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Porter Hospital and the medication erorrs part 2a
Important Notes regarding my husband’s recovery on the 4th floor: 11/6: I arrived in his room at the same time he did. I handed the nurse leaving from the shift the meds. I went over his medications I brought from home for him to use in their original containers and what they were prescribed for with the nurse entering them, andI mentioned that I did not have his Trilipix prescription, however, that he was unsure where he had left it at home. The nurse asked what it was prescribed for, and I told her it was prescribed for hyperlipidemia. My husband then responded that his cholesterol has been very good since taking it. (My 32 year-old son, who is a physics teacher, was in the room during this period of time as well.) 11/7: i. He had severe pain which caused him to cry (he does not cry….ever!) after isometric exercises with Heidi (OT). Ed, the nurse, reluctantly gave him IV Dilaudid to reduce the pain. ii. He was very out of it for a few hours, went with Ward (PT) after became more alert, had another bad episode of severe spasm in Left upper back and had to have another dose of IV Dilaudid for pain. iii. Dr. Fedorowicz saw my husband and said that he would prescribe a “concoction” that has worked in the past. Not once did he relate what this was (I had to ask the nurse). He did not go over the pros and cons of taking this medication or potential interactions with his current medications violated Patient Bill of Rights for informed consent. iv. His “concoction” included Klonipin and Tylenol. Klonipin and the Trileptal are not a good combination and increased his lethargy and general “dopiness”.
Porter Hospital and the medication errors part 4
vi. I called the surgeon’s office, our health insurance, and my husband’s primary care doctor. vii. As of 11/18/2013, I have not received a letter or a call from Deb as of yet. As you can tell, this experience seemed to be a snowball effect of one blundering event after another. I shudder to think what would have happened had I not stayed the entire time to be the Patient Advocate. However, what is most disturbing is that no one went over the medications to try to figure out why my husband was so sleepy. He has never had seizures or been diagnosed with neuropathy. I would have thought that someone should have asked why he was on Trileptal, but no one did. They supposedly had his medical history in the EMR, however, I wonder who reviewed it because it is evident that those medicating him did not. Because of this egregious error, my husband suffered needlessly when trying to recuperate from a major surgery by being denied pain medications because he was being given a medication that he had never been prescribed! Furthermore, he had to suffer through the indignities through the encounters of Fedorowicz, Becky, and Lila. If my husband had not been given this medication, his pain would have been under control, he would not have had to stay one additional night, he would not have been overmedicated, and he would have made better progress while hospitalized. I find this situation deplorable as well as a total debacle! If this happened to a family member of yours, how would you feel about this situation? In the healthcare delivery system, there are three priorities in healthcare, cost, access, and quality of patient care. In my opinion, these priorities were either loosely met or not met with regards to my husband’s services by your hospital. If there had not been a medication error, my husband would have received a more cost-effective hospital stay with wise stewardship of both the hospital expenses as well as our out-of-pocket expenses. My husband felt that access to care was potentially denied due to the collection techniques of your patient financial office. As for quality of care, there was such a lack of it in this situation, however, I will avoid the redundancy of going back over it. Thank you for your consideration in this matter. I would encourage you to review this experience and use it as an opportunity to improve the risk management strategies for patient safety as well as a review of your quality assurance program. As for the individuals that caused my husband undue and needless stress, they should take this opportunity to evaluate their patient care methods and initiate change so another patient will not have to suffer the indignities my husband had to. Our insurance has also launched an investigation regarding this experience and to determine if Porter should continue as an in-network facility. Sincerely
Porter Hospital and the medication errors part 1
November 15, 2013 Centura Board of Trustees C/O Porter Hospital 2525 South Downing Street Denver, CO 80210 Dear Board of Trustees for Porter Hospital RE: Patient Medication Error and Serious Patient Communication Issues As you are well aware, the Healthcare Reform Act will incorporate pay-for-performance allowing hospitals to be paid according to a value-based purchasing program in 2014. This program requires that hospitals will need to achieve certain measurable criteria relative to patient satisfaction and patient safety as well as other factors. After our experience with Porter Hospital, I can irrefutably say that Porter Hospital would fail miserably in both the patient satisfaction and patient safety criteria. I can say without a doubt that every effort will be made to ensure that neither my husband nor myself will ever go to Porter Hospital again for any type of service. I would like to explain what our experience included that has led me to this most radical decision. Please note that although some of this does not solely relate to the medication error, I have highlighted the text in red that relates to the medication error. My husband was scheduled for a major surgical procedure to be performed by Dr. Choi at Porter Hospital on 11/6/2013. The following occurred: The week prior to the surgery, my husband received a call from the financial department asking for a $1500 deposit. My husband stated that this full mount would be difficult at this time.After a somewhat uncomfortable conversation with the Porter rep, my husband got off the phone and was under the impression that if we did not pay the full $1500, his surgery would have to be cancelled. I scheduled a pre-op for my husband on 11/5/2013 to occur at 0845 with a check in at 0830. 30 minutes later, I received a message that my husband would need to come in at 0815 for an 0830 appointment and to call to confirm. I called back within 30 minutes and confirmed that this was okay. The rep thanked me for calling and stated many patients do not call back. My husband showed up for the appointment, and he was not on the schedule. The receptionist, remembered the call and put him in as a work in at 0930. I believe because we didn't give them the $1500.00 up front someone removed his appointment, but can't prove it. He had to wait an hour for the appointment . My husband handed the orders for the pre-op to the individual performing it, and they did not do the chest x-ray that was required for this procedure (he had to do this before going in for surgery on 11/6/13). We received another call asking for the $1500 that day. I explained our situation and that we would put money down. The individual stated that this is normal protocol because at Swedish they refused to treat her mother for cancer until she paid her full deductible-last I knew, Swedish is for-profit, and Porter is non-profit…makes a difference in collection practices, or should. (I did put $200 down at time of service) We received a call the afternoon of 11/5 stating that his surgery was scheduled for 1300 and to check in at 1000. According to the surgeon’s office call that previous Friday, the surgery was to be done at 1500 with a check in for noon. After some tracking down and a call later that afternoon, we found out the surgery had been rescheduled by the surgeon’s office and the new time was correct. I met with the anesthesiologist and went over all of my husband’s medications. I told him that he was on Trilipix and he asked if that was for hyperlipidemia, and I responded that this was correct. (this is important to note for now!!)