Archive for category Care Not Meeting Expectations

Leaving the hospital — what meds to take?

medlistHospital 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?

  1. Duplicate lists of home medications were collected but the transcription error was not detected because the lists were not compared.
  2. The list of medications used during the hospital stay was not marked as equal to or changed from home medications.
  3. 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.
  4. 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?

  1. 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.
  2. 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!
  3. 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?
  4. 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.

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Dermatology — prices that get under your skin

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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).

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Doctors and Warfarin — patient expectations

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Bill(*) had a really bad headache and died before he could call 911
.  He died of a complication of warfarin which he was taking to prevent blood clots.  Instead, the best intentions to prevent a stroke lead to uncontrolled bleeding in the brain, high pressure inside the skull and death.

Warfarin and other anticoagulants are necessary medications but also dangerous medications.   People take the medications because the risk of blood clots, for them, is higher than the risk of anticoagulation.   The last thing a patient wants is for drug management errors to tip balance so the risk of the medication is too high.

So, what are the expectations of people who take warfarin?  What do they expect of their providers?  What do the providers expect of them?

  1. Patients expect providers to follow drug guidelines to the letter
  2. Providers expect patients to follow instructions and learn about warfarin
  3. Patients want to be in the loop — meaning the risks are high so they want to be in a position to make sure the necessary communication happens and dose adjustments make sense.
  4. Providers need to be able to contact patients and expect positive feedback — “message received, will change dose to ___ as directed”
  5. Patients expect a consistent process no matter the day of the week or which provider is on call.
  6. Above all, patients expect adequate prevention and minimum risk.

Here are several marks of quality warfarin management:

  • The same day of drawing lab (INR)  the patient is informed 1) the result  2) the change in dose and 3) the date of the next lab.  Finger-stick methods with quick results allow some offices to provide instructions before the patient leaves the office.
  • The patient is asked to keep a record of results and instructions.  And, to “read back” the instructions.  Thus the provider knows the patient got the right message.
  • The patients have the phone number to call for any evidence of abnormal bruising or bleeding.  They should expect to get lab tested or go to the emergency room.
  • There is no impediment to getting the warfarin prescription refilled when needed.
  • Providers use computer applications or paper tables to select the correct warfarin dose.  Only if there are unusual problems do they deviate from established guidelines.
  • If the INR is out of range the dose is changed and the INR is rechecked within a week — even if the patient was on a monthly lab routine.
  • The day the INR is checked patients do not take the usual warfarin dose until the results are available.
  • Providers never say “just keep taking the same dose unless we call you”.   That is a recipe for disaster if a lab test is lost or sent to the wrong provider.
  • The lab the patient uses is open 7 days a week.
  • Providers instruct patients to follow a consistent diet so the amount of vitamin K in the diet is fairly constant.  A sudden drop in vitamin K intake causes the INR to rise and bleeding risk to increase.

Back to the case of Bill.  He forgot to get his INR checked on Friday and nobody called him to check why.  He knew the lab was not open on the weekend.  The nosebleed was unusual but not too bothersome — besides, his doctor was not on call and he did not know who to call.  He took a slight fall and bumped his head – he didn’t think small head injuries were risky.  He had a good memory but sometimes forgot how many warfarin pills to take on Saturday so he took 2.  Wrong, wrong and wrong. The outcome might be better if the medical process was better and if patient education was better.


(*) Bill’s case is not real but such deaths have been reported.  It is true warfarin is related to rat poison.

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Rate Your Health Care Provider

The following rating system is intended for adult primary care office visits, but could also apply to some specialty visits.  There are no extra points for famous doctors, university clinics or the only provider in town.  Add up the points to see how your provider’s office is doing.

Performance Points
When I call the office, who answers?
 A real person 2
 A computer answering system that connects to a real person 1
I know the office will provide appointments:
New patient appointments within 3 weeks or
Follow-up appointment for new problem in 3 days
2
Urgent problem (during office hours) on same day 3
 The office designates time for walk-in visits  2
 The office has some evening and weekend hours  2
Moving through the office (assuming you were on time)
 Checked-in within 5 minutes 2
 Checked-in within 5 to 10 minutes 1
 Face to face with the provider
within 5 minutes of appointment time or
within 30 minutes for a walk-in visit
3
 Face to face with the provider
within 10 minutes of appointment time or
within 45 minutes for a walk-in visit
2
Checked-out within 5 minutes of leaving provider 2
Checked-out within 5 to 10 minutes of leaving provider 1
 Provider visit
 I do not have to take off clothes before seeing provider 2
 I can sit in a chair at eye level with the provider 2
 Provider seems to care about me 5
 I am not interrupted while I say the reasons for the visit 4
 The part of my body with problems is examined 3
 The paper chart or the computer is just used
by the provider to find information to help me
2
 The diagnosis of my problem is made clear 4
 I am directed to handouts or Internet sites about my problems 1
 Before I leave, the provider asks if I have any other questions 3
 It is clear when I need to return for recheck 3
 Medication Management:
 The reasons I need to take all medications are explained 3
 My provider sends prescriptions by computer 2
 Possible side effects of medications are discussed 1
 At each visit I receive a list of my active medications 3
 Tests (x-rays, blood tests, EKG, biopsies etc.)
If I need tests I am told why 2
 The office always lets me know test results within a week 2
 I always get copies of test results 2
 Practice environment
 My provider has associates who substitute when needed 2
 Hospital care is done by hospitalists 2
 My provider is part of a system including specialists 2
 Physician assistants or nurse practitioners work at the office 2

 TOTAL POINTS  =  

Score Rating
 60 and over  5 star
 50 to 59  4 star
 40 to 49  3 star
 30 to 39  2 star
 below 30  1 star

Hotels have struggled to get the coveted 5 star rating for decades.  It is not just whether the hotel chef can make a souffle but whether the whole experience of staying in the hotel is superior.   The items in the above score are considered elements of quality for health care delivery.  It’s not easy to get 5 stars.

