Thursday, 3 May 2012

Liverpool Care Pathway – Misdiagnosis, Misdiagnosis, Misdiagnosis


Misdiagnosis...
Misdiagnosis may result in any one of many outcomes.

Medical Malpractice – Medical Misdiagnoses

July 12, 2011
Medical errors are far from rare, according to several comprehensive studies of the issue. But diagnostic errors – a subset of the overall problem – haven’t received nearly as much attention as other medical errors since the nationwide patient-safety movement began in 1999 with the publication of the landmark Institute of Medicine report, “To Err is Human.”
“Diagnostic error is barely on anybody’s radar screen,” said Dr. Mark Graber, 62, a nephrologist in Long Island, N.Y., and an expert on diagnostic errors.  The “To Err” report estimated that at least 44,000 and as many as 98,000 Americans die each year from all types of medical errors. More recent studies indicate there has been little progress since 1999, with as many as one in three or one in four hospitalized patients being harmed in some way by medical errors.
The statistics indicate as many as 9 million patients nationwide and between 400,000 and 528,000 patients in Illinois are harmed each year. According to Graber and other researchers, deaths and serious harm associated with diagnostic errors are uncommon even though an estimated 5 percent to 15 percent of medical diagnoses are incorrect. But for those harmed, Graber said the impact can be devastating.
via Medical misdiagnoses can have fatal consequences – Springfield, IL – The State Journal-Register.

Misdiagnosis, Misdiagnosis...
Misdiagnosis will affect outcomes. 

This from The Globe And Mail -

Hassan Rasouli, who recently started reacting after being in vegetative state at Sunnybrook Hospital, photographed with his daughter Majgan and wife Parichehr Salasel at the hospital on Bayview Ave.,Toronto 24, 2012, - Hassan Rasouli, who recently started reacting after being in vegetative state at Sunnybrook Hospital, photographed with his daughter Majgan and wife Parichehr Salasel at the hospital on Bayview Ave.,Toronto 24, 2012, | Fernando Morales/The Globe and M

Vegetative patient now able to give ‘thumbs up,’ fuelling debate over life support

From Wednesday's Globe and Mail

A hospital patient deemed vegetative is now able to make a “thumbs up” gesture – a sign to family that he is aware, but not yet strong enough to persuade doctors to drop a recommendation to withdraw life support.
The symbol marks a dramatic turn for Hassan Rasouli, 60, who until recently was in a persistent vegetative state. An affidavit filed with Canada’s top court says he’s now minimally conscious, and doctors’ reports say he can “voluntarily control” certain behaviours – suggesting he may be aware but trapped in a paralyzed body.
This new diagnosis seems certain to inflame an already divisive ethical debate about who decides to withdraw life support. And it raises the discomfiting notion – the stuff of relatives’ nightmares – of a patient being aware but unable to communicate when the machines are turned off.
“He is still there,” Mojgan Rasouli, 29, said of her father who has been at Toronto’s Sunnybrook hospital since October, 2010, after sustaining a brain infection after surgery for a brain tumour. “He can feel us and we can feel him.”
The case before the Supreme Court of Canada was begun by two doctors from Sunnybrook Health Sciences Centre, Brian Cuthbertson and Gordon Rubenfeld, who saw no medical purpose in keeping Mr. Rasouli on life support and proposed shifting him to palliative care.
The affidavit, filed by Dr. Cuthbertson, chief of critical care at Sunnybrook, spawned activity in and out of the courtroom. Gary Hodder, lawyer for the Rasouli family, filed a motion to quash the appeal as moot. A leading neuroscientist, Adrian Owen, travelled to Mr. Rasouli’s bedside at Sunnybrook on Tuesday, to conduct investigations to determine whether he can communicate.
His investigations come on the heels of a study he published in the medical journal The Lancet, revealing that 19 per cent of patients believed to be in an irreversible vegetative state showed signs of full consciousness when tested with an electroencephalography machine.
This is a murky area. Medicine is as much art as science, and sometimes even the most seemingly hopeless of patients experiences a change in condition. Whether Mr. Rasouli can communicate is a crucial question on which the medical case is expected to turn.
If he can, he “may be able to, or even capable of, expressing end-of-life wishes, such as whether to discontinue life support,” said Mark Handelman, an expert in health-care law.
If he cannot, Dr. Cuthbertson and other treating physicians “remain of the view that the standard of care does not require continuation of mechanical ventilation given his condition,” the affidavit says. It says Mr. Rasouli has also been diagnosed with other conditions, including spastic quadriplegia, which are extremely unlikely to improve in the long term.
Mr. Rasouli, a retired engineer, receives round-the-clock care: A mechanical ventilator does his breathing; a tube inserted into his stomach provides nutrition and fluids, while a catheter drains his urine. Medications maintain his blood pressure and he must be turned to prevent bed sores.
Sunnybrook neurologist Richard Swartz initially diagnosed him to be in a persistent vegetative state. But he noted things had “clearly changed” when he assessed Mr. Rasouli in late January, nearly 11 months from his last visit.
The patient was “consistently able to show a ‘thumbs up’ ” to verbal requests, with his wife, Parichehr Salasel, translating to Farsi. “… Importantly, he has consistently shown visual pursuit, one of the earliest signs of MCS [minimally conscious state].”
Lawyer Harry Underwood, who represents critical-care physicians Dr. Cuthbertson and Dr. Rubenfeld, declined comment. Dr. Swartz could not be reached.
Mr. Hodder said the new diagnosis “changes the entire texture of the situation. We’re now talking about someone who has some degree of consciousness.”
Bernard Dickens, professor emeritus of health law and policy at University of Toronto, says if it turns out Mr. Rasouli is aware, his lawyers could argue that disconnecting him from life support would cause him moral anguish and could violate the “do no harm” oath of physicians.
For the Rasouli, family, however, this is important not only personally but for other patients facing the same painful issue.
“This could help other families, future patients,” Ms. Rasouli said. “Maybe some families give up. Everything is possible.”
Misdiagnosis, Misdiagnosis, Misdiagnosis...

