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An all too common story?

Stewart

Stewart

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I came across this article in the NYT the other day:
An Infection, Unnoticed, Turns Unstoppable
What alarms me the most, is the comments that all seem to start with "'m an ER DR" and always seem to dismiss the fact that he was sent home without labs confirmation as "normal" and if they held everyone the ERs would be "swamped." Most DRs in these comments seemed completely oblivious to the points raised in the article and came across as very defensive.

I know in our "socialized" system here it is standard practice to not discharge without labs being returned. I have often been on hold for a few hours while I waited. It's considered a check before discharging to make sure they didn't miss anything and I find it alarming that it seems that this is seen as common in the US Emergency rooms. And it should be noted our AnE DRs are just as full and our DRs overworked as yours. Is it possible that their are other people who have tragically lost their life to other practices similar as this who don't have the distinction of knowing a NYT columnist and thus has been swept under the carpet. If this is a common practice, statistic dictate that it has happened before.

Whenever there is a Aircrash from the smallest propjet to a International Airliner, there is a large protracted investigation. The purpose of this is not to find criminal negligence but to learn where mistakes were made and how we can fix them to prevent it from happening again. Thus the safety of our Airplanes has been increasing over time. In each case there is a long trail of mistakes that each occurred in a specific order for the accident to occur. All too often imperfect information, overworked staff and other human related factors are ruled to be the cause.

From what is observable in the article I can think of perhaps two major mistakes in the chain of errors. These I believe were both caused by the failing of the system and not the decisions made by the people involved.
Lack of handover between the family DR and ER rooms, the physician who first saw him had already made several abnormalities and were these passed along to the staff of the Emergency Room, why double up and rely on them picking it up a second time?
Why were the patient discharged without the labs results known? I know DRs in the comments said that they could easily have contacted the family by phone if abnormal results were returned, however this clearly didn't happen. It's all to easy to understand once he was out of the ER he was essentially out of mind, completely understandable in a busy ER. However this still represents a clear failing of the system.

I guess my whole point of this is should the Review of this case occur behind close doors by the hospital themselves or by a public, impartial figure with the sole goal of fact finding and not laying criminal charges. It is important that researches and other involved stakeholders are able to understand how the system fails on a microlevel, if reviews are internal is it not possible that this information may be suppressed? Especially by a hospital with a sterling reputation like NYU Langone.

Disclaimer I am not accusing anyone of clinical malpractice.
I am focusing on how the system can be improved to prevent or at least decrease these kind of outcomes.
 
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What alarms me the most, is the comments that all seem to start with "'m an ER DR" and always seem to dismiss the fact that he was sent home without labs confirmation as "normal" and if they held everyone the ERs would be "swamped." Most DRs in these comments seemed completely oblivious to the points raised in the article and came across as very defensive.
Click to expand...

Mmmm. What did you expect?

Whenever there is a Aircrash from the smallest propjet to a International Airliner, there is a large protracted investigation. The purpose of this is not to find criminal negligence but to learn where mistakes were made and how we can fix them to prevent it from happening again.
Click to expand...

There isn't enough time and money in the universe to do this kind of thing with medical errors. Are you seriously implying that it's what you want? The whole medical system would bog down.

I guess my whole point of this is should the Review of this case occur behind close doors by the hospital themselves or by a public, impartial figure with the sole goal of fact finding and not laying criminal charges.
Click to expand...

This sort of thing is being done already in some hospitals, particularly VA hospitals. It does not amount to an NTSB scale investigation, though. The matter is referred to one or two peers for their opinion on the appropriateness of what was done, and it's reviewed by a committee.

Doctors, Nurses, and other health care providers are human and sometimes make mistakes. I don't know of any way to get around that. If you want perfection in your health care then I suggest that you take care of yourself.

And, by the way, it's going to get worse, not better. The PPACA isn't going to increase the quality of health care professionals out there one bit. Quite the opposite, in fact.
 
In my last couple of hospitals I put an in house IM group together.. Very sharp young people with lots of stamina and drive.. Your private physician could refer to you to this group for admission and evrything happened much faster. Tests were ordered and read immediately, medications were adjusted.. It actually cut length of stay and improved outcoms.

Stewart said:
I came across this article in the NYT the other day:
An Infection, Unnoticed, Turns Unstoppable
What alarms me the most, is the comments that all seem to start with "'m an ER DR" and always seem to dismiss the fact that he was sent home without labs confirmation as "normal" and if they held everyone the ERs would be "swamped." Most DRs in these comments seemed completely oblivious to the points raised in the article and came across as very defensive.