Medical and surgical care has focused on diagnosis and treatment for hundreds of years.  To that end individual providers spend years, if not decades, honing diagnosis and treatment (some say, to a fault).   The vast majority of problems in primary care are fairly easy to diagnose (like diaper rash, acne and diabetes).  Treatment is harder because it spans time, is a process and requires patient engagement.  So, as it turns out, the wrapper may be as important as the package.  Providers are well trained and licensed but the wrapper of delivering care is where quality, safety, cost-effectiveness and satisfaction reside.

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Getting Satisfaction

OK, patients are not satisfied with many provider visits.    Some people just avoid health care or just complain about it.  Consider that mummies have been found who had serious health problems during life.  Is that what we want, a postmortem in a thousand years? — “yep, he didn’t get good care”.

It is  not the patient’s job to make health care give satisfaction, but that may be what is necessary while we wait for system changes.   And yet, many patients currently walk away from a provider visit, the hospital or outpatient surgery feeling satisfied with the care and satisfied their questions were answered.  How did they do it?  What did they say?  Were they just lucky to have the “right” provider?   Getting satisfaction currently involves being proactive, doing your homework and speaking up.  Those who do are getting some degree of satisfaction.

First, understand the cycle each health care provider works in.

The “agenda” for the visit is made in step #1.   Make a list of 3 things you want to get accomplished during the visit and keep the list in hand.   Be assertive with the list right after the greeting “Just so I don’t forget I made a list of things I need today: 1)____ 2) ____ 3) ____”.  For example, this might be “review my stomach pains,  would a specialist help, get prescription refills”.  ABSOLUTELY do not wait until step #5 with these questions.  Make sure all items were answered by step #3 — if not, look at the list and repeat the items not addressed.

Make step #2 easy.  Have an up to date history in hand including past illness, past surgery, current medications and allergies.

Make step #3 understandable.  Before the visit research the symptom or known diagnosis on the Internet (like http://www.mayoclinic.com).  So when the situation is discussed you have some basis for questions, and ASK THEM.

Make step #4 interactive.  As each action is listed if you don’t know what it is (like CBC or CT scan) then  speak up “what is that and what will it tell us”.   If a procedure or surgery is suggested make sure to understand the top 2 risks and what the provider and you can do to reduce the risk.  And, what are the alternatives — understand the alternative of not doing the surgery or procedure.  Understand how you will get test results (make it clear you want the result as soon as  available whether  “normal” or not).

An informed and engaged patient will ask the above questions.  Many patients ask such questions.  Don’t be demanding, just persistent.  Give the provider a chance to do the right thing since most really want to please patients.  And, give the provider a second chance.  If there is a problem with the plan or medications discovered later, call the provider’s office for clarification.  But, repeated failure to respond to these simple questions means it is time to find another provider.

Sometimes people just can’t think clearly knowing a shot, pelvic exam, or prostate check are going to be done.  Thinking during a health care visit is essential.  So, if there are bothersome aspects to a certain visit ask to have those things done at a separate visit (yes it is more trouble for you but at least you can discuss problems intelligently).

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Care Not Meeting Expectations – Where do the expectations come from?

The “Sick in America Poll” shows 45% believe the quality of healthcare is a very serious problem.   Quality is always based on a comparison with “something else”.  In the past it was difficult to compare health care with “something else”.  But now, a patient can look on the Internet for a world of comparisons (where health care does not look so good).  Or the patient will just ask a relative.

Quality is sometimes undercut by the providers themselves.  Rather than just say “an annual blood count is not supported by medical evidence”  too many doctors just say “insurance won’t pay for it.”   Rather than say “eating too soon after surgery may cause nausea”, too many nurses say “the doctor won’t let you eat.”  Rather than say “it is usually a safe drug but watch out for a rash” the pharmacist says nothing and passes out a huge list of side effects.  Where is the teamwork?  It is a set up for failure and poor satisfaction.

An academic view of quality health care is provided by the Institute of Medicine (a government organization).   They have defined six attributes of health care quality:

  1. Safe: Avoiding preventable injuries, reducing medical errors
  2. Effective: Providing services based on scientific knowledge (clinical guidelines)
  3. Patient centered: Care that is respectful and responsive to individuals
  4. Efficient:  Avoiding wasting time and other resources
  5. Timely:  Reducing wait times, improving the practice flow
  6. Equitable:  Consistent care regardless of patient characteristics and demographics


The Institute of Medicine is concerned with finding that “something” for the quality comparison.   Unfortunately, the Institute of Medicine did not list system assets such as “reasonable cost” or “sound  management” or “continuous improvement” or “reliable care” or “high national ranking”.   The goal is good, the means to the goal is lacking.  An old business saying is “measure to manage.”  Americans need to know how the health care system is being managed, at the speed of the stock market, not at the speed of academic reports.  We need to see the ticker tape for cost and quality.  If the system is not being managed well then get a new manager.

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