In addition to the original mission, this blog will now serve as a companion blog of my website, http://www.competentdoctor.com/
The original mission is to tell real medical stories and inform visitors about medical errors and medical errors reduction strategies. This mission still stands.
One frequent medical or medication error at the time of a patient's discharge from a hospital's The Discharge Instructions about Medications.
Most patients before being admitted to a hospital are on several medications and most of them neglect to take the list or the actual medications to the hospital.
During the hospital stay, a patient's medications can be changed substantially.
At the time of discharge, most physicians in the past will write "continue all meds at home", although now most hospital rule will not allow this type of discharge order but it still happens due to certain hard-headedness, and "I am the boss" mentality of some physicians.
Recently a patient of mine, under the care of a a specialist in the hospital, was discharged home with very poor medications instructions. Please notice the instructions is in pleural.Actually there were 2 sets of instructions, one written with the list of medications taken during the hospital stay to be continued at home, and a verbal instruction from the nurse to to continue all the meds at home.
To make matters worse, the patient has Alzheimer's and the caregiver did not question the instructions. Also the caregiver did not call me immediately after discharge. This medications error was found out 7-10 days later at a follow-up visit in my office. By that time the patient was even more confused and could hardly stand up due to overdosage of a few medications. Luckily the patient survived.
The Discharge Medication Sheet must be the one and only instruction. It must list all the medications to be taken, including over the counter ones. The patient must also be informed to continue any medication that the patient was taking before admission.
The communications between the patient, the admitting physician, the nurse and the primary carep hysician, if he or she is not the admitting physician is very crucial to prevent this kind of mistake.
One more very effective measure: The patient or caregiver inform the primary care physician about the discharge medications immediately after discharge and ask which medications to take, to prevent duplication or discard of expensive medications the patient was taking before admission.
The primary care physician must respond to this request professionally and as soon as possible to prevent waste of medications and harm to patient. This is the safeguard to prevent medical errors committed by human almost daily in any hospital.
Monday, December 25, 2006
Monday, November 20, 2006
To err is human, but every effort must be made to reduce prescription drug error which is a common type of medical error.
There are many ways that a medication error can occur due to a prescription error.
1) Illegible handwriting causing a pharmacist to dispense the wrong drug, wrong strength of drug, wrong direction, wrong dosage or wrong quantity.
2) Legible handwriting but with wrong strength, wrong direction or wrong quantity.
3) Prescribing medication that patient is allergic to.
1) Misread the name of the medication and therefore dispense the wrong medication without cross-checking with the prescribing physician.
2) Changing the strength of the medication without informing the prescribing physician and or the patient. Example: Hydrochlorthiazide(12.5 mg) was prescribed and the direction was for patient to take 1 tablet or 1 capsule a day. The pharmacist dispensed a 50 mg strength and the correct direction to take 1/2 of a tablet was printed correctly on the medication label. The patient who was so used to taking one tablet a day may or will continue to take 1 tablet a day, causing an inadvertent overdosing. This is quite a common error.
3) Guessing physician's handwriting which is illegible.
4) Do not crosscheck with physician about potential error committed by physician.
1) Do not read the direction on the label on the bottle of the medication especially when it is a refill.
2) Can not read the medication instruction due to poor eyesight or lack of proper education.
3) Unintentional over or under dosing due to forgetfulness.
4) Increasing or decreasing the dosage for whatever reason without telling the physician.
To Err Is Human! But every effort must be made to minimize prescription error. The physician, pharmacist and patient all play important roles in preventing this kind of error.
The followings are a few suggestions and should be a common practice.
1) The physician must write legibly. Writing the name of the medication in capital letters is a good idea. The strength, dosage and instruction of the medication must be accurate. When in doubt, consult the Physician Desk References(PDR) or other resource.
2) The pharmacist must verify with the ordering physician, if there is any doubt about all aspects of the accuracies of the prescription whether it's a written or a phone order.
3) The patient must read the prescription before leaving the office to spot any error and remind the physician to correct it, if any. If the prescribed medication is not familiar to you, feel free to ask whether you can be allergic to it, if you have history of allergic to certain medications.After the receipt of the prescribed medication from the pharmacist, the patient must read the all the information on the label on the bottle.
