I don’t believe in the phrase “it was meant to be” or “this is all happening for a reason” because I can’t believe that people are meant to be hurt. I can’t believe that children are meant to starve to death or women abused. I do think that when something happens, even though it’s not meant to be, we have an opportunity to create change.
If you follow me on twitter you will see that I’ve been tweeting a lot about my experience with St. David’s HealthCare. I have never seen or experienced so many medical errors and medical record errors in one person’s case. What astonishes me aren’t the individual errors alone but the number of errors – a true systems failure where there were inexcusable errors at every single point of care. Honestly, it is amazing that I am physically okay considering the errors made – the potential that I could have died. But the mental recovery is ongoing as I process my personal experience and consider how to use the opportunity to ask for change in the medical system.
As I write my story with great personal detail the pages accumulate to nearly 30 pages. I recount that in my stay from February 17-21, 2014 I had a doctor who nearly sent me home with an infection that perhaps could have left me in sepsis, I was left in my room bleeding because my IV fell out, and another doctor sent me home with a prescription for a medicine I am allergic to (which Target pharmacy filled though they should have known my allergy). I recount having to return to the ER for readmission on February 22, 2014 and having to beg – nearly screaming – for a phone the hallway to contact a friend and patient advocate – Allison Peacock – to come help me, medications not being administered at the right time or in the right dose – or for that matter the correct medication at all, and providers falsifying records. I recount since then the errors I’ve found in my medical records and then caught a serious HIPAA violation where the hospital sent me someone else’s records. All told, I am astounded beyond belief at all that has gone wrong in the past month – quite literally my worst nightmare. None of it was meant to be.
But beyond my personal story is the story for change that needs to occur. This was a failure, as I said, at every level. As I process my experience, I am hoping to find the strength to write on the broader scale about the overarching issues that affected my care and that affect many patients entering the healthcare system. These include:
- Access to medical care: Many states chose not to expand Medicaid, thus leaving many low income individuals such as myself uninsured and do not qualify for Obamacare. Texas was one of those states. I am only qualified to receive care in an emergency situation (by the grace of EMTALA).
- Hospitalists: I once wrote how I had mixed feelings about hospitalists. My feelings are no longer mixed, I do believe their presence decreases quality of care and increases risks to patients.
- Continuity and coordination of care: How there was no continuity or coordination of care between multiple ER doctors, multiple Hospitalists, a surgeon, an anesthesiologist, nurses, specialists, pharmacists, and other providers.
- Health IT: Why was the Meditech system not properly flagging my allergy to the doctor? Are there usability issues? Was there a rush to implement a system to get money under the Meaningful Use program?
- Hospital readmissions: Medicare is keeping a close eye on readmission rates. But it’s not just the reason for readmission that matters, it is also the process of readmission. When I returned to the ER, no one in the hospital realized I’d been discharged less than 24 hours before and all of my information was lost.
- Recognizing and addressing mental health issues in the hospital: Most patients are anxious upon coming into an ER, some of us panic when the care goes so badly – yet providers are not equipped to deal with these issues at any level.
- Hospital acquired infections: from MRSA to C. diff. to ESBL to even the flu – what protocols are being implemented for patient safety and how effective are they?
Nothing will take away what happened to me. There is no litigation to file, no cause of action to sue someone. Apologies, though appreciated, will only amount to so much before they seem empty. Still, good can come from this if, at every level, responsibility can be taken to make true change.
This was not meant to be. This does not have to be the story of another patient.
Many more thanks to my mother, a pharmacist in Colorado, who realized the doctor prescribed me a medication I’m allergic to and stopped me from taking it. (The hospital and pharmacy should be thanking her too.)