Misdiagnosis is not good for your health...


Medical misdiagnoses can have fatal consequences



03292011reindl2.jpg
Posted Jun 25, 2011 @ 11:00 PM

Stephen Reindl told his mother what he thought would be his final goodbyes as she struggled with pneumonia and a blood infection the day after Thanksgiving.

Mary Reindl had been taken to Memorial Medical Center in late November after she broke her leg in her Taylorville home. At 78, the longtime smoker and retired state Department of Revenue employee had come to the hospital with labored breathing and abdominal bloating that was getting worse, her son said.Doctors reviewing her case suggested Mary Reindl had fewer than 24 hours to live, and that her condition was the result of advanced lung cancer and chronic obstructive pulmonary disease, Stephen Reindl said. After he talked with Memorial staff and his mother's doctors, she was taken off oxygen, and her pain medication was increased.

"They told me there was nothing more they could do for her," said Stephen Reindl, 51. "It tore me up."

Then the case was reviewed by Dr. Thomas Shanahan, a radiation oncologist who bucked what he called "the assumption bandwagon" by Mary Reindl's other doctors and fought to treat her for a condition that had prevented her bowels from emptying.

What happened in the next days showed the potential for medical error in complex cases such as this. It also showed how one doctor's vigorous - some say abrasive - fight to counter an established course of treatment ultimately led to Mary Reindl's recovery and how questions were raised over how the doctor advocated for his patient.

Was this a case of doctors getting on "the assumption bandwagon," as Shanahan says, or was this a case in which the complexities of treatment clouded an alternative diagnosis? It's hard to know for sure, because the Springfield Clinic doctors who treated Mary Reindl wouldn't speak to The State Journal-Register.

But interviews with the Reindl family, Shanahan and other doctors, and a review of records and documents related to the case, show how an apparent error in diagnosis can be life-threatening.

Errors not rare

Medical errors are far from rare, according to several comprehensive studies of the issue.

But diagnostic errors - a subset of the overall problem - haven't received nearly as much attention as other medical errors since the nationwide patient-safety movement began in 1999 with the publication of the landmark Institute of Medicine report, "To Err is Human."

"Diagnostic error is barely on anybody's radar screen," said Dr. Mark Graber, 62, a nephrologist in Long Island, N.Y., and an expert on diagnostic errors.

The "To Err" report estimated that at least 44,000 and as many as 98,000 Americans die each year from all types of medical errors. More recent studies indicate there has been little progress since 1999, with as many as one in three or one in four hospitalized patients being harmed in some way by medical errors.

The statistics indicate as many as 9 million patients nationwide and between 400,000 and 528,000 patients in Illinois are harmed each year.

According to Graber and other researchers, deaths and serious harm associated with diagnostic errors are uncommon even though an estimated 5 percent to 15 percent of medical diagnoses are incorrect. But for those harmed, Graber said the impact can be devastating.