The subjects of ePrescription, high-risk medications, mail-order prescriptions and phone-order changes of medication dosage and or instruction deserve to be on another post.
Tuesday, October 10, 2006
Medication samples given to patients in medical offices is common thing in this country. This endeavor is very helpful to patients who do not have prescription coverage.
Medical errors can easily be committed in the process of giving patients drug samples. There are many areas that that mistakes can occur:
- The sample medication has already expired but it has not been discarded for whatever the reason.
- Wrong strength of the sample medication is given when it contains a combination of 2 medications.. For example, AtacandHCT(16/12.5) is ordered but the staff gives Atacand(16mg.) instead. AtacandHCT(16/12.5) contains 2 medications: Atacand (16 mg.) and hydrochlorthiazide (12.5 mg.)
- Wrong strength of the sample medication is given even when it is a single medication. For example, Atacand(32mg.) is ordered but the staff gives Atacand(16mg.) instead.
- The wrong sample medication is given to patient outright.
- The wrong quantity of sample medication is given. For example, the physicain orders 14 tablets to be given but the staff gives out 7 or 21.
- Staff gives out sample to patients without the physician's knowledge.
- Staff takes medication sample for personal use or to give it to others who is not patient of the particular office.
How do we prevent medical errors or potential errors mentioned above?
- Disciplinary action must be imposed on any staff who who commits any of the errors above. The severity of the disciplinary action will depend on the severity of the infraction or whether any harm has been done to the patient.
- The patient should be instructed to always read the information on the drug sample package and the written instruction of how to take that particular medication. If the patient notices any discrepancies, he or she will notify the office before taking that medication.
A policy must be instituted in any office to prevent the aforementioned medication errors or
In my office we have such a policy :
- Physician writes the sample medication order in the office chart,including the name of the medication;its strength and the dosage direction.
- The first office staff will take the order by doing the following steps:
- Pull the sample medication from the storage .
- Makes sure that the pulled medication is exactly the one that the doctor order.
- Reminds the doctor if it seems that the doctor has ordered the wrong dose or wrong strength.
- Writes the expiration date of the medication in the chart next to the doctor's order.
- Writes her initial next to the order.
- Writes the name, strength, dosage, and expiration date of the medication on a small paper called patient-instruction sheet.
- Let a second staff verify and initial in the chart if if every thing is correct and put her initial next to that of the first staff.
- Let the doctor double check everything before signing the patient-instruction sheet.
- The first or second staff will then check the sample and direction one more time before giving the medication to the patient.
- The medication and the patient instruction sheet is then put into a special bag
which will have the same function as any prescription bottle. This staff will sign another initial on the chart right before giving the sample medication to the patient.
- Instructs the patient to keep the sample medication and the instruction sheet together in the bag. One bag will contain one medication.
Penalty for staff who commits an error by not following the above drug-sample policy:
- Put on probationary status for 3 months. Possible dismissal if another similar error is committed during this probationary period.
- Outright dismissal if any staff takes drug sample for personal use without the doctor's permission.
This policy has been in effect for more than 20 years. Staffs comes and go due to different reasons but no one has been dismissed due to committing error by not following the policy carefully. There were a few incidents of probation. On paper, it looks cumbersome but it becomes second nature for my staff in a very short time, with good supervision for new satff.
In conclusion, this policy works.
Saturday, September 30, 2006
Wrong site or wrong side surgery is vary rare. But if it occurs, it can ruin the surgeon's career.
What about the patient who was operated on the wrong site or side. It will be tremendously devastating.
It is better to prevent this from happening. How? And what is the best way?
I believe that every hospital in the United States must have some kind of protocol or guideline to prevent wrong site or wrong side surgery. One of the most common component of the protocol is to mark the surgical site or side in the operating room, before the start of the operation.
The protocols that I have seen or involved with were all excellent to prevent wrong side surgery but, in my opinion, contained one potential weakness. Let me explain by using a fictitious case to illustrate my point.
An elderly patient with history of mild cognitive impairment, with right inguinal hernia, sees his surgeon today. The diagnosis was confirmed. A right inguinal hernia is scheduled to be done three weeks later. This surgeon is a world renowned hernia surgeon. He usually will line up four or five hernia cases in a row.
