My father, left, on my wedding day 1970

Let me back up. Another reason I am thinking about autopsies is that I also read an article today about the drastic decline in autopsies. Called, “Without autopsies, hospitals bury their mistakes”, it identifies the trend of a drastic decline in autopsies, from 50% of hospital deaths 50 years ago to 5% now. Why such a drop? Lack of reimbursement for the procedure, no Joint Commission mandate to do them, and fear by hospitals and doctors that an autopsy will reveal medical malpractice are reasons that are cited.

What are the medical consequences of not getting an autopsy? For one, the medical team does not learn from their mistakes, or even that a mistake has occurred. The feedback loop is gone. They don’t learn about the effectiveness of the treatment they ordered. They don’t learn how diseases progress.

What are the medical legal consequences of not getting an autopsy? We in the legal world know that proving causation can be infinitely more difficult without an autopsy. Several times a year we ask attorneys, “Was there an autopsy?” And a few times a year we have discussions with attorneys about the effectiveness of digging up a body and performing an autopsy several months after death. Will an autopsy, even if done, provide the answers about the cause of death? Not always. Earlier this month a pathologist told me four causes of death that will not show up on autopsy.

When I was a student nurse, I saw autopsies being done. When I edited chapters on autopsy medical records and forensic medical records for Medical Legal Aspects of Medical Records, I helped the authors sort through after death photographs to include as figures in the chapters. As legal nurse consultants, we routinely read autopsy reports and sometimes see photographs included with records that flow through our office. Legal nurse consultants can slip into the mask that allows us to dispassionately read these reports and look at the photographs.

But in 1977, when I sat in a conference room at Atlantic City Medical Center with my father’s attending physician on the phone, I had only my student nursing experience watching autopsies. My 56-year-old father developed back pain around Thanksgiving, and saw a chiropractor. A week later, when the back pain was still strong, he woke up one day and could not urinate and could not move his legs. At the hospital, he was diagnosed with metastatic cancer that had metastasized to his spine and lung. The primary site was unknown. Four short weeks later, he was dead. The tumor in his lungs suffocated him. When my grandfather walked into his son’s hospital room on Christmas Day, he found him dead. We felt like we had been hit by a truck. There was no time to prepare.

My father’s attending physician argued that we should agree to the autopsy because the primary site was unknown. My grandfather said, “No.” He passed the phone to my husband, who also said, “No autopsy.” Then I took charge of the phone call. I told the attending physician that I had seen autopsies done, and that my father would not have wanted that done to his body. The attending physician continued to argue with me, telling me that cancer was one of the leading causes of death. “There is nothing you can say that will change our minds”, I told him. In a situation in which we felt out of control, refusing the autopsy gave us some tiny sense of being in charge. The lack of the autopsy did not change of his children’s lives in terms of routine healthcare or monitoring.

However, if someone I loved died today and I was suspicious about the cause of death, I know I would have to fight to get the autopsy done, pay for it out of my pocket, and use the knowledge to understand what occurred.

There is one other point I want to make about my father’s death. After he and my mother got divorced, he lived with his parents. His mother died of malignant melanoma in 1976. My grandfather was a controlling man who did not want to see his son date or travel. A week before my father was diagnosed with back pain, he told me that after his father died, he would travel, date, and really enjoy his life. He never got those opportunities, and his father lived for five more years after his son’s death.

When my father died, I learned at the age of 27 that life is short, and the only day you can count on is today. By dying at age 56, my father missed out on seeing so much of life and having family experiences – grandchildren and great grandchildren. Don’t make the mistake of thinking you have endless time. Life is now.

Pat Iyer MSN RN LNCC is president of Med League and the mother of two sons, one of whom her father was not alive to meet. Her firstborn son was 2 years old when her father died.

