A 2009 study published by the New England Journal of Medicine analyzed almost 12 million Medicare beneficiaries and found:

• 20% of patients were readmitted within 30 days of discharge
• 34 % of patients were readmitted in 90 days of discharge
• 67.1% of patients percent were readmitted one year after discharge or had died

This revolving door effect cost Medicare $17.4 billion dollars in 2004 and the problem continues to escalate.

Medicare is responding by collecting data on all hospitals and will keep a running three-year average on readmission rates. Those hospitals having high rates will be financially penalized.

According to a Medicare Payment Advisory Commission study, 75 percent of all 30-day hospital readmission are preventable and if they can be avoided, the quality of patient care will improve. Higher rates of hospital readmission are associated with infections and other complications acquired by patients during hospital stays.

In a pilot project in which hospitals were paid bonuses and held accountable for better outcomes and less bounce backs, quality improved and readmission rates fell substantially.

The cause for patients having to readmit patients after a hospital stay seems to fall into one of the following categories:

1. Lack of communication between patient and doctor
2. Complete lists of medications missing from patients
3. Follow-up appointments were never made or communicated
4. Wound care or other instructions were confusing or never received
5. No official hand-off from one physician to another
6. Insufficient monitoring of patients after discharge — especially regarding medications

Medicare does not currently pay hospitals for monitoring or mentoring patients after discharge.

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Every day on TV, we are bombarded with advertisements urging us to purchase numerous prescription and over-the-counter drugs that will cure everything that ails us (and even cure diseases and conditions unknown or non-existent prior to drug company marketing efforts).

Do these medications really work?

Do they cause more harm than good to our well-being?

Do the risks outweigh the benefits?

Are there some bothersome conditions that should be tolerated and accepted rather than treated with medications?

The number of medication-related injuries and deaths in the U.S. are estimated at over 1.5 million per year, making medications one of the leading causes of death according to a 2006 report from the Institute of Medicine of the National Academies.

Dr. Leo Galland, M.D., a practicing physician and noted medical author, says that not all medications are created equal and that many have serious side effects that the manufacturers failed to adequately disclose to the FDA prior to approving them for marketing.

Dr. Galland believes that a number of common medications can be hazardous to your health.  For example, nonsteroidal anti-inflammatory drugs (NSAIDs), which include over-the-counter drugs such as aspirin, ibuprofen, and naproxen (also known as Aleve), cause a number of serious injuries and deaths each year.  Dr. Galland’s studies have found that these drugs relieve pain and inflammation by blocking an enzyme called cyclo-oxygenase (COX), but at what cost?

“Although COX activity contributes to pain and inflammation, this enzyme also performs important functions such as protecting the stomach from the corrosive effects of its own acid, regulating circulation of blood to the kidneys, and modulating the activity of the immune system,” says Dr. Galland. “Almost all drugs today are intended to act like biochemical strait jackets which suppress cellular functions that appear to be overactive,” adds Dr. Galland. “They also interfere with the natural and healthy functions of the body. It is like throwing a wrench into a sophisticated machine in an effort to fix it.”

The net result of disturbing this delicate balance in the COX enzymes is that a number of patients suffer life-threatening gastrointestinal bleeding and ulcers as well as renal failure and other significant health problems as a result of ingesting these popular drugs.

The manufacturers of Vioxx sought to build a better mousetrap – a pain killer that was as effective as other popular NSAIDs without blocking Cox-1 enzymes and thereby causing bleeding issues.  In doing so, however, Vioxx caused other disturbances to the COX system that rather than causing ulcers, instead caused pro-thrombotic events that led to heart attacks and strokes.  “What scientists behind the creation of Vioxx failed to recognize is that all forms of the COX enzyme are important for health,” says Dr. Galland.

Many physicians are now recommending proper nutrition, which when used properly, can achieve results that drugs cannot, because nutrients are essential components of the cellular information network in our bodies.

“The regular use of Omega-3 fatty acids in the diet is an excellent example of how the cells of our body use the Omega-3’s to make powerful chemicals that help to maintain normal cell function under conditions of stress,” advises Dr. Galland.