I know in our "socialized" system here it is standard practice to not discharge without labs being returned. I have often been on hold for a few hours while I waited. It's considered a check before discharging to make sure they didn't miss anything and I find it alarming that it seems that this is seen as common in the US Emergency rooms. And it should be noted our AnE DRs are just as full and our DRs overworked as yours. Is it possible that their are other people who have tragically lost their life to other practices similar as this who don't have the distinction of knowing a NYT columnist and thus has been swept under the carpet. If this is a common practice, statistic dictate that it has happened before.

Whenever there is a Aircrash from the smallest propjet to a International Airliner, there is a large protracted investigation. The purpose of this is not to find criminal negligence but to learn where mistakes were made and how we can fix them to prevent it from happening again. Thus the safety of our Airplanes has been increasing over time. In each case there is a long trail of mistakes that each occurred in a specific order for the accident to occur. All too often imperfect information, overworked staff and other human related factors are ruled to be the cause.

From what is observable in the article I can think of perhaps two major mistakes in the chain of errors. These I believe were both caused by the failing of the system and not the decisions made by the people involved.
Lack of handover between the family DR and ER rooms, the physician who first saw him had already made several abnormalities and were these passed along to the staff of the Emergency Room, why double up and rely on them picking it up a second time?
Why were the patient discharged without the labs results known? I know DRs in the comments said that they could easily have contacted the family by phone if abnormal results were returned, however this clearly didn't happen. It's all to easy to understand once he was out of the ER he was essentially out of mind, completely understandable in a busy ER. However this still represents a clear failing of the system.

I guess my whole point of this is should the Review of this case occur behind close doors by the hospital themselves or by a public, impartial figure with the sole goal of fact finding and not laying criminal charges. It is important that researches and other involved stakeholders are able to understand how the system fails on a microlevel, if reviews are internal is it not possible that this information may be suppressed? Especially by a hospital with a sterling reputation like NYU Langone.

Disclaimer I am not accusing anyone of clinical malpractice.
I am focusing on how the system can be improved to prevent or at least decrease these kind of outcomes.
Click to expand...
 
LowDown said:
And, by the way, it's going to get worse, not better. The PPACA isn't going to increase the quality of health care professionals out there one bit. Quite the opposite, in fact.
Click to expand...

Interesting. how do you come to that? I happen to know here, the new reform has led to efforts at improvement. So, what do you have?
 
Stewart said:
I came across this article in the NYT the other day:
An Infection, Unnoticed, Turns Unstoppable
What alarms me the most, is the comments that all seem to start with "'m an ER DR" and always seem to dismiss the fact that he was sent home without labs confirmation as "normal" and if they held everyone the ERs would be "swamped." Most DRs in these comments seemed completely oblivious to the points raised in the article and came across as very defensive.

I know in our "socialized" system here it is standard practice to not discharge without labs being returned. I have often been on hold for a few hours while I waited. It's considered a check before discharging to make sure they didn't miss anything and I find it alarming that it seems that this is seen as common in the US Emergency rooms. And it should be noted our AnE DRs are just as full and our DRs overworked as yours. Is it possible that their are other people who have tragically lost their life to other practices similar as this who don't have the distinction of knowing a NYT columnist and thus has been swept under the carpet. If this is a common practice, statistic dictate that it has happened before.

Whenever there is a Aircrash from the smallest propjet to a International Airliner, there is a large protracted investigation. The purpose of this is not to find criminal negligence but to learn where mistakes were made and how we can fix them to prevent it from happening again. Thus the safety of our Airplanes has been increasing over time. In each case there is a long trail of mistakes that each occurred in a specific order for the accident to occur. All too often imperfect information, overworked staff and other human related factors are ruled to be the cause.

From what is observable in the article I can think of perhaps two major mistakes in the chain of errors. These I believe were both caused by the failing of the system and not the decisions made by the people involved.
Lack of handover between the family DR and ER rooms, the physician who first saw him had already made several abnormalities and were these passed along to the staff of the Emergency Room, why double up and rely on them picking it up a second time?
Why were the patient discharged without the labs results known? I know DRs in the comments said that they could easily have contacted the family by phone if abnormal results were returned, however this clearly didn't happen. It's all to easy to understand once he was out of the ER he was essentially out of mind, completely understandable in a busy ER. However this still represents a clear failing of the system.

I guess my whole point of this is should the Review of this case occur behind close doors by the hospital themselves or by a public, impartial figure with the sole goal of fact finding and not laying criminal charges. It is important that researches and other involved stakeholders are able to understand how the system fails on a microlevel, if reviews are internal is it not possible that this information may be suppressed? Especially by a hospital with a sterling reputation like NYU Langone.

Disclaimer I am not accusing anyone of clinical malpractice.
I am focusing on how the system can be improved to prevent or at least decrease these kind of outcomes.
Click to expand...

