Beware of 'bad apples' in your health care system

Doctors are often an easy target for their failure to cure or keep alive their patients.

And it has been so since quite long. About four hundred years ago, the English poet Francis Quarles wrote that: 

“Physicians of all men are most happy; 

what success soever they have, 

the world proclaims it; 

and what fault they commit, 

the earth covers it”.

The famous Oprah Show has this touching story to tell:

( http://www.oprah.com/health/Dennis-Quaids-Medical-Nightmare)

In November 2007, one such mistake almost took the lives of infant twins, the children of actor Dennis Quaid and his wife, Kimberly.

Dennis and Kimberly's story begins with two small blessings, Thomas Boone and Zoe Grace. "We were so happy to be able to be blessed by those two," Dennis says. "They both came out so perfect."

Days after the twins came home from the hospital, however, they developed serious staph infections. Doctors told Dennis and Kimberly to take their newborns to Cedars-Sinai Medical Center, where they were given antibiotics intravenously.

On their second day at Cedars-Sinai, Dennis says the twins seemed to be doing well, so he and his wife went home to get some rest. That night, Kimberly says she had an overwhelming feeling that something was wrong. Dennis called the hospital to check on their children, but a nurse assured him everything was fine.

They found out later that, at the time of the call, Thomas and Zoe were actually in serious danger.

When they arrived at Cedars-Sinai the next morning, members of the medical staff were waiting with terrible news. "This started probably the worst day of our lives," Dennis says.


The Quaids learned that nurses had accidentally given their children two powerful doses of Heparin, a blood thinner that's prescribed to keep IV lines clear and prevent blood clots. "They got a thousand times the dose of Heparin that they were supposed to get," Dennis says. "They were supposed to get 10 units of Heparin, and they got 10,000 units of Heparin—twice. That's when their blood turned to the consistency of water."

When the Quaids finally saw their babies, Kimberly says they were black and blue. "It was a bad sight," she says. "They were bleeding out."

A series of errors led to the overdose that left little Thomas and Zoe fighting for their lives. First, a pharmacy technician made a mistake and put larger-dose bottles of Heparin in the same bin with the smaller-dose bottles.

Then, the nurse caring for the Quaid babies grabbed a bottle out of the bin without checking the label. The 10,000-unit and 10-unit bottles are similar in color, and some say it's difficult to tell them apart.

Dennis says nurses across the country have made the same mistake. "A very similar incident killed three infants in Indianapolis a year before that," he says. "Even after our incident, two other fraternal twins in Texas, in Corpus Christi, died last summer because of this."

Most people—including parents—don't question nurses and medical technicians enough, Dr. Oz says. In fact, Dennis claims his twins' first overdose occurred while he and Kimberly were in the hospital room. "The nurse came in to change the medication, and we were there," he says. "At the time, we weren't really informed."

For 40 hours, doctors monitored the Quaid twins closely. Dennis and Kimberly say they were in a state of shock. "It was like the floor was pulled from under our feet. I didn't understand it, to tell you the truth," Dennis says. "It was the scariest day of our lives."

After two days, the twins' health began to improve as the blood thinner wore off. When they were sleeping comfortably, Dennis says he realized Thomas and Zoe survived this ordeal for a reason. "[I thought,] 'These two little kids, 12 days old, they're going to change the world in some way,'" he says.

Now, Dennis knows why this happened to his family. "I think that the reason is to raise public awareness and to get something done about computerized record keeping and bar coding in hospitals," he says. "That's going to save lives—a lot of lives."

In March 2008,

Trish Torrey gave

“A Master List of Never Events –

28 medical errors "never events," meaning, of course, that they should never happen.

(http://patients.about.com/od/atthehospital/a/mederrorlist.htm)

First of all, who is Trisha Torrey? 

In her own words:

“I began my quest to help others navigate their own health care after being diagnosed with a very rare, life-threatening cancer in 2004.

I was told two labs had independently confirmed the diagnosis, and I needed to start chemotherapy immediately or I would die within months.

Trusting my intuition that I was NOT  nearly so sick as the lab reports indicated, I set about finding the right professionals, asking questions, researching on the Internet, analyzing medical terms and being doggedly persistent to learn more about the disease I was told would be my demise.

Instead, what I learned surprised everyone. Just short of starting chemo, I determined I had no cancer at all.

My findings were later confirmed by the National Institutes of Health.

Realizing that millions more patients were confronting challenges with their health care every day, I began documenting the work I had done so others could use the tools I had developed, too.”

