Thursday, October 29, 2015

You can't stay ahead of these errors.

Remember the story about my MD friend's elderly mother, the one who was suffering from falls because she was over-medicated for blood pressure issues? Once the doses were reduced, she did fine: "She has more stamina than ever before. She is happy."

Well, here's the next chapter:

So Mom is back in her original assisted living place, walking with a walker, to everyone's surprise. However, the medical errors are following her.

When she was being discharged, the rehab center sat me down and gave me a discharge summary and medication list, saying they had been faxed to the original nursing home. We went over and discussed every medication.

9 pm the night she went back, my phone rings; it's the nursing office of the original place saying they have her on Tramadol but the pharmacy says there is an allergy. I said, "What?" You see, Tramadol was not on her medication list. They said, "It wasn't on the list YOU gave us but it IS on the list that was faxed to us." So, I said, "There are 2 lists out there!" I said, "Take her off it," and hung up.

Today, two WEEKS later, the nurse practitioner calls and starts discussing clonidine, a BP medicine she was on. I said, "What?" You see, again, that wasn't on her medication list.  She said, "Oh, but the rehab center started her on that and I want to discontinue it." I told her there were at least 2 medication lists out there but she wasn't interested. So I said, "Fine, d/c the clonidine."

So . . . she's been on 2 BP drugs instead of 1 for two weeks, which was the original reason she was falling so much!
I'm ready to give up. You can't stay ahead of these errors.


David Rosenthal MD ‏@davidrosenthal said...

From Tiwtter:

Thanks for sharing this. FAX machines!!! we need true interoperabilities- this is a shame.

nonlocal MD said...

As the patient's (retired) MD daughter in this post, I have a couple extra observations:

1. The medical system is really 'performing to the test.' It concentrates on the things mandated to get paid, like medication reconciliation, but entirely misses the big picture - that the lack of coordination within and between facilities is really, truly harming patients, among many other issues. If it's not on their list of 'ways to get paid', they ignore it.

2. I was instructed to give the clinical summary and medication list to the original nursing facility upon my return. Although I did so, no one paid attention to it. It was the faxed (inaccurate) list they worked from. Does this mean what is given to the family is just for show? Is 'give the list to the family' one of the checkboxes that are mindlessly checked?

3. The people, including MD's, who say the lack of interoperability does not really do any harm, are completely full of that brown substance. Instances like this which go unreported are legion. Any estimation of error should be multiplied by 100 or more to capture the real error rate.

4. No one but the family knows the patient. This results in a serious bias of 'treating the number' rather than the patient. No one had a grasp of the goal here to minimize her BP medication to minimize falls, the BP number be damned. There were multiple other instances where knowing the patient would have produced a different approach. (That said, I do not know the answer to this problem except better interoperability of information.)

5. "Patient empowerment' has its downside. I have an M.D. degree and it took all my attention to monitor what was going on. Embrace the family and empower the family, but never, ever have any expectation of performance by the family (i.e. don't expect them to fill the gaps in the medical system). Some will be able to, some won't. You can't run a railroad that way.

Norma Sandrock said...

From Facebook:

They always fax, but that really makes no sense. The actual, correct list, verified by all, should just accompany the patient. Isn't that the whole point of "medication reconciliation?"

Anonymous said...

As a Hospital Quality Director I'd go so far as to say that these issues border on ubiquitous. As a daughter of 2 parents who transferred from a Hospital to a SNF and experienced their own versions of this, I painfully concur with nonlocal MD

David States said...

From Facebook:

FAX: the lowest common denominator of medical communication. Unreliable, insecure, illegible, untraceable. And WAY too often entered into the EMR as a "scanned document" further compounding the problems. When are we going to replace this abomination.

Neville Sarkari MD, FACP said...

Agree with all above, these are errors that actually occur thousands of times a day, every day...!

Anonymous said...

Same here. I find the bigger problem to be admin who don't fix things or dump the patients in lieu of the doctor who brings in $$$$.

Carole said...

To the Caretaker-
My heart goes out to you, your obviously fed up and rightfully so. But don't give up, never give up. Because of my own personal experience I've developed a short fuse now when dealing with medical or any other kind of incompetence, period!! and oh how I can relate to your problem thinking back as I read your story. I found myself having to be extra careful and cautious as my mothers caretaker out of fear that showing justifiable aggravation and frustration could or would make a bad situation worse for her. And no matter how nice, polite or respectful you are at expressing concerns- (sometimes from just one ticked off person- there's repercussions) retaliation is immoral and unexceptable but it "happens". So understanding that I had to bite my tongue And kiss more rear ends than I cared to trying to keep her as safe and out of harms way as I possibly could just in case I wasn't around even for a minute. But in spite of how great and awesome I was at staying on top of things and being super protective of her it just wasn't enough after all. Errors because of Incompetence took her from me anyway. But YOU selfless Caretaker are treasured your needed your important, just do your best and know your mother loves and appreciates you for it, no matter what happens, okay?

Carole said...

nonlocal MD
I don't think there's one comment or opinion you've shared that I've not agreed with or respected. You're truthful and upgront with us on topics that we read from a patients point of view that I for one appreciate. And I must say you do your profession proud and you give people like me who have been emotionally harmed by a medical tragedy a reality check now and then, that the good in you and others like you outweighs the bad and negative I encountered. Lucky and blessed are the patients who have you!!!