On the fateful day, our patient above, woke up in the recovery room with a surgical wound and bandage on the left groin. The patient was supposed to have spinal anesthesia but it was not quite effective. The anesthesiologist had to give him intravenous sedation.
How could this wrong site surgery happened when the surgeon, the operating room(OR) nurses and other personnel all agree that the left inguinal hernia was was the the correct side? The OR schedule showed left inguinal hernia repair. The surgical consent was for left inguinal hernia repair. The surgeon marked the left side correctly. So it seemed.
Here is theoretically what could have happened.
The patient really did have right inguinal hernia but the surgeon wrote in the chart as left. If the mistake was not corrected here, a left inguinal hernia will be scheduled and the wrong side operation could happened. Any alert patient could have prevented this serious surgical error at the time of signing the consent. If he missed this opportunity, he would have another chance when the surgical site was being marked.
But our patient above was elderly and cognitively impaired and our busy and famous surgeon had performed four hernia repairs in one day, two left and two right.
How can we prevent this extremely rare but very serious mistake?
In my opinion, we should be able to prevent wrong site or side surgery 100 percent by following the following protocol strictly. This protocol will be created by the OR committee of a hospital.
1. Create a printed diagram of a full length human figure face-up on a standard sheet of paper . We will call this "Surgical Site Marking Sheet(SSMS)"
2. The surgeon will mark the surgical site on the SSMS, immediately after the patient was examined,right there in the office examination room, corresponding to the site written on the progress note in the medical chart.
3. The patient will be given a copy of the marked SSMS and instructed to bring it to the hospital on the day of surgery.
4. The surgeon will call the OR scheduler to schedule the operation AND fax the marked SSMS to the OR scheduler immediately.
5. No surgical procedure which requires a side or site will be put on the OR schedule without the marked SSMS.
6. The marked SSMS will be a permanent part of the medical record.
7. The procedure can not be started without the marked SSMS in the medical record. If the OR scheduler lost the Marked SSMS, obtain the copy the marked SSMS from the patient. If the patient forgets to bring it to the hospital, obtain a faxed copy from the surgeon's office.
8. The actual surgical site marking on the patient still can be done in the OR.
The above protocol is written in such a way that any patient will understand the process.
Currently, the SSMS protocol, with some variation from above, has been implemented in several hospitals in a Health System in Michigan. I can also say that I was involved extensively in it's implementation, of which the story will be told in a future post.
Posted by Suthin Liptawat,M.D. at 10:24 PM
Wednesday, September 20, 2006
Patients who have coronary artery stent are usually prescribed to take aspirin and Plavix. Most patients tolerate these two drugs quite well. The most common complication seen in my patients is bleeding.
I have two patients who had coronary stents and were put on these two drugs by the same cardiologist. The first patient developed massive lower gastro-intestinal bleeding requiring several units of blood transfusion. The aspirin and Plavix were stopped during this hospital ization. The bleeding stopped . The patient was discharged but was told by the cardiologist who put in the stent to continue to take Plavix and aspirin to prevent the stent from clotting.
The patient was confused. When she came to see me in my office, I told her that this was a dilemma. It's a tug-of-war between keeping the stent open and the risk of bleeding. After explaining to her the pros and cons, she decided to continue to take aspirin and Plavix.
For the next 6 to 8 months after the massive lower GI bleeding mentioned above, she had at least 4 or 5 episodes of lower GI bleedings requiring hospitalizations with blood transfusions once or twice. Of course each time the bleeding stopped after stopping aspirin and Plavix. Finally the patient told me that she was fed up with repeated bleeding. She decided to stop these two drugs permanently and accepting the risk of losing the patency of the stent. I agreed with her completely because she had made an informed decision.
After that decision, she did not have another bleeding episode for the next two years which is the present time. With her age of above 75 and the underlying colonic diverticulosis, she may still have lower GI bleeding in the future even without taking aspirin and Plavix. Her cardiac status has been stable.
The second patient had coronary stents and was prescribed aspirin and Plavix for a while without any bleeding complication.
