Monday, May 2, 2016

Ollie the Ostrich

Once again another failing of our medical industrial complex. First the story of the woman with locked in syndrome who could hear every negative thing her Physician team sad about her case. And subsequent denials that this too place by the Physician with a finger pointing to some "others" who may have been negligent in their professionalism. I am sure denial is a common daily mantra in most hospitals.

Then I read this article about how post discharge is the most dangerous time for a patient (why yes on this I can speak from personal experience) and until we get nationalized health care a patient bill of rights I suspect this will continue.


Hospital discharge: It’s one of the most dangerous periods for patients

By Jordan Rau
The Washington Post
April 29 20126

Joyce Oyler died because of medication mistakes by a Missouri pharmacy and home health agency. Her daughter, holding the photo of her mother and aunt, says the error "should have been caught about five different ways."

Within two weeks of Joyce Oyler’s discharge from the hospital, sores developed in her mouth and throat, and blood began seeping from her nose and bowels.

Her daughter traced the source of these problems to the medicine bottles in Oyler’s home in St. Joseph, Mo. One drug that keeps heart patients such as Oyler from retaining fluids was missing. In its place was a toxic drug with a similar name but a different purpose, primarily to treat cancer and severe arthritis. The label said to take it daily.

“I gathered all her medicine, and as soon as I saw that bottle, I knew she couldn’t come back from this,” said Kristin Sigg, the younger of her two children. “There were many layers and mistakes made after she left the hospital. It should have been caught about five different ways.”

Oyler’s death occurred at one of the most dangerous junctures in medical care: when patients leave the hospital. Bad coordination often plagues patients’ transition to the care of home health agencies as well as to nursing homes and other professionals charged with helping them recuperate, studies show.

“Poor transitional care is a huge, huge issue for everybody, but especially for older people with complex needs,” said Alicia Arbaje, an assistant professor at the Johns Hopkins School of Medicine in Baltimore. “The most risky transition is from hospital to home with the additional need for home care services, and that’s the one we know the least about.”

Medication mistakes like the one in Oyler’s case — which slipped past both her pharmacist and home health nurses, according to court records — are, in fact, one of the most common complications for discharged patients. The federal government views them as “a major patient safety and public health issue,” and a Kaiser Health News analysis of government records shows such errors are frequently missed by home health agencies.

Between January 2010 and July 2015, the analysis found, inspectors identified 3,016 home health agencies — nearly a quarter of all those examined by Medicare — that had inadequately reviewed or tracked medications for new patients. In some cases, nurses failed to realize that patients were taking potentially dangerous combinations of drugs, risking abnormal heart rhythms, bleeding, kidney damage and seizures.

The variety of providers that patients may use after a hospitalization creates fertile ground for error, said Don Goldmann, chief medical and science officer at the nonprofit Institute for Healthcare Improvement. “This episodic care at different places at different times is not designed to keep the overall safety of the patient in mind,” Goldmann said.

One factor is the lack of organization and communication among these other parts of the medical system. Of the $30 billion that Congress appropriated to help shift the system to electronic medical records — to ensure better coordination of care and reduce errors across the board — none went to nursing homes, rehabilitation facilities or providers working with individuals in their homes.

“The systems are not adequately connected,” said Robert Wachter, a professor at the University of California at San Francisco who studies patient safety.

At any point, problems can occur.

At hospitals, federal data show that fewer than half of patients say they’re confident that they understand the instructions of how to care for themselves after discharge.

In nursing homes, case management frequently comes up short. A 2013 government report found more than a third of facilities did not properly assess patients’ needs, devise a plan for their care and then follow through on that.

And at home health agencies, failures to create and execute a care plan are the most common issues government inspectors identify, followed by deficient medication review, according to KHN’s analysis. Over the first half of this decade, 1,591 agencies — 1 in 8 — had a defect inspectors considered so substantial that it warranted the agencies’ removal from the Medicare program unless the lapses were remedied.

‘Devastating’ cancer drug

Oyler’s death in October 2013 shows how a fatal mistake can slip past multiple checkpoints. The 66-year-old retired safety manager left Heartland Regional Medical Center in St. Joseph after being treated for congestive heart failure, in which the heart fails to pump effectively, causing fluid buildup in the lungs, shortness of breath and swelling in the feet. She returned home as a hospital nurse telephoned the local Hy-Vee Pharmacy with eight new prescriptions. One was for the diuretic metolazone.

