I was not the patient’s doctor, but, at the patient’s request, I spoke with the neuroradiologist who had interpreted her MRI films taken during hospitalization. Since the usual MRI did not reveal the source of the bleeding, he recommended an MRI of a type that I had not heard about. He thought that an “MRI with and without infusion, T2 star gradient with echo” might be able to pick up the lesion where the regular, routine MRI’s could not. I had him repeat the exact test, and I wrote it down and he confirmed that what I wrote was accurate. The neuroradiologist assured me that this special test was the best chance of diagnosing what he now suspected after ruling out so many other possibilities.
I then gave a copy of the test to the patient who by this time was being discharged and learned to her dismay that the excellent neurologist assigned to her case when she was admitted was not a participating doctor for her HMO, nor was the hospital she was admitted to as an emergency a part of the HMO network. She had to start over. I told the patient to take charge of and direct her own healthcare. She was now responsible for acquiring a new medical team, and these physicians had to learn about her and take over all future care; and the quicker the better because of a probable delay in the transfer of her records to any new doctor. The HMO directed that she go to another hospital for the test further disturbing the continuity of her care. She was in the middle of a fabricated healthcare maze prone to miscalculations and misadventures because her course had changed and many human beings were involved. As we embark on the new and massive changes in healthcare to come, the situation may worsen. That is why all patients or their advocates must be in charge.
“But I’ll just have the new doctor order that test you wrote out for me. Why should I worry?” she asked.
“You should worry,” I said, “because the neuroradiologist gave me the information about this test, that in all my experience I had never heard about, which I now pass on to you, and you will pass it on to the new doctor, and he will tell his secretary, who will call the hospital and speak to another secretary, who will then speak with a radiological technologist to put you on the schedule for the recommended and unusual test, which by now has passed through multiple hands. In addition, by the time the order has passed through this maze, God knows what it will look like when you appear for the test. Trust me—these foul-ups do occur.”
She took my advice and in attempting to confirm that the new hospital could perform the test, she learned that it could not. What they had done already was place her on the schedule to do the usual MRI. Unfortunately, the usual MRI did not identify the cause of her bleeding. She phoned the HMO to tell them that they had approved the test at a hospital that could not perform it and the hospital had scheduled the wrong test anyhow. This resulted in multiple and lengthy phone hassles until she assured them that she was attempting to prevent them from making a medical error. They advised her of another hospital where the proper test could be performed.
The patient, now the wiser in the ways of potential medical error production, went so far as to call the technologist at the second hospital that would be doing the test. Reading from the paper I gave her, she said, “This is the precise test that the doctor ordered,” “Yes, we will do that,” answered the technologist, J. “I will be performing it myself,” he said.
I told her to be sure when she went for the test, even though she had spoken to the person who would perform the test, that she confirm that the exact test that had been ordered was to be done. She assured me that it was now foolproof, because she had personally spoken with J. who would perform the test. I repeated what I told her.
Well you guessed it—when she arrived for the test and filled out forms stating the test ordered, J. was not there, but another technologist had replaced him. The patient was wise enough to understand this woman was not J., so she asked her where J. was. “Oh, he couldn’t be here today,” she answered. “What test are you going to perform?” the patient asked. The woman technologist answered, “Just a regular MRI.”
The patient controlled herself and said, “No that’s not correct. Here is the exact test that was ordered,” and she handed her the instructions.
“Oh,” said the technician, “that’s a test we don’t do very often, but if that’s what you want we can do it if we get a doctor’s order for it.” “It’s not what I want,” the patient responded, “It’s what the doctor ordered and what J. said he would do.” They did the test after taking more time to confirm the doctor’s order
Had this patient not taken charge of her own health, a medical error would have occurred; a test already done that could not identify the cause of her bleeding would have been repeated; twenty-two hundred dollars would have been wasted, and a serious diagnosis would have been delayed—and that delay had the potential for great harm. You can also see the wasteful financial impact that might have occurred. Is there any wonder that our medical care system could break the bank?
The truth of the matter is—medical errors occur because systems break down. Some of these errors lead to delays, a waste of money, injury—and some lead to death. The healthcare system with its conflicting insurance rules, approved hospitals, unapproved hospitals, approved doctors, doctors not on the list, approved and unapproved testing facilities, different reimbursement formulas, and necessity for approvals from non-medical personnel, is cumbersome and complicated and the patient is in the middle and that is why patients must direct their care. Patient safety, life, limb and financial well-being are all at stake. With the healthcare changes to come what will happen to this already overburdened system?
Because this patient took charge of her health, she had an exact diagnosis established: venous angioma, an untreatable condition as it serves as part of the cerebral venous drainage. She also had an adjacent cavernous malformation of the right frontal lobe that arose from the venous angioma. The patient sought neurosurgical consultation to determine the therapeutic options—surgery, gamma knife radiosurgery, or watchful waiting and anti-seizure medication. In the meantime, she has immersed herself in Google to learn all she can, since most primary care physicians have had little or no experience with these rare cerebral blood vessel malformations. After much research and consultations with several neurologists and neurosurgeons, she has taken the conservative medical and non-invasive route. She is doing well—armed with a final well-researched decision. She took charge of her health—and the decision she made, by personal education and consultations with several experts, is a well-researched decision that she is now comfortable living with. This is an optimal solution, better for the patient psychologically and comfortable for the attending physicians.
Control of concentrated electrolyte solutions
Potassium chloride (KCL) is the culprit here. In the first two years of keeping such records, ten patients died by the direct intravenous administration of the concentrated solution of potassium chloride. The nurse or pharmacist adds small amounts of this concentrated solution to a liter of IV fluid to make a very dilute KCL solution used to treat low potassium levels. However, if given undiluted, the medical error is irreversible—death is the outcome. For this reason, KCL is banned from hospital nursing units. It is designated a controlled substance like narcotics, and can only be kept in the pharmacy under many safeguards including limiting who may handle it. Each vile is required to carry a label stating HIGH RISK and MUST BE DILUTED.
Catheter and tubing connections
Very ill patients may require multiple catheters and tubes used for drainage of body fluids and as portals of entry to deliver necessary medications. Misconnection errors, resulting in wrong medication delivery to the wrong body site, have occurred. Nine such cases reported resulted