Puzzling decline

Mary Reindl's odyssey began Nov. 16 when she fell and broke her leg. Her son, a Taylorville elementary school teacher, said an ambulance brought her to Taylorville Memorial Hospital on Nov. 18 for extreme pain in her leg after the break was set and a cast applied. She also was becoming short of breath.

Based on an X-ray, doctors at the Taylorville hospital thought a potential case of lung cancer might be playing a role in her condition, so they sent her to Memorial Medical Center for more advanced care.

Barely conscious, Mary Reindl was evaluated at Memorial on Nov. 23 by a resident physician under the supervision of Springfield Clinic Dr. James Fullerton. The resident doctor suggested a colonoscopy to determine whether she had a blocked colon or some other problem that might be causing her bloating, breathing difficulties and pain, but Reindl's other doctors didn't follow up on that suggestion, Shanahan said.

Shanahan, 54, who had served as a temporary Springfield City Council alderman, is a member of Springfield-based University Radiologists. He has published dozens of articles and spoken to medical professionals around the world on cancer-treatment techniques.

Shanahan said none of the doctors involved with Reindl's case is incompetent, but he said medical records indicated they became fixated on a suspicion that she was dying of terminal lung cancer and COPD.

"They just assumed she had so many problems that piled up into a non-fixable situation," he said. "They got on this 'assumption' bandwagon.'"

Memorial Medical Center officials wouldn't comment on the Reindl case, but a Springfield Clinic spokesman, chief medical officer Dr. J. Michael Zinzilieta, said Reindl's doctors from the clinic acted based on a thorough review of her symptoms, test results and medical status - not based on any assumptions.

Condition worsens

By Nov. 24, the day before Thanksgiving, Mary Reindl's condition had continued to decline, and her Springfield Clinic doctors, including critical-care specialist Samir Patel and medical oncologist Leonard Giannone, were convinced there was nothing that could be done, Shanahan and Stephen Reindl said.

At about 3 a.m. on Thanksgiving, after talking with a nurse, Reindl agreed to put his mother on "comfort care" to ease her suffering.

She was expected to die in the next six to 24 hours but wasn't dead the morning of Nov. 26, when Shanahan made rounds at the hospital. He happened to be the oncologist who received Stephen Reindl's request, delayed for several days by paperwork, for an evaluation of his mother's cancer-treatment options.

Shanahan used Memorial's electronic medical-records system to look at all of the other doctors' notes and tests she had undergone. He then told Stephen Reindl that a colon problem could be the source of his mother's bloating, breathing problems and other symptoms.

Zinzilieta said Mary Reindl's Springfield Clinic doctors were aware of the potential colon problem and the option to perform a colonoscopy. But he said the doctors "consulted as a team and came to this agreement that at this particular point in time, she's too sick to withstand any type of invasive procedure."

Before introducing himself to Stephen Reindl, Shanahan had checked the results of a lung biopsy performed at the Taylorville hospital and determined that the suspected lung cancer was at an early, treatable stage. It's unclear whether the other doctors had checked the biopsy results, Shanahan said, but Stephen Reindl said Shanahan was the only doctor who told him these details.

The lack of advanced lung cancer created more questions about whether his mother's condition was, in fact, terminal. Stephen Reindl agreed with Shanahan that the colonoscopy's potential to diagnose and possibly treat a life-threatening colon condition was worth the risk.

Futile procedure?

Before proceeding, Shanahan tried to reach Reindl's other doctors, but on the day after Thanksgiving, Fullerton was unavailable. Fullerton's partner, who was available, agreed that a colonoscopy would be justified, Shanahan said.

Giannone was unavailable, according to Shanahan, and Stephen Reindl already had fired Patel out of frustration.

The decision to seek the colonoscopy and hook Mary Reindl back up to life support in the intensive-care unit "set off a chain reaction of hell" at Memorial, Shanahan said.

Shanahan and Stephen Reindl said several Springfield Clinic doctors at the hospital, as well as a nurse and Christine Gorka, a member of Memorial's Clinical Ethical Center, held an impromptu "ethics" meeting - without inviting Shanahan - to dispute the change in Mary Reindl's care.

Stephen Reindl said he was called into the meeting and told his mother shouldn't be put through what doctors believed would be a futile procedure.

"Each one took a turn trying to grind me down," Reindl said. "The only time they worked together was when they said she needed to be put down."

After that meeting, Reindl immediately fired all his mother's remaining Springfield Clinic doctors except for Anthony Firilas, a colorectal surgeon. Shanahan said he had several heated discussions with Firilas over the phone to convince Firilas to perform the colonoscopy.