(See her website : www.AdvoConnection.com)

The Master List of the never events from Trisha :

Most of these mistakes are likely to happen while a patient is being cared for in a healthcare facility. Others can happen anywhere, including in a patient's home.

Surgical Events

• Surgery performed on the wrong body part
• Surgery performed on the wrong patient
• Wrong surgical procedure on a patient
• Retention of a foreign object in a patient after surgery or other procedure

• Intraoperative or immediately post-operative death in a normal healthy patient

Product or Device Events

• Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
• Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
• Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility

Patient Protection Events

• Infant discharged to the wrong person
• Patient death or serious disability associated with patient disappearance for more than four hours
• Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility

Care Management Events

• Patient death or serious disability associated with a medication error
• Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products (transfusion of the wrong blood type)
• Maternal death or serious disability associated with labor or delivery on a low-risk pregnancy while being cared for in a healthcare facility
• Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
• Death or serious disability (kernicterus) associated with failure to identify and treat jaundice in newborns
• Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
• Patient death or serious disability due to spinal manipulative therapy

Environmental Events

• Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
• Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
• Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
• Patient death associated with a fall while being cared for in a healthcare facility
• Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility

Criminal Events

• Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
• Abduction of a patient of any age
• Sexual assault on a patient within or on the grounds of a healthcare facility

Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility.

All said and done, we must find out  how serious is all this :

·        The knowledgeable health reporter for the Boston Globe, Betsy Lehman, died from an overdose during chemotherapy.

·        Willie King had the wrong leg amputated. Ben Kolb was eight years old when he died during ''minor" surgery due to a drug mix-up.

·        These horrific cases that make the headlines are just the tip of the iceberg.

• In 1999, the Institute of Medicine, an agency of the US Government, issued the results of two studies which stood patients and the medical community on their ears. The report, called To Err is Human, stated the following:

• Between 44,000 and 98,000 Americans die each year from preventable medical errors in hospitals alone. That does not account for those who die from medical errors outside the hospital.
• It is the equivalent to the number of people who would die if two Boeing 737-400 aircrafts carrying total 268 passengers crashed every day, and all its passengers died.
• Even when using the lower estimate, deaths due to medical errors exceed the number attributable to the 8th-leading cause of death. More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516).

·        Total national costs (lost income, lost household production, disability and health care costs) of preventable adverse events (medical errors resulting in injury) are estimated to be between $17 billion and $29 billion, of which health care costs represent over one-half.

·        One recent study conducted at two prestigious teaching hospitals, found that about two out of every 100 admissions experienced a preventable adverse drug event, resulting in average increased hospital costs of $4,700 per admission. If these findings are generalizable, the increased hospital costs alone of preventable adverse drug events affecting inpatients are about $2 billion for the nation as a whole.

Let me hasten to add : God bless the doctors and forgive them because they are able to really look after us very well – almost always.

Medical Errors ?  What are they? Iatrogenic events? Never heard of it?

Iatros means physician in Greek, and -genic, meaning induced by. “ Iatrogenic” , loosely stated , means  any adverse condition in a patient occurring as the result of treatment by a physician or surgeon, especially to infections acquired by the patient during the course of or  as a result of medical treatment or caused by a doctor's diagnosis.

A beautiful article by :Nicolas S. Martin
Executive Director, American Iatrogenic Association (http://www.iatrogenic.org/define.html) gives interesting details:

• Perhaps , there is some elasticity of language and therefore, the term ‘iatrogenic’ disease is now applied to ANY adverse effect associated with any medical practitioner or treatment.
• The practitioner need not be a physician, he might be a nurse or a radiology technician, or any one of the scores of differentiated healthcare workers encountered in hospitals, clinics, nursing homes, or offices, or for that matter in the ambulance on the way to one of those places.
• It also covers ‘other’ practitioners such as homeopaths, etc and psychiatrists and even our Grandma, if she is the one handing out the remedy.
• It might refer to something as tangible as surgery or as subtle as a (shocking) conversation by a health specialist.

This 1997 report, “To Err Is Human” has a positive side, too.

·        It was followed in 2001 by another widely cited Institute of Medicine report, "Crossing the Quality Chasm," which goes further to many more points and inspired the “ 100,000 Lives Campaign” , which in 2006 claimed to have prevented an estimated 124,000 deaths in a period of 18 months through patient-safety initiatives in over 3,000 hospitals.

·        The Washington State Legislature (USA) asked the Department of Health to develop recommendations to help practitioners avoid medication errors. The Department developed the following recommendations in consultation with the regulatory boards and commissions, professional associations and Washington State hospitals. Such as : 

• Include a notation of purpose (e.g., for cough) on all prescriptions, unless clearly inappropriate.
• Avoid abbreviations for non-standard drug names on prescriptions and drug orders.