Omega-3 fats provide an alternative to drug therapy for controlling inflammation in the body, a natural process that, when excessive, can lead to cancer and disease.

Patients who change their diets and decrease their consumption of foods that interfere with the anti-inflammatory effects of Omega-3 fats experience less inflammation and therefore have fewer needs for anti-inflammatory drugs.  These dietary changes include reduced intake of red meats and foods that contain certain oils (including corn, sunflower, soybean, safflower or cottonseed oil).  Dr. Galland recommends using olive oil or flax oil as a substitute.

“Making nutrition a cornerstone of everyone’s healthcare has been my longstanding goal and is the first step in real healthcare reform,” adds Dr. Galland. “Moving from a system based on treating symptoms to a system for achieving optimal health will enable healthcare to achieve its true potential.”

One can only hope that our healthcare system takes these maxims to heart, pardon the pun, and seeks to encourage an increase in the healthy foods placed in our grocery cart each week and a decrease in the number of pill bottles placed in our medicine cabinet.

Following published reports and extensive media coverage regarding egregious behaviors in the medical profession, public awareness of physician and hospital errors has increased. Despite that increased attention, data suggests that the rate of reporting by physicians is lower than it should be.

In the JAMA July 14 issue, one of the major themes covered was research articles and commentary on the Physician Peer Review process and its effectiveness. The medical peer review is the process by which a committee of physicians examines the work of a peer and determines whether the physician under review has met the accepted standards of care in rendering medical services. This process is put in place specifically to assure physicians that their statements will remain confidential when commenting on the behaviors of their colleagues (many of whom are a physician’s primary referral sources).

An original research study titled “Physicians’ Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues” found that overall, “…physicians support the professional commitment to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority; however, when faced with these situations, many do not report.

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New studies show that hospital deaths increase sharply in July causing a “July Effect”. The study illustrates the need for patients to practice caution while accepting medical care in that month or over the weekend days.

A recent study by the University of California at San Diego demonstrates that fatal medication errors rose 10 percent in July at teaching hospitals in the United States. This “July Effect,” doesn’t seem to mean that hospital staffs are running amok, but that more medication errors seem to be the culprit in teaching hospitals. The study investigated more than 62 million U.S. death certificates between 1976 and 2006. Of those, 244,388 deaths were caused by medication errors in hospitals such as dispensing the wrong medications, overdoses, and accidents involving drugs or biological agents.

The researchers examined certificates of inpatients, outpatients, and those who died in the emergency department, in which medication error was recorded as the primary cause of death. Counties containing teaching hospitals experienced a 10 percent rise in fatal medication errors in July, whereas counties lacking teaching hospitals did not experience that spike.

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In legal cases, a term regularly shows up: “standard of care”. It is talked about, defined and ruled on by the court. In many state statutes, the term is defined as something similar to: “that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers.”

What is the standard of care in its most basic terms?

If I am a pedestrian, do I have a “standard of care” as I walk along the street? Of course I do. I must watch the pavement as I am walking so as not to trip over obvious hazards. If I come upon a blocked area of the sidewalk, where work is being done for example, I have the duty to navigate carefully and as safely as I can around that hazard in continuing my walk. I have a duty to avoid running into other pedestrians using the sidewalk. If I must cross the street, I have a number of additional duties I must fulfill.

Why do we have “duties” and “standards” by which we must act? Without them, no one would know what was expected of them and we would not be able to anticipate how to expect others to conduct themselves in given situations.

A car is traveling down a dark, deserted country road, approaching an intersection with a stop sign. The car does not stop at the stop sign and, instead travels through it at highway speed. No other cars were approaching the intersection at the time. Was the driver negligent? Did the driver deviate from the reasonable standard of care? The driver was negligent, but, luckily, caused no damage to anyone. So, if a police officer was around, a ticket would be issued, but nothing further.  So, was it excusable, since no one was hurt? Absolutely not. The same example, but the approaching driver does not see an approaching motorcycle. The motorcyclist is struck and killed. A completely different set of circumstances results, but culminate from the exact same perceptions on the part of the driver in the car. In both situations, the driver “honestly” saw no harm by running the stop sign.

