I want to share a recent family tragedy here — it is about my Dad. In 2008, my Dad was in a local hospital where he was given a sulfa medication, despite the fact that he was wearing a red wrist band warning about his well-documented life-threatening sulfa allergy, and despite that many medical references do not support this off-label use of the drug in my Dad’s medical condition. Furthermore, without an emergency, the doctor and the nurses never informed my Dad or me (his medical power of attorney at the hospital 24/7) about the drug being a sulfa drug, or any of its risks. We even repeatedly asked the doctor about the drug risks before its administration. Yet the doctor withheld all this critical drug information, and lied about the drug risks (which turned out to be significant to my Dad). We later learned that there was also a plan to monitor my Dad after the first dose to watch for an anaphylactic drug reaction. But no one told us anything about this monitoring plan, even after my Dad showed signs of a serious drug reaction. My Dad and our family were the only ones who were totally kept in the dark during the whole time!
As a result of what we believe was a drug reaction, my Dad suddenly developed severe hypotension several hours after the 4th dose and suffered subsequent complications, from which he never recovered, and passed away only two weeks after he was given the drug. Six months after my Dad passed away, we found out that the doctor had been warned by the hospital pharmacist about a risk of cross-reaction and/or an anaphylactic reaction prior to him prescribing the drug. We also learned later that the drug carried three significant contraindications to my Dad. According to two specialists who are experts on this particular drug, the hospital doctor gave my Dad 2.7 times the recommended dose for people with my Dad’s medical condition. After my Dad tragically passed away, we filed complaints with the state against the doctor and the hospital.
During the investigations, the doctor and the hospital remained dishonest; they down played the drug risks, denied any wrong doing, and blamed my Dad’s health for his passing. They also never disclosed to the state that they failed to inform my Dad and our family about the drug being a sulfa drug and associated risks. Despite the clear and convincing evidence that the doctor and the hospital seriously violated my Dad’s Patients Rights and provided substandard care and despite two experts’ opinions on the misuse of the drug, the Washington State Medical Quality Assurance Commission (MQAC) and the state hospital Facilities and Services Licensing have refused to take any form of sanction against the doctor and the hospital.
The MQAC claim there is no evidence that the doctor committed unprofessional conduct, even though the doctor lied to us about the drug risks and even though the doctor provided extensive false information to the state investigation, much of which can be easily checked with the hospital records. When we pointed out the doctor’s contradictions to his own statements and hospital records, the MQAC just ignored us. When we asked them to explain why it was legal for this doctor to give my Dad a medication that had been warned for an anaphylactic reaction without informing him first, the MQAC has kept silent and refused to answer any these questions. The state Facilities and Services Licensing also refuses to investigate Patient Rights violation, claiming that “the drug is generally safe” and “hospitals do not have to tell their patients the risks of every drug.” When we met two MQAC’s staff to discuss our concerns over their “investigation” process, they told us that “it was serious to take a doctor’s license away” and that “we are not medical doctors so our opinions do not account.”
Since when is a doctor’s license more important than a patient’s life?! Since when can doctors give their patients drugs without telling them the significant risks?! And since when does our state Department of Health start to promote a medical standard that patients do not need to be informed of life threatening drug risks?! In 2006, a report, “Preventing Medication Errors” by Institute of Medicine of the National Academies, revealed that at least 1.5 million preventable adverse drug events (ADEs) occur in the United States each year. About 400,000 preventable drug-related injuries happen in hospitals alone, which results in at least 3.5 billion to the cost of the hospital stay. For Medicare enrollees alone, the annual cost is estimated to be $887 million for treating medication error. These statistics are shocking, not to mention the loss of patients’ earnings, pain, suffering, and even worse their lives, like what happened to my Dad. To reduce medication errors effectively, the report recommends that doctors, nurses, and pharmacists must know and act on patients’ medical care rights. They should also make it a standard procedure to communicate and inform their patients fully about the risks, contraindications, and possible side effects of the medications they are taking and what to do if they experience a side effect. They should also be more forthcoming when medication errors have occurred and explain to the patient the consequences. This medication error report has been out for three years. Sadly, the same numbers of medication errors still occur annually in our hospitals. Yet, some medical professionals and evidently even our state agencies still believe a patient has no right to be informed about anything when being given a drug, even though the drug may cause serious reactions, even though we have had the Patients’ Rights law since the 1990s, and even though we have these specific federal and state regulations to protect Patients’ Rights. Something is seriously wrong. About ten years ago, the famous report came out stating that about 98,000 of Americans die each year due to preventable medical error. Now ten years later, we still have the same number of patients dying each year. Clearly the medical disciplinary system is a part of the problem. To improve our hospital safety, it requires a greater accountability and transparency in the state disciplinary process.