Bladder cancer occurs in 38 out of 100,000 men and 10 out of every 100,000 women. There are several risk factors for bladder cancer; the most common one is cigarette smoking. People who have been exposed to chemicals in the dye and rubber industries are also at risk. Dry cleaners, clothing manufacturers, and coal handlers are also at risk. (1) You increase your risk of bladder cancer by eating large amounts of fried meats and animal fats.
Blood in the urine is the most common sign of bladder cancer. Some people have pain or burning during urination and a change in bladder habits, such as feeling the need to urinate more frequently. Other conditions may cause these same symptoms, making bladder cancer difficult to diagnose. Bladder cancer may be present without symptoms for a long time. (2)

Bladder cancer is diagnosed by examining the urine for blood, examining the urine for cells (urine cytology), and performing a cystoscopy and an abdominal CT scan or ultrasound. A cystoscopy is performed under anesthesia, and involves inserting a lighted instrument into the urethra to examine the bladder. The balder is filled with fluid to enlarge it. The addition of a blue or white light makes it easier to see abnormalities of the inside of the bladder. The urologist biopsies any abnormal–appearing areas.

The most common type of bladder tumor is called urothelial. It tends to be superficial and not invade the walls of the bladder. It makes up 90% of all bladder tumors. The bladder may also have squamous cell or adenocarcinoma, more aggressive types of tumors. High grade tumors are also more aggressive, as are poorly differentiated ones.

If the urologist sees a tumor, the first step is to remove it and send it for pathology. It may be difficult to cut tumors out of the bladder because of the risk of perforating the bladder wall. Uncontrolled bleeding and perforation occur in less than 5% of cases. (3)

Bladder cancer is the sixth leading cause of cancer death among Americans (4). Complete removal of the tumor is not always possible, and therefore some patients have to undergo radical surgery consisting of removal of the bladder. An artificial bladder is created with a loop of bowel. This surgery has significant quality of life issues. It is accompanied by removal of the uterus and ovaries and part of the vagina or the prostate and seminal vesicles. Urine may drain into a bag attached the abdomen or be removed several times a day with a catheter. Surgery may be used along with chemotherapy or radiation therapy to reduce spread of cancer through the lymph nodes.

Liability issues surrounding bladder cancer include:
• Delay in diagnosis of bladder cancer
• Failure to correctly interpret ultrasounds or CT scans
• Damage to the bladder and surrounding structures during biopsy or bladder tumor removal
• Delay in recognizing hemorrhage or perforation of the bladder
• Failure to correctly read pathology slides
• Treatment – related complications such as extravasation (leaking into tissues) of chemotherapy

Bladder cancer is a nasty disease. Reduce your risks by not smoking, reducing your consumption of meat, and by promptly seeking medical attention if you have any of the symptoms of bladder cancer.

Patricia Iyer is president of Med League Support Services, Inc.

(1) Malignant Neoplasms, Rakel: Textbook of Family Medicine, 8th Edition
(2) Bladder cancer, Dr. Melissa Stopper, emedicinehealth
(3) Endoscopic surgical management, Wein: Campbell-Walsh Urology, 10th edition
(4) Surgery for bladder cancer, Wein: Campbell-Walsh Urology, 10th edition

Wilma (fictitious name) suffered a frontal lobe injury when she was thrown into the windshield after her car was rear ended. Wilma got lost driving in her neighborhood, could not figure out how to operate her security alarm on her house, or to how to assemble food in the right order to follow a recipe.

The frontal lobe is behind the forehead. It controls emotion, personality, judgment, morality, language, problem solving, and impulse control.

Problems in this area of the brain may result in the following problems:
a) Recent memory deficits
b) Inattentiveness
c) Poor concentration
d) Behavioral disorders/personality changes
e) Inappropriate social and/or sexual behaviors
f) Flat affect
g) Depression
h) Expressive aphasia (the person knows what they want to say but has difficulty with communicating the words or sentences)
i) Impulsiveness
j) Psychotic disorders (abnormal thinking and perceptions; difficulty staying in touch with reality)

Roger was hit on the top of the head by an object that fell off a shelf in a store. He suffered a parietal lobe injury. The parietal lobe is under the top and back half of the skull. Roger had difficulty walking because he could not tell where his feet were in relationship to the floor. He also had trouble following conversations. The parietal lobe affects sensory function, pain, temperature, spatial relations, and proprioception (sense of body position).

