Hospital Errors - Frightening and Maddening!

[Luv Bunnies]

I posted earlier this week that my dad was having surgery to remove a benign tumor from his chest. Luckily, the surgery went well and he was able to go home yesterday. But, there was an incident in the hospital yesterday morning that was really scary when you consider what could have happened.

Right after the surgery, the respiratory people started coming in every two hours to give him breathing treatments. This made sense because they had to deflate one lung to reach the tumor. He was in ICU and on some heavy pain meds that made him loopy and he lost track of time and didn't realize how frequent the treatments were.

On Thursday morning, he was taken off the heavy pain meds and moved into a regular room. It was then that he realized the treatments were still every two hours and he didn't understand why he was getting them. He said they woke him up every hour that night for either a breathing treatment or a finger stick (which he understands because he's diabetic).

Yesterday morning, my mom got a call that my dad was confused and being argumentative with the staff. They suggested she come in and sit with him until the doctor could get there. She called me and asked if I would go with her. I got there first and he was sleeping so I talked to the nurse and got basically the same story my mom got. When he woke up, I asked him if he was having a problem. He said, "Yeah! These people keep telling me I had part of my lung removed and I'm trying to tell them I didn't!" Seems he asked the respiratory guy why he was still getting treatments every two hours and the guy said it's standard procedure when you have part of a lung removed. My dad said, "But I didn't have lung surgery. I had a tumor removed from my chest wall." The respiratory guy said, "Well, now you're just confused sir." My dad really took exception to that remark! Then the nurse came in and asked him if he knew why he was in the hospital. When he told her, she said, "No, you seem to be confused." He tried to tell her the chart must be wrong and she labeled him as confused and argumentative.

The nurse called the surgeon and he set her straight, after which she apologized profusely to my dad and said his chart was wrong. Someone entered the wrong diagnosis code and the respiratory protocol for his actual surgery was 24-36 hours of breathing treatments, not 4 days worth every two hours!

The doctor called the room while I was there and I had a nice 15 minute chat with him. He was appalled at the way my dad was treated (being called confused to his face). He said even if a patient is confused, a respiratory therapist shouldn't say it to him. The doctor plans to write a letter to the hospital director about the situation. It's bad enough that someone entered the wrong diagnosis code into the system. But then they treated the patient badly when he pointed out the mistake.

At least he was only receiving extra breathing treatments and not a more invasive procedure! I don't know how closely the doctor looked at the chart when he came in each day. He said he writes his notes after surgery and the staff enters it all into the system with diagnosis codes, etc. I also don't know if the doctor looked at the chart and saw that he was still getting the breathing treatments when he didn't really need them.

By the time he was released, my dad was more than ready to get the heck out of there! He's now at home on the couch with his remote and we'll be heading over soon to open presents and start cooking dinner. It was rough to think for a while that his mind was altered until he woke up and told me the whole story. He was about as far from confused as an 85-year old can be!!! I guess the moral of the story is if you think something isn't right when you're in the hospital, ask questions. If it still isn't right, don't be afraid to call the doctor yourself!

 

[Planogirl]

That is scary but I'm glad that someone at least apologized to him. The poor guy!

 

[dodukes]

wow scary but glad it wasnt something worse!!...i agree, im always amazed at some stories i hear that people get this or that (not the ones that are out obvioulsy) when they felt that it wasnt neccesary and/or they felt something wrong....its your body SPEAK UP is what i want to scream at these people. good for your dad for speaking up!! if he hadnt thrown a fuss, they wouldtn have called you.,

 

[Rumpus]

Most hospitals are running "bare bones" these days, doing their best to provide excellent care with fewer personnel. The respiratory therapist was only following "protocal" established by that particular hospital for a particular diagnosis, he didn't enter the diagnostic code. It was ultimately the surgeon's responsibility to be sure that the post operative diagnostic code was correct and he was being treated according to his needs, not the therapist.

 

[bumbershoot]

Medical errors, missed diagnoses, and mis-diagnosis took the lives of my mom and my father in law. Same hospital that "got" my FIL nearly "got" me (before FIL...we begged MIL hard to get him out of that hospital but we weren't listened to). I'm to the point where I'm mystified when someone leaves a hospital alive, frankly.

With FIL, they kept bouncing him around the hospital, and each time he got a new set of nurses and no one took the time to read more than maybe one page of his notes. Superfun moment was when hubby asked about the protocol once he was off of IV antibiotics, and the nurse said "he's not on antibiotics, what are you talking about?" We told her the situation and told her to read the chart notes, she did, and said a naughty S word audibly as she ran to the drug cabinet. Since part of the cause of his death was the uncontrolled massive infection....her floor's inability to read helped cause his death.


I'm SO glad that your father was finally heard.