But the medications a pharmacy technician wrote down did not include metolazone. Instead, it listed methotrexate, which can damage blood cell counts, organs and the lining of the mouth, stomach and intestines. The drug is so potent that the Institute for Safe Medication Practices includes it among eight “high-alert” medications with consequences so “devastating” that they warrant special safeguards against incorrect dispensing.

Oyler’s prescription included daily-dosage instructions for the diuretic. Methotrexate is never supposed to be taken more than once or twice a week for patients not being treated for cancer, and almost always at a much lower dose.

Kristin Sigg discovered her mother had been given a highly toxic cancer drug, not a heart medicine, after her hospitalization. Joyce Oyler died less than three weeks later. (Travis Young/Austin Walsh Studio for KHN)

In a court deposition taken as part of the lawsuit the family brought, Hy-Vee’s pharmacist blamed himself for not catching the error. “For whatever reason, on that certain day, that didn’t trigger with me,” he testified. Hy-Vee argued that its safeguards were as strong as those at other pharmacies, although the pharmacy manager admitted in a deposition that “quite honestly, there was a breakdown in the system.”

The family’s attorney, Leland Dempsey, said court evidence suggested the drug mix-up was made by the pharmacy technician who took the prescription orders. “The pharmacy tech made numerous spelling errors on the drugs,” he said. “She had a dosage off on another drug.”

In February, a jury awarded Oyler’s family $2 million in damages from the pharmacy. The judge lowered the award to $125,000 because of Missouri’s cap for noneconomic damages in medical malpractice cases. Hy-Vee declined to comment.

Nurses overlook prescription mistake

Yet the error could have been snagged right as Oyler began getting care from Heartland’s home health care agency. Medicare requires home health agencies to examine details of a patient’s medications to ensure all the drugs match the prescriptions ordered, are being taken in the right dose and frequency, and don’t have negative interactions.

Still, neither of two Heartland nurses who visited Oyler at home stopped her from taking the wrong drug. Less than a year before, Missouri state inspectors had cited the agency for inadequately reviewing medications for three patients. State records show it had pledged to make improvements.

“Why they didn’t catch it was beyond me,” Oyler’s husband, Carl, said recently. “They had a printout from the hospital” with every medication correctly listed. “It was all there,” he said.

After 18 days, her family took her to North Kansas City Hospital, where doctors determined that the methotrexate had irreparably damaged her bone marrow’s ability to create blood cells. She died three days later of multiple organ failure.

“By the time we got her into the emergency room, essentially she had no blood cell count,” her husband recounted. “It was irreversible. It was a gruesome, slow, painful way to die.”

Heartland Regional Medical Center paid Oyler’s family $225,000 in a settlement last year, court records show. Mosaic Life Care, the name by which Heartland now operates, said in a statement that it is “consistently improving processes and adopting new technologies to further reduce risks of errors and to improve communication.”

“Most people don’t know this is a problem,” Sigg said. “They assume doctors are talking to each other, until they experience it, and it’s not the case.”

— Kaiser Health News


And it was on this note that I was sharing a horror story about a VA Hospital (in another city) and how they had released a patient after months of being in hospital, sent home via a taxi to an empty house with no caregiver, no food, with nothing that would assist in his needs for either long term care or recovery. It led the man to contact 911 and the operator so horrified about his request for someone to bring him food, she arranged with the police to deliver said food and also came along to prepare some as well. This story shows that at times good people are there despite the horror stories we hear of 911 Operators and Police, there are good ones to share as well.

The young lady I was telling this tale along with others about hideous Veteran hospital abuses, promptly informed me, "That is not what you call 911 for."

What I wanted to say and what I said are not the same. I said yes I was but I thought it was great story about someone who tried to do more than what she needed to and that was a gesture of true kindness which you don't hear enough of, while of course utterly demonizing the VA Hospital. What I wanted to say, "was yes I know but what was the man to do? Do you have any empathy or compassion at all?"

She then informed me that her mother was a 911 operator for 20 years and when people called with non essentials they were given a secondary number to call and that she would not be allowed to leave the call center and go to person's home as it is liability and regulation issues. I decided to move on and say well this was small town and they may have different rules so I cannot comment.

