Hospital medication errors are very frequent. A commonly quoted figure is one error every day of a hospitalization. Meaning: wrong drug or wrong dose or wrong time or missing dose.
Consequently, it should not come as a surprise the instructions patients are given when they are sent home have frequent errors. Patients may be taking medications before they are hospitalized, so in addition to new medications those pre-existing medications need to be considered (a process called “medication reconciliation”).
You may ask: how can this be goofed up? A person has medications at home, the doctor writes a new prescription just before going home, the prescription is filled by the local pharmacy, and the prescription is taken in addition to the same medications as before. What could be more simple?
The answer is: there is plenty of room for error! What if:
- the new medication is actually a generic duplicate of a brand name home medication
- the new medication has severe interactions with a home medication
- the home medication dose is listed incorrectly
- the new medication prescription and the discharge instructions don’t match
- a new medication prescription was omitted
- a doctor outside the hospital is unaware of the new medication and prescribes something that interacts badly
- the patient get an allergic reaction to the new medication but the prescriber is not available to help
- the patient forgot to mention some of the home medications
- unnecessary brand name drugs are prescribed that are not covered under the outpatient insurance plan
- the prescriber forgot to tell the patient to stop some of the home medications that were causing symptoms prior to hospitalization
NOT SIMPLE AT ALL.
Yet, hospitals and prescribers often don’t take much time to get the medications right at discharge (there is a big push to get the patient out the door as soon as possible). Here is an actual example from 2 weeks ago:
A patient was admitted from a care center with an accurate list of medications. The admitting nurse transcribed the list into the medical record but made a mistake on one dose. The physician’s plan was to reduce the does of another medication which seemed too strong but the patient was not taking any medications by mouth at that point so no medication orders were written. A few days later the patient was ready to leave the hospital.
Unfortunately, a different physician discharged the patient rather than the one that admitted the patient. The nurse’s list of home medications was used to generate the discharge medication instructions — no new medications were ordered. But, the transcription error of the nurse was included with the instructions and the plan to reduce the dose of another medications was forgotten. Two major errors. The family actually realized the errors but the nurse the family informed forgot to call the doctor so no change to the list was made so the care center followed the flawed instructions.
So what went wrong?
- Duplicate lists of home medications were collected but the transcription error was not detected because the lists were not compared.
- The list of medications used during the hospital stay was not marked as equal to or changed from home medications.
- The planned change in home medications was not made because there was no place to put such a reminder for discharge in the hospital chart.
- The prescriber did not review the medications with the patient or family personally.
Worse yet, although errors happened there was no plan to change the system to prevent similar errors in the future.
So, as a patient or family member what can you do?
- ALWAYS bring multiple copies of an accurate list of home medications to the hospital — give a list to anyone that asks to review the medications.
- Expect the attending physician to review the discharge instructions with the patient or appropriate family member — if this does not happen immediately complain and make that expectation known. Good physicians plan ahead and sometimes do this review the day before discharge!
- Use one of the copies of the home medication list to compare to the discharge instructions. Make sure to understand ANY changes. And ask — does the new medication, if any, interact with home medications?
- Find out who to call if questions or problems with the medications arise after getting home — get a name and phone number. Often the discharging nursing unit will take the call and find the right person.
Here is the list:
- Pay doctors more
- Let the government pay subsidies to families not covered by the employee’s health insurance.
- Get rid of fee-for-service payments
- Smooth the transition from Medicaid to subsidized health insurance
- Transparent pricing
There are obviously some problems with this “consensus”. To begin with, who is part of the consensus? And who benefits from the 5 suggestions? On the face the ideas seem OK but where is overall cost reduction — the real crux of our health care problem?
So, to address each point:
- Pay doctors more — if the payment is not tied to reducing health care costs and increasing quality then it is money down the drain.
- Covering families — seems simple enough but why should business be exempt from doing what they have traditionally done? Employer insurance needs to cover the whole family — that’s simple.
- Get rid of fee-for-service. Yes that payment method is a problem but there must be an incentive for health care providers to provide a high volume of work and an incentive to do quality work. The simple solution is to pay a health care system (an accountable care organization) to provide care for a large group of people for a yearly fee. The organization must meet quality and budget constraints as opposed to our current “the sky is the limit” fee model.