You're thesis seems anti-county hospital . . . So, should everybody abandon their line of defense?
 
In December, I went into Loyola University Medical Center's emergency room in severe pain -- 10 on the scale. (Well, 11....) I was misdiagnosed and sent home with some nonprescription medication. I was seen by a Nurse Practitioner who diagnosed me and had the "pleasure" of being introduced to the ER doctor on duty. She shook my hand.

Six days later, I was taken by ambulance to another hospital (at my insistence). A nurse practitioner misdiagnosed me yet again; but this time, I had a high fever...so they called in their "physician on call." She correctly diagnosed a severe abscess which, by now, had caused a raging systemic infection. I was admitted into the hospital, put on "all the pain medicine I wanted," inter-venous antibiotics, and had emergency surgery the next morning.

It took me three days to decide to go to the ER and six more days to get diagnosed correctly. And, even then, I had to speak up loudly and firmly, "You're freakin' wrong!" If this out-spoken lady had a hard time with a rare diagnosis, what chance does a little kid have?

Hospital staff is frequently over-worked and becomes, I think, jaded to the complaints of their customers. And don't forget, that's what you are. It has become more important than ever that we not only trust our own instincts, but (especially with children) err on the side of, "We've got another nut out there."

The OP? That was a tragedy of epic proportions. Terrible.
 
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It's NEJM, you can hardly handwave that one away Boo.
However, how much of it is actually hyperbole remains to be seen.
 
Boo Radley said:
I'm sorry, these polls are largely false and a not to be taken seriously. The legislation also wants to encourage more, not less, family practioners (a field that has been shrinking for a long time).
Click to expand...

Well, that's one way to deal with data that contradicts one's opinion.

I suspect that many older physicians will retire early if the cuts in reimbursement go through as advertized. As for primary care, they've been trying to boost that since I was in school 25 years ago, and you can see the results. The ONLY way they are going to do that is to take total control of pay and residency training (in which case you'll see a LOT of physicians bailing out.) I don't see where the PPACA does that, it doesn't fundamentally change the current structure.

More work for less pay - it's not a good way to attract young people.
 
LowDown said:
Well, that's one way to deal with data that contradicts one's opinion.

I suspect that many older physicians will retire early if the cuts in reimbursement go through as advertized. As for primary care, they've been trying to boost that since I was in school 25 years ago, and you can see the results. The ONLY way they are going to do that is to take total control of pay and residency training (in which case you'll see a LOT of physicians bailing out.) I don't see where the PPACA does that, it doesn't fundamentally change the current structure.

More work for less pay - it's not a good way to attract young people.
Click to expand...

Many older physicians are going to retire regardles sor any reform. Good way to suggest you're right, take something it is going to happen regardless and present it as evidence. Doesn't hold water. Sorry.

And the government cannot assure that primary physicians will increase, but they have offered incentives, incentives that were not there before. SO, a problem that was happening before refrom gets some help, and you call it the cause of the problem? You can't see the error in that thinking? Seriously?

And no one is going to be paid less. You're leaping to silly land.
 
MaggieD said:
In December, I went into Loyola University Medical Center's emergency room in severe pain -- 10 on the scale. (Well, 11....) I was misdiagnosed and sent home with some nonprescription medication. I was seen by a Nurse Practitioner who diagnosed me and had the "pleasure" of being introduced to the ER doctor on duty. She shook my hand.

Six days later, I was taken by ambulance to another hospital (at my insistence). A nurse practitioner misdiagnosed me yet again; but this time, I had a high fever...so they called in their "physician on call." She correctly diagnosed a severe abscess which, by now, had caused a raging systemic infection. I was admitted into the hospital, put on "all the pain medicine I wanted," inter-venous antibiotics, and had emergency surgery the next morning.

It took me three days to decide to go to the ER and six more days to get diagnosed correctly. And, even then, I had to speak up loudly and firmly, "You're freakin' wrong!" If this out-spoken lady had a hard time with a rare diagnosis, what chance does a little kid have?

Hospital staff is frequently over-worked and becomes, I think, jaded to the complaints of their customers. And don't forget, that's what you are. It has become more important than ever that we not only trust our own instincts, but (especially with children) err on the side of, "We've got another nut out there."

The OP? That was a tragedy of epic proportions. Terrible.
Click to expand...

I suspect that the OP had a political agenda in his post, although I don't know what it is. Your situation, and the senario that you identified (correctly I suspect) could happen at any institution and under any type of medical system. I can't really come up with a solution, it's certainly nothing that socialize medicine would fix, nor would Obamacare, or our current system.

Maybe we should just make medical care givers all smarter, then have them work less, care about the patient more, recogize that they wouldn't have a job without the patient (the customer as you empasised), and compensate them based upon the outcome.