Problems in this lobe can cause deficits in:
a) Ability to read, draw, or write
b) Receptive aphasia – difficulty understanding others
c) Problems with perception or awareness of one side of the body
d) Ideational apraxia – the loss of the ability to carry out purposeful movements
e) Constructional apraxia – the loss of the ability to copy objects
f) Dressing apraxia – the loss of the ability to know how to dress

Gretta had a seizure disorder. She fell backwards during a seizure and struck the back of her head. She became blind. The occipital lobe in the back of the head affects vision. Injuries to the occipital lobe may cause deficits in:
a) Receiving visual input
b) Visual interpretation
c) May cause blindness

Juan was hit in the side of the head by a baseball bat. He had a temporal lobe injury. He lost his memory of recent as well as distant events, and had a severe speech impairment. The temporal lobe is the major area for memory and affects hearing, language reception, and the sense of smell and taste.

Deficits in this area can cause:
a) Hearing problems
b) Agitation
c) Irritability
d) Receptive aphasia (difficulty understanding others)
e) Attention deficits

By understanding the locations of the functions of the brain, it is possible to understand how injuries to these areas result in deficits.

Patricia Iyer is president of Med League Support Services, Inc. Her firm has handled many cases of traumatic brain injury caused by personal injury or medical malpractice.
Jane Heron is a legal nurse consultant at Med League.

Surgery began about 12:00 PM and ended about 3:00 PM. The surgeons encountered a lot of bleeding during the operation. It took several attempts with sutures to finally control the bleeding, which totaled 1200 cc of blood loss. The patient was given 4 units of blood.

In the recovery room, the patient was awake and could move her arms and legs when requested to do so. She was asked to rate her pain. She rated it as 8; the nurse injected Dilaudid 1 mg by intravenous push. (Dilaudid is one of the strongest pain relievers on the market.) At 3:40 PM, the patient’s artery was stuck to obtain blood to test for blood gases. (Punctures of arteries are exquisitely painful due to the nerve endings that surround the artery.) At 3:45 PM, the patient’s femoral vein in her groin was stuck to obtain blood. At 3:50 PM, Ms. Kelly rated her pain as 10 at that time, the highest possible pain. She was given an intravenous injection of Fentanyl, a narcotic.

The patient left the recovery room at 5:15 PM. She was awake and could move her arms and legs when requested to do so.

Intensive Care Unit 5:45 PM-7:45 PM
Ms. Kelly’s level of awareness was evaluated when she arrived in the intensive care unit. She spontaneously opened her eyes. She obeyed commands. (Commands are requests such as “Open your eyes”, or “Squeeze my hand.”) She could not speak due to the presence of the endotracheal tube. She could purposefully move her arms and legs and had full strength. displayed her heart rate and rhythm.

At 6:00 PM, Ms. Kelly was pulling on her IV lines, attempting to remove the endotracheal tube in her mouth, and pulling on her tubes and drains. Wrist restraints were put on each wrist to tie her hands to be bed frame. This prevented her from doing anything for herself, such as scratching her nose, turning over, or writing a note. The critical care nurse documented the patient had obvious signs of pain. She was given Fentanyl 25 mcg by intravenous push at 6:00 PM.

A nursing note written at around 7:00 PM which summarizes the hour of 6:00 PM to 7:00 PM states three doctors were in and inserted a triple lumen catheter and an arterial line. A triple lumen catheter was inserted into the patient’s upper chest in the right subclavian area. This procedure involves injecting the skin with Xylocaine to numb it, covering the chest with drapes, and piercing the skin with a needle to insert a long tube that is threaded along the subclavian artery to a point close to the heart. A painful arterial stick to insert an arterial line was also performed.

At 6:10 PM, the patient was assessed as needing more pain medication. She was given Fentanyl 25 mcg by intravenous push.

At 6:20 PM, the patient was assessed as still being in pain. She was given Fentanyl 25 mcg by intravenous push for pain.

At 6:40 PM, the patient was again in need of pain medication. She was given Fentanyl 25 mcg by intravenous push.

