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.
- State, Feds Target El Paso Hospital Over TB Exposure Source: Texas Tribune (Monday September 22, 2014)
At an El Paso hospital, more than 700 infants may have been exposed to tuberculosis, alerting state and health officials.
- How safe is your hospital? Chance of serious complications varies widely Source: Dallas Morning News (Saturday June 21, 2014)
Dallas Morning News investigation of Texas hospital complication rates.
- FDA proposes strict changes for transvaginal mesh Source: WFAA (Tuesday April 29, 2014)
“The U.S. Food and Drug Administration is calling for stricter safety rules for a product used by tens of thousands of women.” Consumers Union Safe Patient Project activist Joleen Chambers, interviewed by WFAA, calls the FDA proposal a “real win for women.”
- The Hip Generation: Recalls, redoes agony for some with new joints Source: WFAA (Thursday May 1, 2014)
WFAA’s Byron Harris reports on patients who have implanted artificial hips that failed and the flaws in the device approval system that keeps patients at risk.
- Dallas Anesthesiologist Being Sued Over Deadly Surgery Admits to Texting, Reading iPad During Procedures Source: Dallas Observer (Tuesday April 1, 2014)
Dallas anesthesiologist admits to texting and using iPad during a woman’s cardiac surgery. The patient died and her family is arguing that the doctor was at fault due to “distracted doctoring.”
- Campaigners renew calls for end to mesh implant operations after US court says device is defective Source: Daily Record (Sunday April 13, 2014)
The Daily Record covers a mesh case in TX court that could impact other mesh lawsuits against Johnson & Johnson for its pelvic mesh implants.
- J&J Must Pay Damages in Mesh Incontinence Implant Verdict Loss Source: Bloomberg Businessweek (Friday April 4, 2014)
Bloomberg News reports: “Johnson & Johnson (JNJ:US) was ordered by a Texas jury to pay $1.2 million to a woman who alleged one of the company’s lines of vaginal-mesh implants to treat incontinence was defectively designed, in the first verdict against the company over those devices.”
- 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.”
Research and Reports
- Patient Safety America Newsletter (April 2014) Source: Patient Safety America (Tuesday April 1, 2014)
Summary from John James: For many around the country spring cannot come too soon. Sadly, spring will not come again for too many Americans who sought only to be healed of their illness, and instead experienced a preventable adverse event that harmed them to death. I am sad for those who lost loved ones in the Oso mudslide and in the Malaysian jet disappearance, but far, far more human lives were cut short by suboptimal medical care. I offer this month’s newsletter as a tribute to all who have been lost in the last month to medical errors. They are nameless like the Unknown Soldier; however, few pay any attention to their passing.
Newsletter contents this month are as follows:
• Harm to nursing home patients
• C diff infections – kids and adults
• Do you really need a transfusion?
• White-coat infections
• Beware high-dose acetaminophen
• Surgical site infections in out-patients
• Hospital-dependent patients
• Infections from endoscopes
- Patient Safety America Newsletter (March 2014) Source: Patient Safety America (Friday February 28, 2014)
Summary from John James: “Spring’s renewal of life has arrived in my neighborhood with robins hopping around and trees budding. I saw a spectacular red-bud tree yesterday near a bayou. One must hope that our country will renew its efforts to intelligently manage the way healthcare is delivered in America. As far as I can tell the non-system is not working well for anyone but a few medical specialists. This month’s newsletter addresses the following topics:
• Continuing efforts to identify and discontinue worthless tests and treatments
• The over use of Pap tests in older women
• The failure of renal artery stenting to add value to optimal medical treatment
• Welcome evidence that patient safety is improving in some instances
• Trust and mistrust of medical guidelines
• The case for less mammography screening
• Ways smoking can be further reduced
• Troubled peer review in VA hospitals
• The case for improving management of obesity in very young children
I might note that just as this issue was “going to press” the Houston Chronicle ran a front page story called “Preschooler Obesity Plunges.” It explained that there has been a 43% drop in obesity rate in 2-5 year old children during the past decade.”
- Patient Safety America Newsletter (February 2014) Source: Patient Safety America (Sunday February 2, 2014)
Summary from John James: “The first article in this month’s newsletter describes the new guidelines for management of high blood pressure and the second speaks to new guidelines for healthy living. Both sets of guidelines seem to me to be more realistic than previous ones. In keeping with the guideline theme, the third article summarizes how “patient preferences” could be integrated into evidence-based medical guidelines. This is an important area because patient-centered care must be consistent with your preferences.
I was surprised to read the complications that result from tonsillectomies, so I wrote about that in the 4th article. Treating healthcare associated infections is expensive; find out how expensive in the 5th article. Informed consent, the subject of the 5th article, is often denied patients, despite the sham paperwork that often accompanies the pre-surgical process. The concluding article summarizes how the perverse incentive of money affects the care received by nursing home patients with advanced dementia and an acute illness. If you are looking after such a person, then you need to be aware of the incentives to over-treat.”
- Patient Safety America Newsletter (January 2014) Source: Patient Safety America (Sunday December 29, 2013)
Summary by John James: As this traditional holiday season passes into history, I hope you have found peace and joy as you celebrated with family and friends. We face a new year that has many uncertainties, not the least of which is how to get quality, affordable healthcare. My January newsletter is probably not going to help you feel better about those uncertainties.