Or we could just SUE their arse when they screw up, but of course conservatives wouldn't support that (sorry, I had to make it political some how).
 
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IMAGEP, I think you of all people should know what my 'agenda' is? I stand for a high performance health system. That's it. I don't particularly care how we get there, although I do have some notions about the best way to achieve that in the most efficient manner.

Maybe we should just make medical care givers all smarter, then have them work less, care about the patient more, recogize that they wouldn't have a job without the patient (the customer as you empasised), and compensate them based upon the outcome.
Click to expand...
I'm not trying to pretend that we can abstain from human error, more that we shouldn't be trying to hide human error for fear of litigation. Because of articles like this being circulated it makes Physicians more aware of the potential for mistakes. A ER Dr in Colorado might err on a the side of caution next time. Of course the problem is with high-profile cases like this, it leads to people mistrusting their DRs as well. Reducing or limiting the amount of hours DRs can work, particularly those involved in Emergency and Surgery work might go a long way to reducing fatigue. Of course this is going to reduce the amount of DRs on call and increases the stress In the ER so it's really a double-edged sword.

I stand for a High-Performance healthcare system. That's it. I have NO other agenda. Not expanding the role of the government, nothing else.
 
Stewart said:
I came across this article in the NYT the other day:
An Infection, Unnoticed, Turns Unstoppable
What alarms me the most, is the comments that all seem to start with "'m an ER DR" and always seem to dismiss the fact that he was sent home without labs confirmation as "normal" and if they held everyone the ERs would be "swamped." Most DRs in these comments seemed completely oblivious to the points raised in the article and came across as very defensive.
Click to expand...

I doubt it's common at all, here in the States. When someone comes in with a suspected infection, and has symptoms, particularly an elevation in temperature, and an elevated white blood cell count, they are often admitted. If they aren't, they are prescribed antibiotics. I'm assuming that the lab work you're referring to is a culture and sensitivity, which takes 48-72 hours for a final result. Even if they do have a positive culture, if they are already on antibiotics, even if they are at home, it doesn't mean that the antibiotic isn't working. What would typically happen, is the doctor would review the sensitivity report to make sure the prescribed antibiotic should be effective, and if not, then contact the patient with a prescription change.
 
Boo Radley said:
Many older physicians are going to retire regardles sor any reform. Good way to suggest you're right, take something it is going to happen regardless and present it as evidence. Doesn't hold water. Sorry.

And the government cannot assure that primary physicians will increase, but they have offered incentives, incentives that were not there before. SO, a problem that was happening before refrom gets some help, and you call it the cause of the problem? You can't see the error in that thinking? Seriously?

And no one is going to be paid less. You're leaping to silly land.
Click to expand...

Medicare reimbursements are supposed to be cut by 31% in all. That means less pay:

Vital Signs | Medicare Reimbursement Cuts Could Hit Physicians Hard

And if a lot of physicians decide to retire early then it's going to cause problems. As you said, there's already a shortage of primary care physicians.
 
If I were to announce that I was cutting my prices for the products that I make, everyone would be cheering me on. Some would even suggest that I would end up making more money due to an increase in volume.
 
imagep said:
I suspect that the OP had a political agenda in his post, although I don't know what it is. Your situation, and the senario that you identified (correctly I suspect) could happen at any institution and under any type of medical system. I can't really come up with a solution, it's certainly nothing that socialize medicine would fix, nor would Obamacare, or our current system.

Maybe we should just make medical care givers all smarter, then have them work less, care about the patient more, recogize that they wouldn't have a job without the patient (the customer as you empasised), and compensate them based upon the outcome.

Or we could just SUE their arse when they screw up, but of course conservatives wouldn't support that (sorry, I had to make it political some how).
Click to expand...

Maybe I didn't read the OP carefully enough. I thought he was talking about the boy who died from a mis-diagnosed infection. Yes, I completely agree with your post. Mistakes will always happen. I hate the idea, though, that Nurse Practitioners have taken first-line position in ER's. At least the caliber of the two I ran up against. And it's funny, because when I lived in Door County, our sole medical practitioner was an NP -- and everyone loved him, myself included. He was wonderful. Maybe hospitals aren't "interning" them long enough.....?
 
There have been Automatic cuts called for under the SGR every year. Congress has so far ignored them. Part of Obamacare is replacing the SGR with a different calculation formula.
 
imagep said:
If I were to announce that I was cutting my prices for the products that I make, everyone would be cheering me on. Some would even suggest that I would end up making more money due to an increase in volume.
Click to expand...
It would depend on the elasticity of demand for said product. Hint: Healthcare is inelastic. Ergo it doesn't work like that.
 
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