At 7:00 PM, the cardiac monitor displayed a slow pulse rate in the 40s. Ms. Kelly was given an intravenous dose of Atropine to increase her heart rate. It had little effect. The patient was not responding to painful stimulation. She was given Narcan to reverse the pain relieving effects of the Fentanyl. A dose of Epinephrine was given to stimulate her heart. There was little response.

At 7:15 PM, the code sheet shows the patient had no pulse or heart rate. Chest compressions were given. The plan was to re-explore the patient’s abdomen on an emergency basis.

Surgery 7:45 PM – 8:35 PM
Ms. Kelly’s preoperative diagnosis was “acute abdomen, bleeding post hemicolectomy.” The surgeons saw the entire small bowel was dead, black, and purple. A massive small bowel resection was completed. Ms. Kelly did not wake up after her surgery. A “medical futility” note written that evening around 10:45 PM noted the patient was cold with a body temperature of 91.4°; she was bleeding from all sites and had a hemoglobin below recordable data. (An earlier hemoglobin was 3.7.) The patient expired at 11:23 PM.

When the defense claimed the patient had no pain and suffering, the plaintiff attorney pointed to the report Pat Iyer prepared, a portion of which is in this blog post. The judge agreed the patient experienced pain and suffering and the case was settled.

Pat Iyer is president of Med League Support Services, Inc. Both Pat Iyer and Jane Heron prepare summaries of medical records that detail the care and treatment of patients.

Mr. Nissen’s attorney, Margaret Battersby of Levin and Perconti in Chicago, asked for Med League’s help in summarizing the voluminous medical records. The challenge: to take 11 three inch binders of medical records spanning 5 years, and create summaries of the most important aspects of Mr. Nissen’s condition.

First, we organized the medical records into tabbed sections for each of his hospital and rehabilitation stay admissions. Each admission was broken down into the type of record, such as physician order, nursing notes, and so on.

We created month-by month tables showing all of Mr. Nissen’s symptoms, as signs of discomfort and complications. We showed his ability, month by month, to respond to his environment, by nodding his head “yes” or “no”, lifting his thumb up for “yes” or responding to his name. Using Casemap, we created a chronology of events, and coded each entry into a category. This permitted us to extract all of the entries related to particular aspects of Mr. Nissen’s condition. The end products were chronologies that summarized his communication abilities, comprehension, discomfort, fatigue, functional abilities, hospital admissions, mood, pain, respiratory condition, and seizures. Lastly, we identified and copied over 350 key documents that illustrated key points about his condition, and created a list of all exhibits.

The attorney found our work product essential in understanding and organizing what happened to Mr. Nissen. She was able to settle this claim and enable Mr. Nissen to receive care for the rest of his life.

Accidents and injuries happen in health care in a moment. A patient decides to get out of bed without calling for a nurse, trips on her IV tubing and falls, fracturing a hip. Nurses’ aides use a mechanical lift to get a patient out of bed. The sling under the patient is frayed and in a second, rips and drops the patient to the floor, where he lands on his head. A distracted physician writes an order on the wrong chart. A transporter misjudges the speed of the stretcher he is pushing and takes a corner too fast. The momentum throws the patient off the stretcher. These are all real stories. I could go on for pages about the events that occur in moments. Maybe you could too.

When my mother went into the hospital for surgery, she was taken to the surgical holding area. A nurse walked in with a basket of intravenous supplies, and began to lay out her equipment. She said, “Mary, it is good to see you today.” My mother replied, “My name is not Mary. It is Gladys.” The shocked nurse said, “Your name is not Mary Wilson?” and quietly picked up her equipment and disappeared. The nurse did not take the moment to verify the identity of the patient.

Last year a physician examined an abscess under my arm. He then quickly left the room, and did not take the moment to wash his hands, despite a large red sign over the sink that said, “Wash hands”. Who knows where he carried my germs?

It only takes a moment for a patient to speak up, to ask questions, to request attention. One of my employees had a carpal tunnel surgery done. On her first postoperative office visit, the surgeon began to walk out of the room, not allowing her to ask her questions. She said, “Yo! I have questions. Come back.” He did. He closed the door, sat down, and answered her questions.

