The surgeon was not prepared for my sedative needs, did not listen to my request of what to give me, and because I was holding up the Endoscopic Unit, he called for an anesthesiologist I had never met. He never asked a single question, nor did he check out my charts. He simply injected me with Propofol, without the Lidocaine to ease the pain. I was in hell, and then out for a quick intubation. As a heart patient with all the symptoms from that, I should not have had Propofol. I woke up coughing my guts and lungs up as they extubated me. I was on the other side of the hospital in the main recovery area. Neither doctor came to tell me what happened and what might happen later.
State Disclosure Reports
Consumers Union Documents
- State’s request for federal (ARRA) funding of plans to fight hospital acquired infections
Links to state grant submissions from the American Reinvestment and Recovery Act stimulus money for hospital-acquired infection plans.
- State Hospital Infection Public Reporting Laws
Summary of state laws hospital infection reporting laws.
- Watch Money-Driven Medicine
A new documentary, Money-Driven Medicine, offers a thoughtful perspective to the health care reform debate that couldn’t be timelier.
- Insight from California Safe Patient Network
Guest blogger, Holly Harris from San Diego, shares what she learned at the California Safe Patient Network meeting and calls on us to join and spread the word about preventable medical harm.
- Patients Right to Know
Colorado Citizens for Accountability has launched its new patient safety website: PatientsRightToKnow.org. It contains a U.S. map where you can find out what physician background reporting is available in your state.
- Fund the Texas hospital infection reporting law
In 2007, the Texas legislature had a brilliant idea. They passed a law that required the Texas Department of State Health Services to make public health care acquired infection rates for several surgical procedures and bloodstream infections in hospitals, ambulatory surgical centers and children’s hospitals by no later than June 1, 2008.
- The race to get vaccinated
At least 20 states have recently introduced bills that would require that all young girls receive the vaccine for the HPV virus that causes cervical cancer. The vaccine, Gardasil was only approved by the FDA last June.
- Mandatory vaccine sparks controversy
Last week, TX Gov Rick Perry bypassed the state legislature and ordered that all girls entering 6th grade be vaccinated for the HPV virus, linked to cause cervical cancer.
- North Texas doctor fined over unneeded stent implants Source: Dallas Morning News (Wednesday September 18, 2013)
Dallas Morning News reports: The Texas Medical Board has fined a McKinney heart doctor for implanting unnecessary stents into cardiac patients, according to records released by the board.
- Anatomy of a Tragedy Source: Texas Observer (Saturday September 28, 2013)
Saul Elbein at The Texas Observer writes that it took more than a year for the Texas Medical Board to stop a doctor who had numerous complaints against him for patient deaths and botched surgeries.
- One Step Closer To Getting Her Husband’s Heart Back Source: ProPublica (Friday August 30, 2013)
Linda Carswell is one step closer to getting her husband’s heart back after almost 10 years of his death. According to ProPublica: “A Texas appeals court ruled Thursday against the hospital that has been blocking her from retrieving the heart of her husband, who had died unexpectedly while in the hospital’s care in 2004. The court also upheld a $2 million fraud judgment Carswell won against the hospital.”
- FBI investigating the shredding of records at hospital operated by indicted North Texas doctor Source: Dallas Morning News (Thursday August 1, 2013)
Dallas Morning News reports: “The FBI is investigating the shredding of documents at a Central Texas hospital operated by Tariq Mahmood, the Dallas-area doctor indicted on charges of defrauding federal insurance programs.”
- Patients died amid federal, state regulatory inaction Source: Dallas Morning News (Saturday July 13, 2013)
The Dallas Morning News investigates patient safety and allegations of lax supervision of doctors in training at the public institutions.
- Owner of shuttered Terrell hospital charged with fraud Source: Dallas Morning News (Tuesday April 23, 2013)
“Federal authorities have filed criminal charges against the owner of Renaissance Hospital Terrell, which was shut down in February after inspectors said reckless care caused the death of two patients and endangered others.”
- Jury finds McKinney chiropractor guilty of sexual misconduct Source: Dallas Morning News (Wednesday April 24, 2013)
“A McKinney chiropractor was found guilty of multiple charges of sexual misconduct late Tuesday after a marathon session by jurors that lasted nearly 15 hours.”
- Bellaire doctor's license revoked due to drinking, medical board says Source: Click2Houston (Monday April 8, 2013)
Texas Medical Board temporarily suspends doctor’s license due to his excessive drinking
- Houston family sues after taping ants in breathing tube Source: Click2Houston (Monday February 25, 2013)
Family films a video of ants and gnats crawling through their father’s breathing tube while he was in the hospital ICU. They wonder if he may have lived longer if he had proper care.
- Despite Counsel, Victim Is Hindered by Tort Laws Source: New York Times (Thursday January 24, 2013)
NYT reprint of Texas Tribune story on a woman who says she was the victim of a medical mistake and Texas tort reform laws.
Research and Reports
- Patient Safety America Newsletter (June 2013) Source: Patient Safety America (Friday June 7, 2013)
Summary by John James: I hope this month’s newsletter might prepare you to be a more defensive patient when you need medical care:
• Many nursing home residents receive lengthy antibiotic treatments, placing them at risk of super infections.
• Off-label prescribing of a narcolepsy drug places many at risk of serious side effects.
• Surgeons might leave some surprising things in your body.
• How would you like to see your surgery on video?
• Did you know Medicare has some dumb policies?
• Sloppy management practices are common in cardiac care units.
• Do you know what a contextual medical error is? You should.
