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Bad Medicine, a Personal Horror Story

May 4, 2008
by James Feldbaum
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It seems that everyone has a horror story about the care they received in the hospital. Is it because we providers deserve our patient’s criticism or have they become more suspicious and alert to the risks? Maybe it has just become fashionable to knock the quality of the American healthcare delivery system?

I have had two recent personal experiences as a patient in the operating room. One was perfect. Obviously, this is about the other.

The facts are simple: I have a potentially life-threatening reaction to certain types of anesthesia and I am allergic to Ancef, an antibiotic. Furthermore, you must take into account that I am a consultant making a living by promoting and implementing mechanisms for safer healthcare delivery.

Being a physician, one could argue that the odds would be in my favor. I am more knowledgeable about medical care and I might get special treatment from my colleagues. I know how to be a good patient. I called in to the anesthesiologist a week before my surgery to review the safest route of anesthesia and I brought a printed and detailed medical history with me on the day of surgery. The surgery center’s only electronic capability was for billing (it worked perfectly).

The fiasco began when I was told that the anesthesiologist with whom I had discussed my procedure a week before was not there due to a schedule change. I was assured, however that it had been discussed with his colleague that would be putting me to sleep. It hadn’t. There was no record of our discussion. My nurse, a “traveler” (an agency nurse hired to work during our busy snowbird season) checked my armband and the label on my pre-op antibiotic before hanging it. I asked to see the bag of medication before I allowed it to run in. Despite my red armband it was Ancef. She was apologetic. She returned with clindamycin, an alternative antibiotic, and having learned her lesson from the Ancef offered me the IV bag to examine. Yes, it was clindamycin, but why was I getting an antibiotic in the first place? I asked to see the physician order sheet. My physician had faxed in a standard pre-printed order set. There was a large X by both antibiotics. To my doctor the X meant no. To my nurse it meant yes.

A doctor in scrubs approached my stretcher syringe in hand. He introduced himself as my anesthesiologist (the other was on break) while simultaneously reaching for my IV line to inject “happy juice.” I stopped him abruptly. He too was uninformed of my anesthesia sensitivity.

So what went wrong? What lesson can be learned from this horror story? Would an electronic medical record have provided some protection? Yes, an EMR with CPOE would have caught my allergy to Ancef and an appropriately implemented medication administration system would have blocked administration. Yes, CPOE would have made my physician’s orders clear and unequivocal. No, there is no protection against poor communication, incompetent hand-offs, or bad policy and procedure. We need to get our house in order.

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Wow! Excellent story of first-hand experience with medical errors. The Leapfrog initiative has done a good job at documenting errors that has caused serious patient complications. I wonder how many errors are captured by the patient before it causes complications. The sad footnote to this story is that from a medical workflow stand point, there is no opportunity to do a "Lessons Learned" on your case. No leadership initiative by the nursing staff or physicians to document these types of process faux-pas and figure out how to avoid it from happening. The traveling nurse moves on, the fill-n anesthesiologist goes on to the next case. No post-mortem. Medical process improvement is meant to be reactive to tragedy and not pro-active. But I guess you're just glad there wasn't really a "Post-Mortem."