In my last blog post we explored the topic of shared decision making (SDM) and its impact on patient safety. This made me think of an experience we recently had with my dad. He had a stent placed about year and a half ago to open a blocked artery in his left anterior descending artery (LAD). Now I should tell you that the doctors, 3 to be exact, wanted to send him home because all of his tests came back negative, but the stubborn, yet lovable, man that my father is (I know, the apple doesn’t far fall!), found a cardiologist that was willing to listen to him and discuss his concerns and thoughts. He convinced this cardiologist to do an angiogram. They ended up finding, clear as day, a 90% blockage in the LAD and stented him right then and there, no questions asked. Needless to say he bypassed a major heart attack, (a.k.a. the Widowmaker) which could have very easily ended his life.
My brother and I both have clinical backgrounds, so it was a little unsettling how the events of the 48 hours with my dad transpired. We went from an emergency admission to nothing is wrong with him, he can go home, to he has a 90% blockage in his main artery that we need to stent right away. Talk about an emotional rollercoaster, but in the end we were glad he was okay. However, at time of discharge, another shocking and disappointing incident occurred. The nurse was going over his discharge medication regime. As she was rattling off this medication list at a speed even a pharmacist couldn’t understand, she stated, “…and 10mg of Amaryl two times a day.” My dad, who has NEVER taken a pill in his life (we are Indian so turmeric is our answer to everything!) and was still a little out of it from the whole experience was unable to catch the error that just occurred. Luckily I was there to ask the nurse, “Are you sure it is 10mg and not 1mg of Amaryl?” Her response, “Yes that is what the order states.” Again, I challenged her, “Are you sure, because I thought the cardiologist told us after surgery it was 1mg of Amaryl.” She responded, “I can go check, but I am pretty sure this is correct”. I asked her to call the cardiologist and confirm as pretty sure was not good enough. Just as I suspected, it was an error in dosage. The order was for 1mg of Amaryl, twice a day, specific to before breakfast and dinner. At this point, given all that occurred, I began questioning everything she rattled off and requested (well, damn near demanded) that she go back and reconfirm the entire list. This was my dad, my best friend, I was not going to take any chances that his safety be compromised due to a medication error.
This is just one incident that thankfully didn’t end badly. However, every day patient safety is being compromised because information is not accurately or readily available. Up to 18% of the patient safety errors, generally, and as many as 70% of adverse drug events could be eliminated if the right information about the right patient is available at the right time. Health information exchange (HIE) makes this possible1.”
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