemingly awake but unresponsive, for more than an hour. Such on/off states among Parkinson’s patients are quite frightening to spouses when they occur. They seem to occur when the patient’s brain lacks Dopamine, a chemical that is provided by Sinemet. Alarmed, his wife called an ambulance, which took Raul to a large, well-known medical center. He arrived at noon. Later that afternoon, his wife gave his Sinemet—the mainstay of his treatment for all these years—to the E.R. nurse, with instructions that his next pill was due at 11 pm.

Raul was finally admitted to a hospital bed on the Surgery unit at 9 pm, because no bed in an appropriate unit was available. When Raul’s adult son called Raul’s nurse at 11:40 pm to verify the nurse had indeed given him the Sinemet, the nurse said another nurse was getting it. In other words, the attending physician had to write an order for the same medicine, hopefully in the same dose, with a similar timed release, and the hospital Pharmacy would dispense it—but this had not been done, and the dose was already 40 minutes late. Without their Sinemet, patients with advanced Parkinson’s often have extreme, uncontrollable tremors affecting their whole arms and legs, as viewers of Michael J. Fox’s political advertisement in last year’s Senatorial election in Missouri saw. The nurse mentioned that Raul had been quite “restless.” As my teenager says, Duh!

The hospital’s delay in providing the Sinemet had both caused this upsetting and uncomfortable set of tremors, AND made a recurrence of the on/off state even more likely—and that was the very cause that brought him to the hospital for treatment! Excuse my cynicism, but I doubt that the hospital will withhold their bill, or delay in sending it. Raul’s Medicare should cover the bill, so my thanks to you, Reader, the American taxpayer, for paying for his care

Advice to patient advocates: If a hospital patient depends on the meds he has brought from home, call to ensure that nurses have given them to him on time.