As the Quaid family tragedy illustrates (see post below), prescription drug mix-ups can have devastating consequences. Some drug names in particular are quite similar to others and can lead to confusion for both patients and prescribers. Bad handwriting, smudged ink, or a data entry mistake can change the name of one drug to something altogether different. The results can be dangerous and sometimes lethal. At least 1.5 million Americans are estimated to be harmed each year from medication errors, with name mix-ups accounting for a quarter of them.
The Boston Globe reported in a story on Tuesday that a web-based tool (http://www.usp.org/) is now available to consumers and doctors to check whether they are using or prescribing error-prone drugs and the names they might be confused with. Coming some time this fall from the Institute for Safe Medication Pratices and iGuard (an online health service) is a more patient-oriented website that will send users e-mail alerts about drug-name confusion.
The Food and Drug Administration is also piloting a program that would hold the drug manufacturers more responsible to guard against name confusion. The hope is to avoid confusing drug names before the product gets to market.
Thursday, September 4, 2008
Monday, August 25, 2008
The Quaid Family Tragedy
Many of you may have watched 60 Minutes last night. It was a repeat of a story first aired last spring and chronicled the harrowing experience of the Quaid Family (click here for video). Dennis Quaid, the actor, and his wife's newborn twins were accidentally overdosed on Heparin in a California hospital. The babies survived the ordeal, but the Quaids are speaking out about preventable medical errors.
MITSS posted to the 60 Minutes blog last spring, and we'd like to reaffirm our response to the story here:
Our thoughts and prayers go out to the Quaid family. Medical errors and bad outcomes are a huge problem in healthcare demanding urgent attention by hospitals, physicians, nurses, pharmacists, insurers, regulatory agencies, patients and their families, and everyone else involved. We must all work together to come up with effective solutions -- there is far too much at stake. In the interests of balance and fairness, 60 Minutes should have included the many organizations involved in heroic efforts all over the country in terms of prevention. Still, little attention has been paid to the devastating emotional toll taken on patients, family members, and care providers. We are a non-profit organization dedicated to supporting everyone impacted by a bad medical outcome. Even in the safest of systems, things can and do go wrong. Errors occur at a huge financial cost to the system, but let's not ignore the human cost on both sides of the equation.
It wasn't clear from the piece, but it didn't appear that Dennis, his wife, or any of the clinicians were offered any emotional support following the event. The event must have profoundly impacted the pharmacists, nurses, and physicians involved. Emotional support needs to be "hard wired" into the system when anything goes wrong, for care providers as well as patients and their families. It's simply the right thing to do.
MITSS posted to the 60 Minutes blog last spring, and we'd like to reaffirm our response to the story here:
Our thoughts and prayers go out to the Quaid family. Medical errors and bad outcomes are a huge problem in healthcare demanding urgent attention by hospitals, physicians, nurses, pharmacists, insurers, regulatory agencies, patients and their families, and everyone else involved. We must all work together to come up with effective solutions -- there is far too much at stake. In the interests of balance and fairness, 60 Minutes should have included the many organizations involved in heroic efforts all over the country in terms of prevention. Still, little attention has been paid to the devastating emotional toll taken on patients, family members, and care providers. We are a non-profit organization dedicated to supporting everyone impacted by a bad medical outcome. Even in the safest of systems, things can and do go wrong. Errors occur at a huge financial cost to the system, but let's not ignore the human cost on both sides of the equation.
It wasn't clear from the piece, but it didn't appear that Dennis, his wife, or any of the clinicians were offered any emotional support following the event. The event must have profoundly impacted the pharmacists, nurses, and physicians involved. Emotional support needs to be "hard wired" into the system when anything goes wrong, for care providers as well as patients and their families. It's simply the right thing to do.
Monday, August 11, 2008
A GREAT READ AND WONDERFUL WAY TO SUPPORT MITSS!
We highly recommend a new book, The Best Practice, written by former Boston Globe journalist Charles Kenney. The book tells the story of some of the pioneers of the health care quality movement, from Don Berwick to Lucian Leape, who are finding ways to eliminate preventable medical errors and transforming American medicine in the process.
As an added bonus for MITSS, the Institute for Healthcare Improvement (IHI) has generously arranged for 10% of purchases made through a special Amazon.com link to be donated to MITSS. To purchase a copy of The Best Practice through this special arrangement, click here.
Friday, August 8, 2008
Where can you find MITSS this week? The Boston Herald!
This article in the Boston Herald from Sunday 8/3/08 features MITSS founder and Executive Director, Linda Kenney, and one of MITSS’ esteemed board members, Jim Conway. They were asked to comment on the progress and trajectory of apology and disclosure in medicine. Although we are always pleased when this topic is highlighted, it is likely that the column inches allotted were not enough to do it justice. So, we would like to put the question to you: How do you see the progress and direction of apology and disclosure in healthcare? How does it impact you personally?