One day he presented with upper abdominal pain in the office. Rectal exam showed black tarry stool and positive occult blood. A gastroscopy was done and and a mild bleeding of the gastric mucosa was found. He was told to stop aspirin and Plavix.
Not long after that he was back on aspirin and Plavix by the order of the cardiologist. Informed decision was made by him and his wife to continue these two drugs. So far so good; he does not have any more bleeding from the stomach. Of course he will be taking a medication in the family of Proton Pump Inhibitor(PPI) indefinitely.
In conclusion, informed decision by the patient is the best solution for the dilemmas described above, in my opinion.
Thursday, September 07, 2006
Laboratory errors performed by commercial laboratory service in in any medical office setting are very common. There are also many kinds of of mistakes. I am going to describe one common mistake.
Suppose the doctor order lab. tests as follow: Total Cholesterol(TC) and LDL-Cholesterol(LDL-c) but the lab. reports show the results of the Lipid Panel which consists of TC, LDL-c, Triglycerides(Trig.) and HDL-c. The ordering doctor should spot the error right away and call the lab. to correct the mistake by discarding Trig. and HDL-c.
Why should the lab. discard the 2 tests mentioned above? The answer is that the lab. can not bill the patient or the insurance company for any test without a doctor's order.
How can the mistakes described above happen? It can happen in 2 ways. First,it can be the clerical error of the medical office staff by marking the Lipid Panel slot on the lab. requisition sheet instead of marking just TC and LDL-c as ordered. The second scenario is that the medical office staff is correct but the lab technician carelessly does the Lipid Panel instead. The Trig. level must be done after a 12 hours fasting also.
In my office,we always keep a copy of the lab. requisition in a temporary file folder and file it with the actual test result when available. This copy will also serve to verify who makes the error.
This kind of error does no harm to patient but if not spotted early, it can cost money to patient and/or to the insurance company.
How can we prevent this kind of mistake from happening? In my office, we implement the following protocol:
- Keep a copy of the lab. requisition and file it with the test results when available,usually the next day.
- Staff puts the lab. result in my in-box immediately after it's comes in through the printer.
- I check the lab. results as soon as feasible on the same day.
- If there is any lab. error,I will instruct one of my staff to to call the lab to correct the mistake if it is feasible.
- My office staff will log the error in the lab. error log book. The log will indicate the following: a)Our error or lab.service error, b)If it's our error,who committed the error,c) What type of error
Since the implementation of this policy many years ago, we accomplish the following
- This kind of error was reduced to almost nil.
- The performance of the lab. and my staff improved tremendously because there was no dispute as to who made the mistake.
- Increase patient's satisfaction.
- Help decrease one tiny area of of health care waste.
How can a patient spot this kind of error? Usually it's difficult for any patient to do that but you can do the following to reduce your out of pocket payment:
- Check your medical bill as soon as you receive it.
- If you suspect an error as mentioned above,ask your ordering doctor to explain the detail of the bill. Your ordering doctor or his designate should take time to answer your question.
Friday, September 01, 2006
Last week I posted on my other blog about The Sonoma Diet. It's about one of my patient who, upon my advice,bought and follow the diet plan in this book. He lost 40 lbs. in about 6 weeks. Detail about this real medical story can be read at www.nutrientsriches.typepad.com
There are quite a few other patients that I recommend to read this book with little success. I saw one borrowing the book and reading it while waiting to be seen by me.
I could see that he did not enjoy that much. He promised me that he will finish it. Whether he will follow the diet plan or not,it remains to be seen. This patient weighs more than 350 lbs.
This is the first post after i switched to the new beta template. So far I really like it,being an amateur in blogging and no knowledge of HTML.
Saturday, August 26, 2006
Reduce Medical Errors and Enhance Patient Safety
The following five steps to safer health care are taken and modified from the Patient Fact Sheet from the Agency for Healthcare Research and Quality(AHRQ), Department of Health and Human Service.
1. Ask questions if you have doubts or concerns. There are no stupid questions. Make sure you understand the answers. The answers must be candid. Take a relative or a friend with you to help you ask questions and understand answers. Be careful not to bring some one who has a history of hostility toward the medical profession.