Firilas ended up conducting the procedure the morning of Nov. 27 and found no blockage but declined Shanahan's request to perform one extra step - to use the colonoscopy equipment to suck out excess gas from Mary Reindl's colon.

According to Shanahan, Firilas said he didn't think that step would have done her any good.

The error issue

Several major medical providers in Springfield say they are working to discover, analyze and prevent diagnostic errors. But they say it's a difficult task.

Dr. Rajesh Govindaiah, chief medical officer for Memorial Health System, which operates Memorial Medical Center, said ongoing improvements in electronic medical records could help avoid diagnostic errors in the future.

"We need better tools, and we need better data," Govindaiah said.

Dr. Robert Vautrain, chief quality officer at Hospital Sisters Health System, agreed with Govindaiah. HSHS operates the area's other major hospital, St. John's.

"Diagnostic error and late diagnosis are constantly on our minds," Vautrain said.

He said there is a lot of dialogue in the medical community about identifying and avoiding "thinking traps" that can lead to diagnostic errors.

"This is about deep-seated human characteristics, so there's no quick or easy solution to the issue," he said.

Officials at Springfield's other large physician group, SIU HealthCare at Southern Illinois University School of Medicine, declined comment. SIU uses St. John's and Memorial as teaching sites for medical students and medical residents, and SIU doctors are on staff at both hospitals.

"There just wasn't anybody that was interested in being interviewed for this story," SIU spokeswoman Nancy Zimmers said.

Springfield Clinic provides "performance analysis and support to its physicians and medical staff to help continually improve processes related to patient safety and accuracy," Zinzilieta said.

Evaluations of potential diagnostic errors take place after the fact based on complaints from patients, families and reports of "bad outcomes" from the organization's doctors, he said, adding that Springfield Clinic is considering improvements suggested by experts on diagnostic errors.

"We're always trying to get better," he said.

Life-altering ending

After Firilas' refusal to remove the gas from Mary Reindl's colon, Shanahan arranged for an alternative. Based on his order, a registered nurse placed a rectal tube the night of Nov. 27.

With the tube in place, the equivalent of four 2-liter bottles of gas was released - gas that been compressing her diaphragm - and Reindl began to breathe easier almost immediately. She regained consciousness a few hours later.

It turned out that Reindl had a relatively rare and temporary condition called "Ogilvie's syndrome," in which nerves that make the colon contract and eliminate waste have been turned off somehow, Shanahan said.

Reindl's condition continued to improve, and she eventually was discharged from the hospital. She has returned to her home, but the stress of having impaired breathing and being removed from oxygen for more than 24 hours while on comfort care may have caused some brain damage, her son said.

"She's not the same way she was," Stephen Reindl said.

He said he is still recovering from his own stress.

"I went to hell and back," he said.

There were ramifications for Shanahan, too.

He said he was labeled a "disruptive physician" by doctors and nurses who complained about his conduct to Govindaiah.

Zinzilieta said Shanahan portrayed himself as "somewhat heroic" to Reindl's family and was unnecessarily abrasive toward Springfield Clinic doctors and Memorial employees.

In a Dec. 14 letter, Govindaiah told Shanahan that it is "exceedingly important to have professional and collegial discussions with patients, family, hospital and medical staff to avoid unnecessary confusion and conflict."

'Thankful to be alive'

Shanahan said the only angry comments he made were to Firilas on the telephone.

Shanahan said there is a "balance of trust" required among doctors, but not at the expense of a patient's health. If he hadn't started asking questions, Mary Reindl probably would have died within days from lack of water and food, he said.

"This is one of the most complex cases I have ever worked on in my 21 years of practice," he said. "I am sorry if I ruffled the feathers of one of the Springfield Clinic doctors and some of the ICU staff. This wasn't grandstanding. This patient had options to save her life, and I took them. The fact this patient is alive seven months later speaks volumes about the correctness of my action."

Shanahan said the inquiry at Memorial into his conduct was dropped after one of his partners, Dr. Parashar Nanavati, stuck up for him and called Memorial Health System chief executive Edgar Curtis.

When contacted, Nanavati declined to comment other than to say, "I consider the case to be closed."

Shanahan continues to practice.

Mary Reindl's family isn't interested in suing the hospital or the doctors. Stephen Reindl said he is focusing on caring for his mother. He considers Shanahan an "angel" whose actions allowed the Reindl family to enjoy the Christmas holiday and other special occasions with his mother.