Wednesday, July 16, 2008
Physician Frustrated in Efforts to Prescribe Critically Necessary Medications
In today's post, our guest blogger, a local primary care physician, sounds off on a bureaucratic nightmare and the potential harm to patients:
I am a primary care physician and have been practicing in Cambridge for nineteen years. There are many challenges and frustrations for physicians attempting to provide the best possible and safest office based care to patients. However, never before have I felt more outraged by the unnecessary potential and actual harm and suffering some of my patients have had to endure with the introduction of many of the individual insurance programs that were created by the relatively new Medicare Part D program. Some of these programs are completely unscrupulous in their limitations to essential medication.
Here is one example:
One 63 year old man who has multiple medical problems including diabetes, hypertension, heart disease and decreased kidney function has been fairly stable in recent years, but close to needing dialysis in spite of our best efforts to hold that off with medications. There are many clinical guidelines and studies that support the use of one of his medications (losartan, of the class of medications called “ARB’s) to protect his kidneys and stave off dialysis in the situation he is in (He is unable to tolerate first line medications called “ACE I”). He had been on this pill along with many others for many years. When his insurance was switched to Health Net Orange, one of the 15 or so Medicare part D programs approved to practice in the state, they denied him use of this medication or any alternative in the class. They offered no explanation except to say that it is not formulary. After reapplying a couple of more times and being rejected I called the company myself, hoping to reach a medical reviewer, even the Medical director to explain my rationale for the necessity of this medication. After literally 2 hours of calling, getting put on hold and being transferred, this physician had only spoken to various clerks, and gotten no useful advice. Further calls by the office manager were equally unfruitful. Finally the only way the medication was approved was when I referenced in my clinical notes that I felt that this medication was necessary to prevent complete renal failure which would lead to lifelong dialysis, stroke or heart attack, and that in spite of my best efforts to get the medication approved, his insurer would not do so. I further went on to say in the record that I felt the insurance company should have some responsibility if one of these untoward events occurred while off his medication! I have never written anything referencing any insurance company in a record in my entire career, and might have considered it unprofessional before this, but my patient’s health was at stake and I couldn’t think of any other way to try to get the medication approved.
I sent a copy of this note to the insurance company with the fourth medication request and after about 6 person-hours over a 3 week period of time trying to get this medication approved, it was miraculously approved the very next morning until the year 2039!!
It infuriates me to see patients put at unnecessary risk like this, and it is exhausting the precious resources of primary care practices. Think of the cost of this occurring dozens or hundreds of times per year probably in every office in the state and the harm that undoubtedly has come to easily thousands of patients per year! This is not the only insurance carrier that commits this disservice; but some the Medicare part D carriers are very much more inclined to this sort of practice than the HMO’s and traditional carriers in the area and even much more so than Medicaid and the newcomer Commonwealth Care, in my experience. I write this to help give a voice to practitioners struggling to do their best for their patients in this arena and to let patients know about this threat to the safety of patients that is very real and has disempowered practitioners to get their patients medications they need. I am looking for ideas how to find ways to make these carriers more accountable to patients in the basic area of necessary medications.
I am a primary care physician and have been practicing in Cambridge for nineteen years. There are many challenges and frustrations for physicians attempting to provide the best possible and safest office based care to patients. However, never before have I felt more outraged by the unnecessary potential and actual harm and suffering some of my patients have had to endure with the introduction of many of the individual insurance programs that were created by the relatively new Medicare Part D program. Some of these programs are completely unscrupulous in their limitations to essential medication.
Here is one example:
One 63 year old man who has multiple medical problems including diabetes, hypertension, heart disease and decreased kidney function has been fairly stable in recent years, but close to needing dialysis in spite of our best efforts to hold that off with medications. There are many clinical guidelines and studies that support the use of one of his medications (losartan, of the class of medications called “ARB’s) to protect his kidneys and stave off dialysis in the situation he is in (He is unable to tolerate first line medications called “ACE I”). He had been on this pill along with many others for many years. When his insurance was switched to Health Net Orange, one of the 15 or so Medicare part D programs approved to practice in the state, they denied him use of this medication or any alternative in the class. They offered no explanation except to say that it is not formulary. After reapplying a couple of more times and being rejected I called the company myself, hoping to reach a medical reviewer, even the Medical director to explain my rationale for the necessity of this medication. After literally 2 hours of calling, getting put on hold and being transferred, this physician had only spoken to various clerks, and gotten no useful advice. Further calls by the office manager were equally unfruitful. Finally the only way the medication was approved was when I referenced in my clinical notes that I felt that this medication was necessary to prevent complete renal failure which would lead to lifelong dialysis, stroke or heart attack, and that in spite of my best efforts to get the medication approved, his insurer would not do so. I further went on to say in the record that I felt the insurance company should have some responsibility if one of these untoward events occurred while off his medication! I have never written anything referencing any insurance company in a record in my entire career, and might have considered it unprofessional before this, but my patient’s health was at stake and I couldn’t think of any other way to try to get the medication approved.