Now it's time to get on the phone to the doctor and the hospital, as well as the insurance company, because you can bet your life that insurance will NOT be paying for all those out-of-standard-protocol breathing treatments he received, and you have to get those treatments OFF of his bill immediately!

Get a separate notebook for this, write down every call you guys make, date, time, rep's name, doctor's name, etc. This will very likely be a PITA and will take some time, and since the doctor is aware of the errors that happened for two days, you've got to get his input now.

 

[chloelovesdisney]

Well that should have been caught earlier. Either the surgical team or anesthesiologist should have given a full report including the procedure when we was brought to either the recovery room or ICU and the nurse should have seen it didn't match the records. Additionally, the surgeons at my hospital review the medications of each and every one of their patients on rounds in the morning before heading to the operating room. The surgeon shoud have also noticed that the nubulizing treatments were still ordered and that the wrong diagnosis was listed in the chart. Doesn't he write his own post-op note and a progress note each day? Both the respiratory therapist and nurse should have been able to look at those and see the correct information.

My grandmother also was told she was confused and was restrained in the bed. The actual problem was that she was very hard of hearing and didn't own up to it and would just say yes if she was unsure what the nurses were asking her instead of saying she couldn't hear them. She wasn't confused at all and was not pleased to be tied to the bed. Luckily I arrived very shortly after this occurred and we straightened everything out.

 

[lsyorke]

Been a nurse for 26 years and have never worked in a hospital that has "protocols" based on a diagnosis code. If there is a protocol, the surgeon/doctor has to sign to initiate them and discontinue them. No protocol is started without a physician approval.

 

[chloelovesdisney]

Been a nurse for 26 years and have never worked in a hospital that has "protocols" based on a diagnosis code. If there is a protocol, the surgeon/doctor has to sign to initiate them and discontinue them. No protocol is started without a physician approval.

Yes, that would also be true. We have protocols for specific surgeries (individual items can be deleted or added) that are ordered by the doctor following the procedure, but I as the nurse would also know what surgery the patient had and would obviously alert the doctor that the wrong protocol was ordered and would not sign off and initiate it.

 

[Luv Bunnies]

Most hospitals are running "bare bones" these days, doing their best to provide excellent care with fewer personnel. The respiratory therapist was only following "protocal" established by that particular hospital for a particular diagnosis, he didn't enter the diagnostic code. It was ultimately the surgeon's responsibility to be sure that the post operative diagnostic code was correct and he was being treated according to his needs, not the therapist.

True, the respiratory person was following orders. However, he took it upon himself to tell the patient he was "confused." According to the surgeon, it's not the place of the therapist to make that determination or, even worse, say it to the patient. When my dad questioned the diagnosis, the therapist should have alerted the nurse, not stood there and argued with my dad about how he didn't know what he was talking about.

 

[Luv Bunnies]

I'm SO glad that your father was finally heard.

Now it's time to get on the phone to the doctor and the hospital, as well as the insurance company, because you can bet your life that insurance will NOT be paying for all those out-of-standard-protocol breathing treatments he received, and you have to get those treatments OFF of his bill immediately!

Get a separate notebook for this, write down every call you guys make, date, time, rep's name, doctor's name, etc. This will very likely be a PITA and will take some time, and since the doctor is aware of the errors that happened for two days, you've got to get his input now.

Thanks for the advice! The surgeon said his office will deal with the insurance companies (Medicare and a supplemental policy through his police officer's pension). In fact, the insurance company already balked before the surgery because the doctor was out-of-network. My dad's primary doctor referred him to this particular guy because he's so experienced in this type of surgery. My dad said he was willing to pay whatever the insurance wouldn't pick up, but the surgeon agreed to do it for the reduced, out-of-network fee (nice guy!). But, he had to find an assistant surgeon and an anesthesiologist that were in the network to work with him, which he did.

 

[Rumpus]

Been a nurse for 26 years and have never worked in a hospital that has "protocols" based on a diagnosis code. If there is a protocol, the surgeon/doctor has to sign to initiate them and discontinue them. No protocol is started without a physician approval.

And in some hospitals, respiratory therapists are given a wide latitude with regard to respiratory care. It sounds like the surgeon "signed off" on the orders without catching the error and the orders existed. With regard to the patient being told he was confused; if that was said, it was not appropriate. If the respiratory therapist said that is incorrect, he was basing it on the record. I have no doubt that much younger patients aren't always well informed about what procedures they have had. Unfortunately, with the decrease in staffing due to financial issues, everyone should have a family member visiting often or staying there to be sure that the patient's needs are met.

 

[DonkeyGreatness]

Most hospitals are running "bare bones" these days, doing their best to provide excellent care with fewer personnel. The respiratory therapist was only following "protocal" established by that particular hospital for a particular diagnosis, he didn't enter the diagnostic code. It was ultimately the surgeon's responsibility to be sure that the post operative diagnostic code was correct and he was being treated according to his needs, not the therapist.