Mary Reindl told The State Journal-Register that she is grateful to Shanahan.

"I'm thankful to be alive," she said. "I didn't realize I was so close to not being alive."

***

Errors can be prevented

The little attention diagnostic errors receive gives doctors a false sense of security, according to Dr. Mark Graber, a nephrologist in Long Island, N.Y., who's among the handful of U.S. researchers looking into the issue.

They point out that it's easier for hospitals and health systems to identify and develop methods to prevent other problems - such as medication errors, surgery on the wrong body part or hospital-acquired infections.

Identifying, analyzing and preventing diagnostic errors is more challenging than dealing with other medical errors, but not impossible, Graber said, adding that some strategies involve the way doctors approach cases while others involve the ways hospitals and health-care organizations help doctors sort out information.

Diagnostic errors are a leading cause of injuries that lead to malpractice claims and settlements, Graber noted.

"Most of the time, mistakes boil down to some combination of things that go wrong in your health-care system and things that go wrong cognitively," he said. "And it's possible to identify them all and think about them and think about ways to make them less likely."

The lack of feedback doctors receive about their own diagnoses can lead to overconfidence by doctors, Graber said.

"They get it right so often that they don't really appreciate that they get it wrong," he said. "And they just take it for granted that everything they're doing is OK."

Patients can help avoid errors
  • Tell your story well. Medical diagnosis is dependent on having an accurate history. Try to present your symptoms and problems as clearly, completely and accurately as you can. Pay attention to what factors make your symptoms better or worse. Look for patterns. And don't assume your story will be accurately transmitted to your main physician, regardless of whether you have told that story first to a nurse or nurse's aide.
  • Be a good historian. What treatments have been tried in the past, and what was the response? How has the illness evolved?
  • Be a good record-keeper. Keep you own records of test results, consultations and summaries of hospital admissions. Keep an accurate list of your medications.
  • Be an informed consumer. Read about your condition online or at patient libraries. Learn about the tests you are having done.
  • Facilitate communication and coordination. If you are seeing other physicians and consultants, make sure that everyone involved in your care knows what other members of your team are thinking and planning. Don't assume your care is being coordinated behind the scenes.
  • Ensure test results are known. Don't assume that no news is good news. Make sure that both you and your doctor receive the results from diagnostic tests.
  • Ensure follow-up. Ask what to expect if you have "Disease X." Ask what the process would be to inform the clinician if new symptoms develop, or if the expected outcome is different from what you experience.
  • Encourage your doctors to think broadly. If your doctor offers a diagnosis, don't be afraid to ask, "What else could this be?"
  • Medical errors are often detected by a fresh set of eyes. Second opinions offer a way to substantially decrease the risk of diagnostic error. But extra testing and extra stress from the uncertainty that may result if the opinions on your condition vary.


Source: Dr. Mark Graber, senior scientist at RTI International and professor emeritus of medicine at State University of New York at Stony Brook
National perspectives on preventing medical errors

Communication errors between doctors and other health-care providers are "a huge problem," according to Lisa McGiffert, director of the Consumers Union's Safe Patient Project. "The culture in hospitals is one of hierarchy, one of intimidation" and "a culture of acceptance that things are going to go wrong."

"I believe that the system has made some very, very important steps forward ... but our current health-care system is still incredibly fragmented, and the care is poorly coordinated, and there's not enough communication between providers. We don't have electronic health records in most settings," said Janet Corrigan, president and CEO of The National Quality Forum and a contributor to the Institute of Medicine's "To Err is Human" report.
Improvements in safety are needed, but patients shouldn't fear hospitals, according to Jessie Gruman, president of the Center for Advancing Health, a patient-advocacy group in Washington, D.C. "Most people go in and out of the hospital with no mistakes and no problems," she said.
Online resources
Causes of diagnostic error
Cognitive problems: Include knowledge deficits, which are rare; errors in gathering the data, which are more common and may involve the doctor having an incorrect picture of a patient's symptoms or how they have evolved; and errors in synthesis, which are the most common and involve the complexity of "putting it all together."
Health-care system-related problems: The most common involve communication and coordination of care. Diagnostic tests can be mishandled, resulting in errors. There are inherent limitations with diagnostic tests that can't be overcome, such as a certain number of false positives and false negatives.

Misdiagnosing death that results in being placed on the Liverpool Care Pathway will have only one outcome.Clearly, LCP is a one-way ticket on the NHS (National-socialist Health Service) into the next world!

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