An incident that forever alters a patient’s life can take place in an instant. Hopefully safeguards are in place that serve as part of the safety net. The fact that they don’t work is one of the foundations of the medical malpractice legal system.

What case have you worked on that resulted from an error that took place in a moment? Share your comments.

The government is pushing e-prescribing. This number will continue to grow based on the Centers for Medicare and Medicaid Services “voluntary” incentive program. Although it is voluntary now, the program forces physicians to adopt e-prescribing by transitioning from incentive payments to penalties on covered Medicare charges.

E-prescribing should get another boost as the Drug Enforcement Agency interim final regulations that took effect June 1, 2010, will allow for e-prescribing of controlled substances (typically narcotic pain-relievers) in the US. Pharmacies may not begin to receive these orders for another 6-18 months as the software vendors make the updates to computer systems that will allow prescribers to transmit the medication orders, intermediaries to process the prescriptions, and pharmacies to receive them. Furthermore, as the regulatory barriers to controlled substances become more streamlined patients may be more likely to receive prescriptions for them.

Benefits
E-prescribing can and will benefit quality of care. The following are just some of the ways.

Drawbacks
A new technology is not without its drawbacks. Some of the more notable issues with e-prescribing include

About the author: Dave Boblenz, PharmD, is a pharmacist with over 14 years experience. He operates www.pharmacytechniciancertification.com.

Comments
As is true with any prescription, whether handwritten on a prescription pad or sent electronically to the pharmacy. Errors may be made in the drug selection, dosage and route of administration. The physician, nurse practitioner or physician’s assistant may fail to provide education about side effects or provide sufficient details to provide an informed consent about the risks of the medications.

In one study, doctors agreed to be recorded during patient visits as they prescribed drugs new to those patients. Here is the percent of time the doctors gave people the following critical pieces of information:
Reason for taking the drug: 87%
Name of the drug: 74%
How often to take it: 68%
How much to take each time: 55%
Side effects: 35%
How long to keep taking the drug: 34%

In addition to errors in prescriptions covered by a previous blog post, http://krmno.th8.us consider errors in filling e-prescriptions. The pharmacist or technician may have pulled the wrong drug off the shelf or provided the wrong dose. While e-prescribing reduces errors, it does not eliminate them.

References
Use of E-Prescribing Grows Dramatically
Physician Quality Reporting Initiative
A Clinician’s Guide to Electronic Prescribing
Elizabeth Bewley, author of Killer Cure, Dog Ear Publishing, cites the study by Derjung, T., Heritage, J. Paterninti, D. et al, “Physician communication when prescribing new medications”, Archives of Internal Medicine 25 September 2006

medication errors

It is estimated that 3.4 billion prescriptions were filled in the United States in 2003, which averages to 11.7 prescriptions per citizen. The enormous quantity of medications distributed each year translates to an inevitable number of misprescriptions–prescriptions that are inappropriate for a particular ailment and may be downright dangerous for a patient to take. A 2004 study found that 1 in 12 doctor’s visits in the U.S. resulted in the patient receiving misprescribed medications.

When misprescribing and overprescribing occurs, the negative effects range from simply not solving the health issue in question to actually worsening the condition. An over-prescription of anti-depressants, for example, could have reverse effects on a patient with depression. Misprescribing drugs could mean that the prescribed drug would pose a health threat. Prescribers advise not to take medication when one is not ill; thus, the dangers of prescribing something that shouldn’t be prescribed are clear. There is also a vast amount of money that is wasted when misprescriptions occur, a devastating dilemma for those who pay for their own medications or have expensive copays.

Healthcare providers may misprescribe for a number of reasons. The drug industry is a driving factor behind this persistent issue. Advertisements provided by drug companies promote certain medications to the point where patients request them by name, often leading prescribers to tailor their prescriptions around the patient’s wants rather than medical necessity. Additionally, the dangers of mixing certain medications are not always widely publicized and discussed. Prescribers may not ask for adequate background information from their patients, a vital step in determining whether a patient should add a new medication to what they are currently taking. Furthermore, research has shown that some doctors–particularly those who are ACoAs (adult children of alcoholics)–feel the pressure to please their patients and will act according to their patients’ requests.