A therapist "blew off" a patient who was telling him that he did not have a part of his lung removed. How is that not a serious problem? That smells like someone who's in a hurry to get it done rather than taking the time to listen to concerns from a patient. Terrible!!

 

[left210]

A respiratory therapist killed my mother this year in a hospital. She cut off her airway by not deflating the cuff when switching her from a vent to her trach. Then on top of that when the alarms went off the ICU dept did not hear them and her heart stopped. They admitted to all of these mistakes. Medical errors in hospitals are more common than anyone realizes. It is imperative that family members are there monitoring a loved ones care and speak up when something appears out of order.

 

[DonkeyGreatness]

A respiratory therapist killed my mother this year in a hospital. She cut off her airway by not deflating the cuff when switching her from a vent to her trach. Then on top of that when the alarms went off the ICU dept did not hear them and her heart stopped. They admitted to all of these mistakes. Medical errors in hospitals are more common than anyone realizes. It is imperative that family members are there monitoring a loved ones care and speak up when something appears out of order.

did you file a lawsuit?

 

[LindaG4458]

Latest medical scandal in the Boston newspapers:

Three patients, two with the same surgeon, had back surgery. All three had the surgery performed at the wrong location. The surgeon and the assistant had different methods of counting the vertebrae.The errors were discovered when follow-up x-rays were done when the patients complained of continuing pain.

 

[tasha99]

Latest medical scandal in the Boston newspapers:

Three pateients, two with the same surgeon, had back surgery. All three had the surgery performed at the wrong location. The surgeon and the assistant had different methods of counting the vertebrae.The errors were discovered when follow-up x-rays were done when the pateints complained of continuing pain.

How could they count differently? They each have a name (C1, C2, . . . T1, T2 etc)

 

[MomRN]

How could they count differently? They each have a name (C1, C2, . . . T1, T2 etc)

Silly numbers... it all starts getting confusing after 4

 

[IDoDis]

I had a friend who tried for 6 years to get pregnant. Her and her DH were thrilled when she finally was pregnant -- a miracle baby (as they said) because they had been through fertility without success.

Fast forward 4 or 5 months into the pregnancy. Friend goes in for routine ultrasound. Her DH had to work, so she went alone. OBGYN doc (not a tech, but actual doc) does the ultrasound and says there is no hearbeat & no movement. Checks again and says the baby passed away. Doc suggests she make an appointment to have a D&C done in two days. Friend and hubby are distraught.

The next day, friend says she still feels pregnant. No movement, but still had nausea (which she had throughout pregnancy). Calls doc and tells him. Doc says hormones are still in her body so she still has pregnancy symptoms.

The morning of the scheduled D&C, friend and hubby decide not to go to D&C appointment and instead go see another doc to get a second opinion. Second doc does ultrasound and baby is alive and well and heartbeat is strong. Friend finishes pregnancy and has a baby boy. She never was able to get pregnant again (this was 12 years ago). Imagine had she gone in for that D&C! My sister works in for a company that insures hospitals & doctors and says the machine tape from the D&C would have indicated that the fetus was alive, but they would probably not have said anything unless friend asked for the tape and had it evaluated.

 

[Claudia1]

Not a medical problem but a hospital issue.....

When we adopted DS 18 years ago, our insurance picked up his portion of the hospital bill. For very specific and legal reasons, it was a closed adoption with neither party knowing names or virtually ANYTHING about the other. Long story but a closed adoption was critical for safety issues and our attorney was diligent about keeping all details private.

The medical records department sent his birth mother his hospital bill, complete with all of our insurance info, our name, address, and his adoptive name.

It was not a computer generated billing. It had been flagged to not send (or something similar) and our attorney actually visited the department immediately after his birth to see the notes on the system. Someone specifically sent it. We assumed it was a friend or other contact with the mother who "slipped up" accidentally/on purpose.

Nothing bad happened but our attorney made sure that everyone knew how serious that was and I think he scared the other party into not trying to find our DS.

On another note, we have never had any negative issues with patient care and have always had great nursing care in DH's multiple hospitalizations in multiple locations. So, so sorry that all of you had horrific experiences! Nobody is perfect but negligence is another matter.

 

[kacaju]

When my Dad was in a nursing/rehab after being sick he had a nurse who was so nasty to him. He was 63 at the time and was in for rehab before coming home. He had a trach tube in so he could not talk, instead he wrote everything down. She used to take forever to come to his room when he pushed the call button. When he told me that I confronted her and her comment was....well, we never keep the patients waiting... when they get old they sometimes get confused and they think a lot of time goes by when it really doesn't.
hmmm...my Dad was not *old* and funny thing...there was a CLOCK right on the wall so he started to keep track of the time by writing it down.
She did get in trouble about a week later when I brought my Dads notes to the director.