The lead feature this month is a book review of “How We Do Harm” by Otis Brawley, MD. The other articles are as follows:
• A new way to dramatically improve care in a children’s hospitals
• Medical care that refuses to bend to evidence-based guidelines
• The cost of lost lives from having no health insurance
• The possible health benefit of eating nuts
• Over-diagnosis of lung cancer
• A proposal to deal with Medicaid patients
• Dealing with seasonal weight gain
- Patient Safety America Newsletter (December 2013) Source: Patient Safety America (Sunday December 8, 2013)
Summary from John James: “December’s newsletter is a little late due in part to a long and joyful visit of my daughter’s family. Her two little children remind me that there is a good reason why old folks are not new parents – insufficient energy! These little ones also remind me that each generation must pass along better ways to the next generation. Automobile safety, industrial safety, and aviation safety have improved greatly since the days when I was a young man with small children, yet the safety of medical care has lagged other industries. This month I emphasize some reasons for that situation: lack of patient access to information, perverse incentives that drive up costs and put patients in harm’s way, costs that cause harm to people who cannot afford care, insufficient evaluations of hospital quality, failure to help patients with addictive behaviors, barriers to transparency, and inadequate management of hospital patient loads. Yes, it’s all a mess.”
- Patient Safety America Newsletter (November 2013) Source: Patient Safety America (Thursday October 31, 2013)
Summary from John James: “The devastation wrought by hurricane Sandy leaves us full of empathy for those who lost loved ones and homes. When disaster unfolds suddenly, we notice it as the news media graphically magnifies the events on our TVs. The disaster that comprises much our medical industry quietly unfolds as medical errors occur in hospitals spread across the nation, and no one is there to produce graphic images of the death and suffering. In an attempt to display some of the suffering, my November newsletter begins with a review of the book “Unaccountable” by Marty Makary, MD. I was not fully aware of the endemic nature of the dangers lurking in hospitals.
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. I hope you find these stories informative.”
- Patient Safety America Newsletter (October 2013) Source: Patient Safety America (Wednesday October 2, 2013)
Summary from John James: “These are frustrating days in our country because it seems that anyone left in the middle ground on major political issues is rare, or at least they dare not speak. As we chide Congress for its ineptness, we must acknowledge that we put those people there, and in most cases they reflect what we want.
This month I was honored to have my new estimate of harm to hospitalized patients, which was published in the September issue of the Journal of Patient Safety (http://journals.lww.com/journalpatientsafety/pages/articleviewer.aspx?year=2013&issue=09000&article=00002&type=abstract), picked up Marshall Allen of Pro Publica (http://www.propublica.org/article/how-many-die-from-medical-mistakes-in-us-hospitals). He brought validity to my estimate by asking MDs in the patient safety community what they thought of my work. I have marked his and other sources that wrote about the new estimate with an asterisk in my “SitesLinks” collection this month. There are many examples of medical care gone bad.
October’s newsletter deals with 1) over-diagnosis of mental illness, 2) the secrets of the medical industry, 3) how unintended consequences can occur when physician performance is measured, 4) the death toll on women from painkillers, 5) the need to stop calling so many things cancer, and 6) the issues associated with high blood pressure and too much sodium.”
- Patient Safety America Newsletter (September 2013) Source: Patient Safety America (Wednesday August 28, 2013)
John James’ summary: “Young children often grow up in a world where everything is about their needs, both perceived and real. Wise parents work against this self-centered worldview so that by the time children become adults, they understand that they are not the center of the universe. There is one circumstance where this view must be discouraged – medical care. When receiving medical care you should be the center of all that can be reasonably done for your wellbeing – with you giving informed permission for anything invasive.
In reality, medical care, although headed in the direction of patient-centered care, has a long way to go. My newsletter’s first article demonstrates this reality. The second suggests that intense care is not usually patient-centered for critically ill patients; furthermore, the money we spend on medical care can be misspent, in part due to the fee-for-service scheme that doctors prefer. The third article describes how stress from medical bills can become pervasive, especially for the uninsured.
The fourth article slams the FDA for not enforcing a law that requires drug makers to do additional testing of their drugs, and a fifth criticizes Congress for not requiring stronger control of compounding companies. The newsletter ends with an article on regulating those who could misinterpret images, and with another article on cancer-drug makers who downplay the side effects of their potent products.”
- Patient Safety America Newsletter (August 2013) Source: Patient Safety America (Saturday August 3, 2013)
This month is the 5 year anniversary of the first issue of Patient Safety America Newsletter. In those years of reading medical journals and writing to inform patients of the hazards of medical care, I have learned some difficult realities.
Perhaps foremost is that when people want to believe that their healthcare system is safe and just, their opinions are not going to be easily swayed by data and facts, regardless of how reliable the source may be. Secondly, people want to believe that physicians always have their interest at heart; this naïve supposition is not easily replaced by caution when seeking medical care. Thirdly, most people are less interested in preventing their own poor health than getting treatment when a preventable disease has gotten the best of them. Finally, most people cannot view the healthcare industry in terms of how it affects less fortunate Americans – for them it is about me and my healthcare.
This month’s newsletter speaks about questionable drug prescribers, important new views of salt and high blood pressure, cautions for those with sleep apnea, unstable relationships between doctor and patient, and finally why can’t we pay more attention to disease prevention.
- Patient Safety America Newsletter (July 2013) Source: Patient Safety America (Friday July 5, 2013)
Summary by John James: Having spent some time lately with elderly members of my extended family, I am reminded how important healthcare is to those who suffer from collections of debilitating illnesses. As the saying goes, “Getting old is not for sissies.” That journey can be made better or worse by the healthcare system through which the elderly seek to be healed or at least sustained. The newsletter topics this month center on bias and dangers in the current medical care system. The topics are as follows:
1) Dealing with impaired doctors.
2) Who is buying your doctor?
3) Getting rid of fee-for-service medical care.
4) How to reduce overuse of medical services.
5) Potassium as an important food-labeling target.
6) A sleep aid that is causing too many ER visits.
7) Continuing bad news on American infant mortality.
8) Intrusion of government to protect its citizens.
In key places I have given links to further information that you can use to become a more informed patient.