- Patient Safety America Newsletter (May 2013) - Practical Advice Source: Patient Safety America (Wednesday May 1, 2013)
The May newsletter includes summaries that are targeted to alert patients to ways to manage risk and cost: outpatient diagnostic errors, shopping for a hip replacement, too much calcium, radiation risk to your heart, screening for cervical cancer, and finally a series on patient-safety “progress.”
- Patient Safety America Newsletter (April 2013) Source: Patient Safety America (Sunday March 31, 2013)
Summary by John James: “Changes are long overdue in American healthcare as pointed out by the Institute of Medicine and National Research Council in their new book “The US health Disadvantage Relative to Other High-income Countries.” My first newsletter article attempts to summarize this report. In the second article I discuss the risks associated with sleeping pills. The third article considers legislation that often has collateral damage. The fourth involves one doctor’s view of how he was led into care that was not patient centered. My next two articles deal with mental health: 1) As we age, we all fear the loss of mental capabilities, but a new study has linked mid-life fitness with a reduction in the risks of dementia. 2) Young people often do not have access to mental health facilities as pointed out by experts writing in the JAMA. The next articles deal with unintended death from pharmaceuticals and with loss of confidence in drug companies. The newsletter concludes with a short piece on the vanishingly small value of robotic surgery for those who might need a hysterectomy.”
- Patient Safety America Newsletter (March 2013) Source: Patient Safety America (Monday March 4, 2013)
John James, Ph.D., Patient Safety America: “This month I’ve tried to put some important things in perspective for you. Ben Goldacre’s book called “Bad Pharma,” which I reviewed, is a worth-while read. Gun violence is compared with “medical violence” as far as they affect our children’s lives. The cheap, effective medical care received in Cuba is summarized as a lesson for us, and then I pound on the dangers of drugs and the unstoppable overpricing of medical care in our country. Finally, you’ll learn what post-hospital syndrome is and how to manage it to remain out of the hospital.”
- Patient Safety America Newsletter (February 2013) Source: Patient Safety America (Friday February 1, 2013)
This month’s topics include injury risk from common medications, unnecessary testing, and unsafe injection practices in outpatient settings
- Patient Safety America Newsletter (January 2013) Source: Patient Safety America (Tuesday January 1, 2013)
John James, Ph.D., Patient Safety America: “This month I address the discriminatory medical care system in this country. Why are the poor left behind when they need competent medical care? Next – why does Medicare keep spending your tax dollars on procedures that are not “necessary and reasonable?” What is behind the 29+ deaths that resulted from injection of the fungal-contaminated medication from a compounding company? The answer might surprise you. On the controversial front, I summarize an article critical of overuse of mammography screening. Why do prescription pain killers kill at least 16,000 Americans per year? How can a medication be dispensed to you when your doctor has ordered it stopped? Be wary of these potentially dangerous practices.”
- Patient Safety America Newsletter (December 2012) Source: Patient Safety America (Saturday December 1, 2012)
John James, Patient Safety America: “This month I write about the so called ‘war on cancer’ in terms of those who are losing the battle to stay alive. Do they know that the chemotherapy that is making them so ill is not going to cure their disease? Do those who undergo screening for cancer know the risks they are taking on? What should we do about the overuse of imaging? Why do we continue to do human experimentation on premature babies with uncontrolled and unapproved procedures? Isn’t it time to stop this potentially risky practice on these little one? The obesity epidemic is growing like a plague in the United States – Are there new drugs that could reverse the trend toward more obesity and more chronic illness? Nursing homes are risky places for infections – here’s one you may not have thought about – norovirus. Finally, would you like electronic access to your doctor’s notes?”
- Patient Safety America Newsletter (November 2012) Source: Patient Safety America (Wednesday October 31, 2012)
Review of book “Unaccountable” by Marty Makary, MD. The first two articles deal with medical errors – the first on diagnostic errors and the second on errors of omission. On page 3 I take a look at recent misdeeds of big Pharma, and then deal with ethical issues associated post-marketing drug testing on patients. A business model suggests that providers should start giving us what we really want – health – not medical care. Finally, we have a look at why hospital prices continue to escalate.
- Patient Safety America Newsletter (October 2012) Source: Patient Safety America (Sunday September 30, 2012)
1) The first order of business is to mark the passing of Dr. Barbara Starfield, a champion of improving medical care, especially through more emphasis on primary care.
2) Most of us have had a urinary catheter inserted for some reason or other, and it seems that the vast majority of the time infections associated with these are not evident in billing records.
3) Several articles that I review deal with overbilling and over-diagnosis, two pillars of our current medical industry.
4) A troubling article from Archives of Surgery enumerates the dependence many surgeons have on use of alcohol. You might be surprised at the findings.
5) The refusal of Jehovah’s Witness patients to accept blood transfusions after heart surgery offered an opportunity to study the need for such transfusions, with surprising outcomes.
6) Finally, I summarize information suggesting that a lot of money could be saved each year if drug-eluting stents were used with more evidence-based discrimination in patients receiving coronary artery stents.
- Patient Safety America Newsletter (September 2012) Source: Patient Safety America (Thursday August 30, 2012)
This month’s newsletter emphasizes past themes of improved medical care and brings in some new ones. The first article cautions against too much imaging following acute back pain unless there are clear indications that imaging is needed. The second is a new theme – loneliness in older folks as a risk factor for loss of mobility and an early death. The next article is critical of how patients are treated when they show up to the ER with chest pains. The fourth article explores the idea that science can improve patient safety, and then acknowledges that enlightened leadership in the healthcare industry may offer genuine safety improvements. The last article hits on a common theme – risk of harm from adverse drug events at critical times in the recovery pathway.