- Smooth the the transition away from Medicaid. At this point Medicaid is less expensive than standard indemnity plans — why think about a change? If the person enters the workforce the employer just pays the cost — simple. Changing providers is not easy but if quality is uniformly better there would not be such concern.
- Transparent pricing. This is presented to suggest people could decide on what tests and treatments to buy if only they knew the prices — patients have never had the knowledge to make that decision and never will. The transparency of pricing should be the price for ALL the healthcare a person needs per year. Market forces may be helpful on the macro level (like for a healthcare system) but there is no free market for healthcare on the micro level — imagine a person being asked to choose between various methods of treating diabetes or the best way to remove an appendix (the decision is either random or biased by what the very person asking the question tells them).
The U.S. is experiencing something its citizens have not witnessed before: the transition away from population healthcare decisions being made behind closed doors at insurance companies to those decisions being made in the political arena. Other countries experience this all the time — just look at newspaper headlines in the UK or France over the past 20 years!
Elisabeth Rosenthal reported “Patients’ Costs Skyrocket; Specialists’ Incomes Soar” in the New York Times today 1/19/19. She particularly targets one of the most popular specialties for US trained physicians, dermatology. Good hours, great pay, and compared to other specialties, easy to learn.
A highly trained thoracic surgeon can only do 2 bypass surgeries per day but a dermatologist can to 20 lesion removals per day and make almost as much money. Patients choose to go to a dermatologist when most primary care doctors can just as easily solve the problem at a fraction of the cost (like benign skin lesions, sun related pre-cancers, and acne). And, when infection sets in on the weekend the dermatologist’s answering machine says to go to the emergency room ($300 co-pay).
She describes a situation where a woman had a facial skin cancer removed at a cost of $26,014. The astounding cost was the result of a dermatologist removing a lesion and then being unable or unwilling to close the wound — but still billing for the procedure. And, the patient also received bills from the doctors that actually fixed the problem (perhaps they should have billed the dermatologist). Sadly, a bad system is more profitable than a good system.
It is easy to see why the patient and Ms. Rosenthal believe there is a problem with US healthcare. Because, THERE IS A PROBLEM!
Rather than complain about the problem, what is the solution? It is not rocket science. The dermatologist, surgeon, operating room personnel and anesthesologist all need to be employed by an accountable care organization (ACO)– that way there is just one predetermined fee for taking care of the whole patient for a year. If the system does the work correctly they make some money, if they goof-it-up (as in this case) they lose money. The incentive should be to do good and efficient work. Not to make money by making mistakes.
This solution is extremely easy yet extremely unpopular with hospitals, surgeons, anesthesiologists, pathologists, radiologists, ophthalmologists and dermatologists. The reasons are obvious — they make less money and must follow quality guidelines. Given the low quality and extreme high cost of US healthcare is that really a problem? A few more articles by Ms. Rosenthal and a few thousand letters to congress might help. Sadly, one industry lobbyist equals one journalist in this battle.
By the way, the lesion at the top is a benign seborrheic keratosis — harmless, but gladly removed by dermatologists ($250).
The PBS NewsHour reported on 12/23/13 an astounding survey — they found a generic medication for breast cancer (letrozole) ranged in price from $9 to $400 dollars for a 30 day supply. Even more surprising the company that charged $400 dollars agreed to match the $9 price at a competitor.
Not only do pharmacies price gouge so do insurance companies. Almost uniformly insurance drug plans add $20 to every generic prescription. So a typical $10 generic prescription without insurance involvement will cost you a copay of $30 with insurance. And, do you think the pharmacist will suggest you avoid using insurance — not usually, since the $20 copay is for them!
What should you do?
- Shop around — check prices at several pharmacies
- ASK if there is any program the pharmacy has to lower that price (sometimes if you get a shoppers card you get better prices)
- You don’t need a membership to get prescriptions from Costco. Consumer Reports rated them as having the best generic prices.
- Here is a great place to check prices: goodrx.com (and they will print coupons for free!)
- You can get mail order generics here with free shipping. Usually their prices are good: healthwarehouse.com
- Don’t involve your insurance plan if it costs you more out of pocket than just outright paying for the prescription.