“With doctors stretched thin, some [...] think writing prescriptions is the easy way out,” states an article about the stress of the medical community over misprescribing pain medications and other pills. Healthcare providers oftentimes go straight into prescribing another medication when the “disease” for which it is being prescribed is in fact a side effect of a drug that the patient is already taking. The professional will prescribe a drug to “treat” what is actually an adverse reaction to another medication, which could have been more effectively solved by lowering the dosage of the initial medication or replacing it with another form of treatment.

Due to adverse reactions to misprescribed and overprescribed pills, half a million people are hospitalized each year. The medications they are misprescribed lead them to experience reactions that could have been avoided had the pills been properly prescribed or not prescribed in the first place. Mistakes happen even in the realm of medical science, but prescribers must take more careful measures before issuing their patients a prescription. By exerting greater care in the issuing of medications, misprescriptions can be avoided.

This guest post is contributed by Adrienne Hurst at AllTreatment.com, a rehab center directory and substance abuse information resource.

Comments: Attorneys and their experts who evaluate the liability and damages issues surrounding prescriptions should consider:

Careful analysis of the medical record, with the assistance of a legal nurse consultant, can make all of the difference in the outcome of a case involving misprescription.

Sources:

http://www.worstpills.org/public/page.cfm?op_id=3

http://www.e-tmf.org/downloads/Why_Physicians_Misprescribe.pdf

http://www.in-pharmatechnologist.com/Packaging/No-improvement-in-misprescribing-rates

http://sundaygazettemail.com/News/201101161143?page=2&build=cache

Medical Malpractice
Turn, Turn, Turn – The Byrds
You Take My Breath Away – Queen
Whiter Shade of Pale – Various Artists
Stairway to Heaven- Led Zeppelin
You’re Only Human – Billy Joel
Can’t Take My Eyes off of You – Frankie Valle and the Four Seasons
Communication breakdown – Led Zeppelin
Cool Jerk – Various Artists
Couldn’t Get it Right – Various Artists
Devil or Angel – Billy Fury
Doctor Robert – The Beatles
Fever- Ray Charles
Piece of My Heart- Janis Joplin

Nursing Home
Where’ve You Been – Kathy Mattea
I Forgot to Remember to Forget – The Beatles
Nowhere man – The Beatles
When I’m Sixty Four – The Beatles
Eleanor Rigby – The Beatles
Back When We were Beautiful- Matreca Berg
Bygone Days – Eileen Ivers
Fixin To Die- Bob Dylan
Last Night I had the Strangest Dream – The Weavers
Last Kiss – J. Frank Wilson and the Cavaliers
Memory – Andrew Lloyd Webber
The Old Man – Kate Rusby
Old Hippie- Bellamy Brothers
The Gumby Cat – Andrew Lloyd Webber
Sometimes She Forgets – Travis Twitt
Only the Good Die Young – Billy Joel
That’s How I Remember Yesterday- the Limeliters
You Don’t Know Me – Ray Charles and Friends
When You Are Old – Gretchen Peters

never events

Ken Kizer, a physician and former chief operating officer of the National Quality Forum, coined the term “Never Events”. These are particularly shocking medical errors, like operating on the wrong patient, that should never happen. The NQF defined 27 such events in 2002 and revised and expanded the list in 2006. The list is grouped into six categorical events: surgical, product or device, patient protection, care management, environmental, and criminal. They are also referred to as serious reportable events. Some or all of these events are reportable to state agencies. Organizations accredited by The Joint Commission are expected to report these events to The Joint Commission.

See the list: SRE_FactSheetv2

Beginning October 2008, the Centers for Medicare and Medicaid Services stopped reimbursing hospitals for care that resulted in one of a limited list of never events. Private payors followed suit. The healthcare facility is not permitted to bill the patient for the revenue that was lost as a result of this never event.

Why do these events continue to happen? Health care is incredibly complex and there are multiple opportunities for errors – related to communication, the environment, fatigue, stress, and a host of other factors. Healthcare providers don’t want set out to hurt people – this blog explores some of the reasons why that happens and how that influences the litigation process.