2.Keep and bring a list of ALL the medicines you take. The list should include non-prescription medicicines. Don't forget to tell your pharmacist and doctor about any herb or supplements that you are taking also because these can cause bad interaction with your prescription medicines.
Tell or remind them of your dru allergies.
Read the label on the bottle of the medicine before taking it.
Ask questions if the medicine looks different than the one you are taking or the dosage seems incorrect.
I go one step further. I always tell the patient to bring all the bottles of medicines in at each appointment. This way I can spot any discrepancy in the strength and dosage of each medicine and corrct it timely.
3.Get the results of any test or procedure. Ask when and how will you get the results of tests or procedures. Call your doctor for the results if you don't hear from him or her in a reasonable time. This way you will prevent a potential medical error by alerting your doctor to look for the results. Once in a while the doctor never receive the result of the test/procedure and does not have a good tracking system to make sure to receive all test results. A lot of this kind of error is due to human error,such as misfiing or machine down.
4.Talk to your doctor about which hospital is best for your health needs. In general,you would prefer to be cared for in a hospital where your doctor is on staff. The reason is that your doctor knows your condition better than any other member of your health care team while you are in the hospital.
5.Make sure you understand what wil happen if you need surgery. Make sure you,your doctor, and your surgeon all agree on exactly what will be done during the operation.
Ask your doctor,"who will manage my care when I am in the hospital?"
Ask your surgeon: What,Where,When,Why,How?
What exactly you will be doing?
What time of the day and what day of the week will the operation be done? Avoid late in the day or friday for major elective surgery.
How long the operation will usually take?
What will happen if "I refuses or delay the proposed surgery?"
How can I feel after surgery?
When will you(the surgeon) see me after surgery? Avoid an elective operation if your surgeon will leave town the next day and leave the postoprative care to another surgeon? Your operating surgeon will be in the best position to reoperate on you due to unforeseeable complication.
In conclusion,speak up,and you will be able to help reduce medical eror for yourself.
Posted by Suthin Liptawat,M.D. at 11:55 PM
Friday, August 18, 2006
This is a true story
It happened to one of my patients about 10 or more years ago in a local community hospital.
The mistake: A nuclear liver scan was done on my patient without my order.
I received a call from the radiologist informing me that a liver scan was mistakenly performed on my patient and we have to notify the nuclear regulatory commission of this mistake.
I also informed the patient of the error and explain that no harm was done. I also apologized to the patient for the inconvenience and some pain caused by the intravenous injection of the radioactive material. The pain was caused by the insertion of the intravenous needle. The patient was very understandable.
How did this error happened? The transporter took the wrong patient. He or she was supposed to check the patient's ID and signed the patient out at the nursing desk. Apparently this transporter did not do that.
The clerk in the Xrays department did not identtfy the patient correctly. The xrays technician and the radiologist also did the same mistake by not double checking the identity of the patient.
In this case,the ultimate responsibility lied on the radiologist. If he had opened the chart he would have found out that I did not order a liver scan on this patient.
The scenario mentioned above can happen again and again due to human error even in the setting of a well written policy and procedure of avoiding the error like this.
How can you as a patient prevent this kind of error from happenning? By being inquisitive or in other words: speaking up. Feel free to ask any health care personnel what kind of test is going to be done on you. If you don't get a clear cut answer,call or have the nurse page your doctor to verify. In case of patient who can not make his or her own decision,this responsiblity of speaking up will be upon the guardin or care giver.
The physician's role is also important. The attending physician should always inform the patient verbally about any test to be done. The radiologist must make sure that there is a wriiten order for the test and identify the patient according to the written protocol.
Posted by Suthin Liptawat,M.D. at 12:22 AM
Sunday, July 30, 2006
This is a true story.
An 80-year-old female patient of mine with high blood pressure,chronic irregular heart beats(chronic atrial fibrillation) and moderate narrowing of the internal carotid artery in the neck,was sent to an orthopedic surgeon for consultation for carpal tunnel syndrome(pinching of the median nerve at the tunnel called carpal tunnel at the wrist)
She was treated with a wrist splint but her symptom of pain was not getting any better. The pain in her right hand was getting worse and she is right-handed. She was frustated and ask if any thing else can be done besides taking pain killer.
