Hospital discharge: It’s one of the most dangerous periods for patients - Celestial Care

Hospital discharge: It’s one of the most dangerous periods for patients

Within two weeks of Joyce Oyler’s discharge from the hospital, sores developed in her mouth and throat, and blood began seeping from her nose and bowels.

Her daughter traced the source of these problems to the medications present in Oyler’s home in St. Joseph, MO. One drug that keeps heart patients such as Oyler from retaining fluids was missing. In its place was a toxic drug with a similar name but a different purpose; one used primarily to treat cancer and severe arthritis. The label instructions were to take it daily.

“I gathered all her medicine, and as soon as I saw that bottle, I knew she couldn’t come back from this,” said Kristin Sigg, the younger of her two children. “There were many layers and mistakes made after she left the hospital. It should have been caught about five different ways.”

Oyler’s death occurred at one of the most dangerous junctures in medical care –  when patients have recently left the hospital. Bad coordination often plagues patients’ transition to the care of home health agencies, as well as to nursing homes and other professionals involved with helping them recuperate, studies show.

“Poor transitional care is a huge, huge issue for everybody, but especially for older people with complex needs,” said Alicia Arbaje, an assistant professor at the Johns Hopkins School of Medicine in Baltimore. “The most risky transition is from hospital to home, with the additional need for home care services, and that’s the one we know the least about.”

Medication mistakes like the one in Oyler’s case — which, according to court records,  slipped past, both, her pharmacist and home health nurses — are, in fact, one of the most common complications for discharged patients.

The variety of providers that patients may use after a hospitalization creates fertile ground for error, said Don Goldmann, chief medical and science officer at the nonprofit Institute for Healthcare Improvement. “This episodic care at different places at different times is not designed to keep the overall safety of the patient in mind,” Goldmann said.

At hospitals, federal data show that fewer than half of patients say they’re confident that they understand the instructions of how to care for themselves after discharge.

In nursing homes, case management frequently comes up short. A 2013 government report found more than a third of facilities did not properly assess patients’ needs, devise a plan for their care and then follow through.

At home health agencies, failures to create and execute a care plan are the most common issues government inspectors identify, followed by deficient medication review, according to a Kaiser Health News analysis.

Oyler’s death in October 2013 shows how a fatal mistake can slip past multiple checkpoints. The 66-year-old retired safety manager left Heartland Regional Medical Center in St. Joseph after being treated for congestive heart failure, in which the heart fails to pump effectively, which causes fluid buildup in the lungs, shortness of breath and swelling of the feet. As she returned home, a hospital nurse telephoned a local pharmacy with eight new prescriptions. One was for the diuretic, metolazone.

However, the medications a pharmacy technician wrote down did not include metolazone. Instead, it listed methotrexate, which can damage blood cell counts, organs and the lining of the mouth, stomach and intestines.

In a court deposition taken as part of the lawsuit the family brought, the pharmacist blamed himself for not catching the error. “For whatever reason, on that certain day, that didn’t trigger with me,” he testified. The pharmacy, Hy-Vee, argued that its safeguards were as strong as those at other pharmacies, although the pharmacy manager admitted in a deposition that “quite honestly, there was a breakdown in the system.”

The family’s attorney, Leland Dempsey, said court evidence suggested the drug mix-up was made by the pharmacy technician who took the prescription orders. “The pharmacy tech made numerous spelling errors on the drugs,” he said. “She had a dosage off of another drug.”

Yet the error could have been snagged as soon as  Oyler began getting care from Heartland’s home health care agency. Medicare requires home health agencies to examine details of a patient’s medications to ensure all the drugs match the prescriptions ordered, are being taken in the right dosage and frequency, and don’t have negative interactions.

Still, neither of two Heartland nurses who visited Oyler at home prevented her from taking the wrong drug. Less than a year before, Missouri state inspectors had cited the agency for inadequately reviewing medications for three patients. State records show it had pledged to make improvements.

“Why they didn’t catch it was beyond me,” Oyler’s husband, Carl, said recently. “They had a printout from the hospital” with every medication correctly listed. “It was all there,” he said.

After 18 days, her family took Oyler to North Kansas City Hospital, where doctors determined that the methotrexate had irreparably damaged her bone marrow’s ability to create blood cells. She died three days later of multiple organ failure.

“By the time we got her into the emergency room, essentially, she had no blood cell count,” her husband recounted. “It was irreversible. It was a gruesome, slow, painful way to die.”

“Most people don’t know this is a problem,” Sigg said. “They assume doctors are talking to each other, until they experience it, and find out it’s not the case.”

The Washington Post