•  For children under 14 years of age, always record the child’s age (and weight when appropriate) on prescriptions.

• Use standard terminology.

·         Always use a zero before a decimal point (0.1 mg) 

         Use the metric system

· Never abbreviate “microgram”

·         Spell out “units” rather than using “U”

Extracts from “20 Tips to Help Prevent Medical Errors from US Deptt of Health” (http://www.ahrq.gov/consumer/20tips.htm

What are Medical Errors?

Medical errors happen when something that was planned as a part of medical care doesn't work out, or when the wrong plan was used in the first place. Medical errors can occur anywhere in the health care system:

• Hospitals.
• Clinics.
• Outpatient Surgery Centers.
• Doctors' Offices.
• Nursing Homes.
• Pharmacies.
• Patients' Homes.

Errors can involve:

• Medicines.
• Surgery.
• Diagnosis.
• Equipment.
• Lab reports.

They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet is given a high-salt meal.

Most errors result from problems created by today's complex health care system. But errors also happen when doctors and their patients have problems communicating. For example,

a recent study supported by the Agency for Healthcare Research and Quality (AHRQ) found that doctors often do not do enough to help their patients make informed decisions. Uninvolved and uninformed patients are less likely to accept the doctor's choice of treatment and less likely to do what they need to do to make the treatment work. 

1.   The single most important way you can help to prevent errors is to be an active member of your health care team.

That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results. Some specific tips, based on the latest scientific evidence about what works best, follow.

2. Make sure that all of your doctors know about everything you are taking. This includes prescription and over-the-counter medicines, and dietary supplements such as vitamins and herbs.

3. Make sure your doctor knows about any allergies and adverse reactions you have had to medicines.

4. When your doctor writes you a prescription, make sure you can read it.

 

If you can't read your doctor's handwriting, your pharmacist might not be able to either.

5.   Ask for information about your medicines in terms you can understand—both when your medicines are prescribed and when you receive them.

• What is the medicine for?
• How am I supposed to take it, and for how long?
• What side effects are likely? What do I do if they occur?
• Is this medicine safe to take with other medicines or dietary supplements I am taking?
• What food, drink, or activities should I avoid while taking this medicine?

6.   When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed? (A study by the Massachusetts College of Pharmacy and Allied Health Sciences found that 88 percent of medicine errors involved the wrong drug or the wrong dose.)

7.   If you have any questions about the directions on your medicine labels, ask. They can be hard to understand.

8.   Ask your pharmacist for the best device to measure your liquid medicine. Also, ask questions if you're not sure how to use it.

Research shows, for example, that many use household teaspoons, which often do not hold a true teaspoon of liquid.

9.   Ask for written information about the side effects your medicine could cause, so that you will be better prepared if it does—and you can report the problem right away and get help before it gets worse.

10.   If you have a choice, choose a hospital at which is well known for the procedure or surgery you need.

11.   If you are in a hospital, 

consider asking all health care workers who have direct contact with you whether they have washed their hands. Hand washing is an important way to prevent the spread of infections in hospitals. Yet, it is not done regularly or thoroughly enough. A recent study found that when patients checked whether health care workers washed their hands, the workers washed their hands more often and used more soap.

12.   When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will use at home.

This includes learning about your medicines and finding out when you can get back to your

regular activities. Research shows that at discharge time, doctors overestimate what their patients understand about what they should or should not do when they return home.

13.   If you are having surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactly what will be done.  Doing surgery on the left knee instead of the right is  rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. The American Academy of Orthopaedic Surgeons urges its members to sign their initials directly on the body part site to be operated on before the surgery. 

14. Speak up if you have questions or concerns. You have a right to question anyone who is involved with your care.

15. Make sure that someone, such as your personal doctor, is in charge of your care. This is especially important if you have many health problems or are in a hospital.

16.   Make sure that all health professionals involved in your care have important health information about you. Do not assume that everyone knows everything they need to.

17.   Ask a family member or friend to be there with you and to be your advocate (someone who can help get things done and speak up for you if you can't). Even if you think you don't need help now, you might need it later.

18.   Know that "more" is not always better. It is a good idea to find out why a test or treatment is needed and how it can help you. You could be better off without it – you don’t know unless you find out.

19.   If you have a test, don't assume that no news is good news. Ask about the results.

20.   Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources. Ask your doctor if your treatment is based on the latest evidence.

In short, be  A SMART PATIENT.