Without sending a consultation report to me,the orthopedist mentioned-above scheduled a surgical procedure to release the pinched median nerve within about a week or 10 days after he saw her. He did not call me. The patient called me to inform me about the date of the proposed surgery.
The patient was advised to come in to dicuss about the proposed procedure. She was advised to call the orthopedist to postpone the surgery. She did so but very reluctantly because she was afraid that she might make him mad. This prompted a call from the orthopedist asking me for the reason to postpone the procedure. I told him the reasons which were explained to the patientlater.
Even though the surgery will be done under local and or regional anesthesia,I explained to the patient that sometimes it will have to be converted to general anesthesia which will put a burden to her heart. Therefore she should be ready for that. The patient was also at high risk of developing a stroke due to atrial fibrillation and blockade of the internal carotid arteries.
The patient was sent to a cardiologist who cleared her for surgery,provided that the ventricular rate(heart rate) was under controlled. At that time her ventricular rate was a little fast and it was finally controlled by adjusting one of her medication. She was also on a blood thinner called coumadin.
A radiological procedure called CTA(CT Angiography of the carotid arteries) was done to more accurately assess the severity of the blockage of the internal carotid arteries. It turned out that the stenosis was not critical enough to require carotid endarterectomy(removal of the atherosclerotic plaque from the internal carotid aretry)
All these time,the patient was wearing the wrist splint faithfully.
On an office visit after the above work-up,the patient's symptoms of pain of the carpal tunnel compression was dramatically relieved. She did not have any more pain in the three middle fingers in the right hand. I told the patient that she should consider to postpone the surgery indefinitely because the carpal tunnel release will not accomplish any more symptom improvement. Again the patient felt so intimidated that she asked me to call the orthopedist to cancel the operation for her.
After explaining to her the concept of patient's autonomy,she began to understand that it was her right to decide whether to undergo a surgical procedure or not. A day later I received a call from her. She cancelled the surgery indefinitely.
- Always inform your primary care physician about any proposed procedure recommended by the specialist consultant.
- You have the right and autonomy to decide whether to undergo anr kind of surgery after the surgeon gives you the informed consent.
- Always ask the following questions:What is going to be done? What will happen to you if you don't want to have the procedure done? What is the usual result for the particular procedure? Will there be any complication? Will the condition come back? When will it be done? Why any rush to do it?,etc. There are no stupid questions. If the surgeon answer all your questions to to your satisfaction,and you have made a decision. This is called an informed decision and if you sign a consent to have the procedure done,the consent is called an informed consent.
- If you have multiple medical problems,and the procudure is not urgent,it is always wise to have your primary care physician perform proper preoperative assessment to prepare you to be in the optmimal condition for the surgery to prevent or minimize potential complications.
Lessons learned in this case: An elective surgical procedure is postponed indefinitely. If the diagnosis is in doubt or the pain comes back,a repeat EMG(Electromyography) can always be done.
Posted by Suthin Liptawat,M.D. at 2:32 AM
Friday, July 28, 2006
This weblog is created to try my best to inform any patient to play a central role in reducing medical errors. If my fellow physicians happen to read this blog and found it useful,feel free to use it. There are many,many areas of potential medical errors that can be prevented,if the patients are more educated and not intimidated to ask their health-care providers any kind of questions before undergoing any medical treatment.
I will use real medical histories to illustrate or highlight the error or potential error. The sources of the stories can be from my experiences or those of my medical colleagues. The patient will be identified by gender and his or her approximate age only. If the story resembles any reader's real medical story,it is coincidental. Only rarely that I will create a story to illustrate the potential medical errors. In this situation,i will tell the readers that it is a created story.
The only intent of this blog is to alert,inform,and guide patients to prevent potential medical errors that can happen to them,by working with their health-care providers.
I am a board certified general surgeon,with formal training in peripheral vascular surgery,who also practicing primary care for more than 25 years.
At one time or another,I was involved in administrative functions of the medical staff of a couple of hospitals which belong to a major Health System in Southeastern Michigan.
I was chairman of surgical care evaluation committee,chairman of department of surgery and president of medical staff.
With the experiences mentioned above,I hope that I can accomplish my goal and intent.
Posted by Suthin Liptawat,M.D. at 12:30 AM