- Insurance plans often limit the prescription to 30 days (with a copay every time). Getting your prescription in 90 day amounts saves trips to the pharmacy and often improves the discount.
- Pharmaceutical companies often make a long-acting medication just before the patent runs out on the short-acting form. Ask your doctor if the long-acting medication is absolutely needed. Sometimes taking a medication twice a day at a generic price is much less expensive than once a day at a brand name price.
The price gouging is astounding. Patients often think a pharmacy just adds a small amount to the wholesale price. Not so. They often set the price at some percentage less that the brand name — hugely more profitable for them and devastating for consumers.
The price gouging makes you understand better why the UK and other countries have legislated a solution — they negotiate a country-wide price for each generic medication and allow only a few dollars to be charged as a dispensing fee. The US has a long way to go to protect consumers and reduce health care costs.
Jennifer Levits reported in the Wall Street Journal 12/18/13 “Doctors Eye Cancer Risk in Uterine Procedure“. She recounted the story of Dr. Amy Reed who had a hysterectomy. The uterus contained fibroids and the fibroids contained cancer. The procedure was done with an instrument, the morcelator. In kitchen terms it is a combination blender and vacuum cleaner. It is used during laproscopic surgery to chop up things (like a uterus with fibroids) and remove them through a small incision in the abdomen.
The problem is the morcelator does not remove all the tissue. A few cells escape the vacuum and they are left behind in the abdomen. If those cells contain cancer the cancer is then planted in the abdomen later to grow and likely kill the patient. Dr. Reed developed the seeding of cancer and claims other procedures would be better. Traditional surgery removes the uterus and fibroids intact with less chance of spreading any unsuspected cancer.
Here is what the package insert that comes with the morcelator says:
CAUTION: … use of the … Morcellator may lead to dissemination of malignant tissue.
So what are the statistics?
- 20% – 40% of women will develop fibroids
- 1 in 1000 cases of fibroids contain cancer
- intact removal of fibroids with malignancy failed to stop the malignancy 19% of the time
- morcelator removal of fibroids with malignancy failed to stop the malignancy 44% of the time
The big question is: should a morcelator be used if a woman has fibroids because it may double the risk of spreading an unsuspected cancer?
The simple answer is NO, because there are other surgical options. But, will women accept that answer? The laprosocopic procedure has less pain and quicker recovery, so the answer turns out not to be so simple. There are many forces at work on the decision to continue to use the morcelator. The analysis of these forces is called force-field analysis which was originally described by social scientist Kurt Lewin in the 1940′s. The following is such an analysis (the rating of force vectors is by the author of this blog):
So, what will happen? It seems at this point the morcelator will continue to be used. But, the risk remains. Law suits will continue. Perhaps a safer device will be developed. Perhaps a high risk of litigation will be perceived by gynecologists and the malpractice insurance companies as being too great. Such risk will lower the forces from doctors and perhaps tip the balance. Time will tell.
Again, Steven Brill of Time Magazine twists the knife in the hospital chargemaster with his article “Bungling the Easy Stuff” published 12/16/13. Uninsured patients continue to suffer hospital price gouging and personal bankruptcy even though legislative relief was passed years ago when the Affordable Care Act was enacted.
Mr. Brill explains that the ACA prevents hospitals from collecting fees based on the chargemaster (the discredited fee schedule of astronomic charges). But, because no rules were published in the Federal Register no legal help is available to victims of the practice.
How could this happen? Because the work to implement the rules to prevent overcharging did not seem worth the effort, after all, in 2014 everybody will have insurance! Sadly, during the 4 years up to the time when everybody supposedly will have insurance legal enforcement was sidelined.
Although Mr. Brill piles blame on the Obama administration one must also blame those in congress who pass bill after bill to try to stop the ACA — this is unbelievable — one side not implementing the law and the other side trying to kill the law both without regard to the finances of the vulnerable uninsured while hospitals ignore the will of congress and continue an unethical practice.
Mr. Brill has been hammering on the problems of the chargemaster. It’s time to listen and help your fellow citizens — hospital boards need to stop the practice immediately. Citizens need to ask hospital board members why they stand for such a cruel and unethical practice? Perhaps they should give the money back. However, the current plan is to use the money to buy ads to extol the caring nature of hospitals — that will make us all feel better.