I sent a copy of this note to the insurance company with the fourth medication request and after about 6 person-hours over a 3 week period of time trying to get this medication approved, it was miraculously approved the very next morning until the year 2039!!
It infuriates me to see patients put at unnecessary risk like this, and it is exhausting the precious resources of primary care practices. Think of the cost of this occurring dozens or hundreds of times per year probably in every office in the state and the harm that undoubtedly has come to easily thousands of patients per year! This is not the only insurance carrier that commits this disservice; but some the Medicare part D carriers are very much more inclined to this sort of practice than the HMO’s and traditional carriers in the area and even much more so than Medicaid and the newcomer Commonwealth Care, in my experience. I write this to help give a voice to practitioners struggling to do their best for their patients in this arena and to let patients know about this threat to the safety of patients that is very real and has disempowered practitioners to get their patients medications they need. I am looking for ideas how to find ways to make these carriers more accountable to patients in the basic area of necessary medications.
Tuesday, July 15, 2008
THE POWER OF A PERSONAL/PROFESSIONAL STORY
Over the past six years on behalf of MITSS, I have had the great fortune of travelling the country and abroad. I have spoken at conferences and forums, large and small, speaking with patients, family members, and clinicians. It seems that everyone has a story. Each time I speak with a clinician who has been affected by a medically induced trauma, I not only relate on a truly personal level, but it has served to strengthen my commitment and resolve to change the systems which fail each of us every day.
There can be nothing more powerful than a personal story, and we have encouraged anyone affected by an adverse event to share their experience with us on our website. While it seems that I hear from healthcare providers in equal numbers, they don’t appear as willing to share their stories. There has been a very moving entry recently added, and we invite you to take a look at our clinician story page. Also, if you’d like to share your own story, please feel free. The submission is anonymous, and confidentiality is assured. By sharing your personal and professional experience, you may be helping a colleague out there to feel less isolated and alone. We hope to hear from you.
Linda
There can be nothing more powerful than a personal story, and we have encouraged anyone affected by an adverse event to share their experience with us on our website. While it seems that I hear from healthcare providers in equal numbers, they don’t appear as willing to share their stories. There has been a very moving entry recently added, and we invite you to take a look at our clinician story page. Also, if you’d like to share your own story, please feel free. The submission is anonymous, and confidentiality is assured. By sharing your personal and professional experience, you may be helping a colleague out there to feel less isolated and alone. We hope to hear from you.
Linda
Saturday, July 5, 2008
Communication Loop Following Adverse Events
Below is a Post I wrote last week but we held off posting it....
All the literature out there tell us that patients and families want several things following bad outcomes and medical errors:
1. They want the truth and in a timely manner.
2. They want either an apology or an acknowledgement.
3. They want to know what the organization is going to do to prevent another occurrence.
4. They want support.
a. emotional support
b. financial support when appropriate
My observation, though, is that many hospitals still struggle with looping back to the patient and family with the information about what happened and how. But, more importantly, they neglect to relay to patients and families the changes to be made moving forward to prevent reoccurrence.
There isn't a mechanism to loop back to staff to give them the same information. I can see why this would be difficult given all the different departments and staff involved. But, I think it just as important that we be transparent with the staff as well. It would also diminish assumptions and rumors among staff.
Does anyone have ideas for how this can be done effectively and routinely?
Does anyone have any suggestions on how we can start doing this better?
...this post seems fitting given the news last week of a Boston Hospital that had done a wrong site surgery. They disclosed to the patient who is recovering at home. But, the President/CEO and the VP of Quality and Safety sent an internal email (click here for full text) letting the staff know about what they described as a horrific incident. I was truly impressed!
Linda Kenney
MITSS
All the literature out there tell us that patients and families want several things following bad outcomes and medical errors:
1. They want the truth and in a timely manner.
2. They want either an apology or an acknowledgement.
3. They want to know what the organization is going to do to prevent another occurrence.
4. They want support.
a. emotional support
b. financial support when appropriate
My observation, though, is that many hospitals still struggle with looping back to the patient and family with the information about what happened and how. But, more importantly, they neglect to relay to patients and families the changes to be made moving forward to prevent reoccurrence.
There isn't a mechanism to loop back to staff to give them the same information. I can see why this would be difficult given all the different departments and staff involved. But, I think it just as important that we be transparent with the staff as well. It would also diminish assumptions and rumors among staff.
Does anyone have ideas for how this can be done effectively and routinely?
Does anyone have any suggestions on how we can start doing this better?
...this post seems fitting given the news last week of a Boston Hospital that had done a wrong site surgery. They disclosed to the patient who is recovering at home. But, the President/CEO and the VP of Quality and Safety sent an internal email (click here for full text) letting the staff know about what they described as a horrific incident. I was truly impressed!
Linda Kenney
MITSS
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