So to prove that point that 911 is used inappropriately and again the VA seems to have no problem with that,  I shared story about our own local Veteran Hospital and former vet managed to drive himself there but could not walk nor get out of the car without assistance and when he called the hospital to tell him he was just outside the hospital, they told him to call 911 for assistance. So I asked her is that what you call 911 for?

She said yes as that the employees should not due to liability issues and workman comp issue, such as getting injured themselves while helping the man get out of his car, so of course they won't. I asked why are they working there if they are not able to actually well help people? And her response they will just not without being sure that they are not injured and if they are they are covered by workman's comp insurance.  Well that is good to know isn't it?

I asked if that if it was an Emergency and an ambulance brought him then they are covered but not in an non emergent situation, despite the fact that there was no actual policy stated by the VA that justified that and that calling 911 seems to then make it an emergency when not so how is that policy?

She went on about workman's comp and liability and that again her mother was a Government employee and there are many rules about protocol and procedure that dictate what workers can and cannot do. And my response is now you see why people are angry and believe that crushing the Government will actually be better for people and that private industry is the panacea we need for this despite again no proof that they are actually better either and in fact there is more than ample evidence to the contrary.

And oddly she agrees despite that her mother is in fact a long term Government employee and then she launched into  a criticism of why do they have VA Hospitals at all if the Government is not capable to providing a service then they should no longer do it. This is again another argument that requires reading understanding and seeking inquiry to the reasoning behind the VA failures. And like most other Governmental agencies it is about funding. That while the Government has no problem funding wars the true need of funding comes after the fact and that is akin to "entitlements" of which many in the chief seats feel should not be adequately done and so they don't.

Our Congress ensures that Government doesn't function.  It  doesn't fund the IRS despite the fact that due to this million in taxes that we do need go uncollected; we fail to fund prisons so we outsource and force men and women to remain in incarcerated needlessly; we don't fund education which is a prime factor in elevating one's life and socioeconomic status and yet also claim that college is a necessity, leaving billions in student debt.  We don't fund anything that the private sector has not mandated as necessary  And this same young lady claimed that the private sector was the reason space is being explored... well they are now as we no longer fund that program either and if anyone thinks the private sector is doing so for any reasons other than ulterior, think again.   Again a millennal that is sure the answer is not the goverment yet a family dependent upon for it income.. how well Rand Paulish.

She was having none of my belief that we are capable of having a functioning government  and I cannot tell if all of this is due to the Millennial constant need to be argumentative and be quasi libertarian socialists (meaning legal pot, love gays and have medicare for all but that is about it) or she is just one angry angry unhappy girl. I went with the later.

The contradictory and constant need to say one thing do another is also very much a character trait.  Espousing hate for unions while receiving the benefit of said unions, that 40 hr, 7 day workweek is one.  Not realizing that Education is in fact Socialist as are Public Libraries and Parks.

And millennial have never experience positive Government or workers Unions. They and their parents who are of the X generation are angry people who have only ever seen and experienced the exact opposite.  So to come of age in the era of neo liberalism, anger is badge worn with pride.  So for every argument there is another argument, for every solution there is a criticism.  If you wonder how we got where we got today, look to the left and the right to see the person next to you, they are an angry lot.

So what is the problem?  It seems to is be us but we are also the solution and it is a relatively simple one -  it's called voting. From that we can and must demand change, not with money but with votes.  From offering those versus checks we can  demand overturning Citizens United, ending Lobbying and push the concept of public funding for elections.  All of these are possible but not without an army - of active voters.  

It is medal of honor for people in Seattle to be proverbial scolds under the guise of being liberal. Now with the advent of population growth related to the tech sector, a field dominated with the need to be adversarial and accusatory, it furthers the dynamic  to constantly reprimand and dismiss anyone who disagrees with them or they don't understand. I work in the schools and see endless issue of this when it comes to truly helping kids learn, instead it is endless meetings, summits, groups and pledges that go nowhere. It is akin to a circle jerk where no one cums.

I feel badly in all my exchanges with people here as the negativity is palpable. I am honest and I am not one to pull punches but I like to focus on the good side, it may not seem that way in the blog but in reality there are solutions to problems but you have to be willing to do the heavy lifting - most people are not.

I think it is easier to be an Ostrich and live life with your head in the sand only today that sand is filled with social media, blogs and other Ostrich's who reaffirm your beliefs, misconceptions and more importantly refuel your anger. Anger needs oil to feed the flames and there is a lot of gas in Ostrich air.