This is particularly true for professionals. The public absolutely must be able to depend on certain standards of performance from professionals. For an engineer who constructs a bridge, we expect that the bridge will carry the weight reasonably expected and will not collapse with that weight. We expect that the professional will act in a manner expected from other similar professionals.

When a doctor decides to treat people, she decides to work within a reasonable standard of care accepted by other physicians. Does that mean if a physician or other professional makes a mistake that they have deviated from the acceptable standard of care? Not necessarily. It means that the professional is obliged to act reasonably as judged by similar health care providers.

If a patient arrives at the hospital with symptoms consistent with 3 or 4 different potential illnesses, it is the job of any physician to determine those illnesses, which are life threatening and try to eliminate or include those first. If the condition could be life threatening, the professional is obligated to continue their investigation until they can determine what course of treatment is best for the patient.

Physicians, like any professional, have pressures extraneous to their profession. In the case, of an engineer, it may be cost overruns and their client may be pushing to cut corners somewhere to minimize those cost overruns. With physicians, it may be a hospital or insurance company. It is the job accepted by the any professional to comply with the reasonable standard of care. In the case of physicians, it is to determine those patients who require hospitalization in order to determine their illness and those who do not need hospital care.

Professionals are required to reach reasonable, well thought, courses of action within their profession. They typically go through additional schooling to prepare them for evaluating a reasonable course of action.  The subject of a professional’s decision may seem complex, but their standard of care is no less real than the driver or pedestrian.

In his June 11, 1963 civil rights address, President John F. Kennedy confronted head-on the unfair treatment of African Americans in our society under our then-existing system of laws. President Kennedy, in imploring Congress to pass fundamental civil rights legislation, stated:

“…the old code of equity law under which we live commands for every wrong a remedy, but in too many communities, in too many parts of the country, wrongs are inflicted on Negro citizens and there are no remedies at law.”

Unfortunately, President Kennedy’s reference to our system of justice having the ability to remedy every wrong states only an ideal, but, sadly, not reality. Sometimes the difference between principle and truth is the result of legislative inaction or by legislative activism. Perhaps the most glaring example of legislative activism stripping away the “guaranteed” rights of citizens to have both their day in court and a remedy for every wrong can be seen in the medical negligence arena.

Let us examine the following two hypothetical scenarios.

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Recently, a woman was impregnated at a fertility clinic with another woman’s embryo.  The woman has decided to give birth and give the baby to the biological mother.  This preventable and heart breaking mistake should not have happened.

There have also been mistakes in which parents have had their eggs tested for genetic defects only to have the genetically damaged egg implanted rather than the genetically sound egg.  It is a very costly investment both emotionally and financially.

A California couple discovered that the Laurel Fertility Care Clinic destroyed 7 of 13 viable embryos because they were mistakenly inseminated with the wrong sperm.  In this case the couple had a contract that provided no embryos were to be destroyed and the decision by the clinic prevented the couple from the opportunity to make their own decisions.

What is the cause of this problem? At least in part it is likely connected to the burgeoning demand for fertility treatment in the last several years. A report from Mail OnLine sets forth that the number, in Great Britain, of women going through in vitro fertilization has increased from 23,000 in 1995 to 35,000 in 2009. Yet, the number of facilities who handle in vitro fertilization there has not increased with the numbers of women seeking this treatment.

Last Thursday, Carolyn Savage gave birth to a child belonging to another couple. The embryo was mistakenly implanted in Ms. Savage, but actually belonged to Shannon Morrell. Both Ms. Savage and Ms. Morrell were hoping for a child; because of Ms. Savage’s unselfish act, she will be denied her child, but she will provide another family with their child.

The American Fertility Association issued the following press release:

The American Fertility Association Responds to Alleged Embryo Mix-Up Case in Ohio
September 24, 2009 – An Ohio woman, 40 year old Carolyn Savage, claims a fertility clinic implanted the wrong embryo and that the baby she’s due to deliver the first week in October is not hers.  Several media reports state Savage and her husband plan to give the baby boy to his biological parents.  The name of the clinic is not being released in this very rare alleged case.
The AFA is issuing the following statements regarding the matter:
Medical:
“If the facts in the Ohio case are concordant with media reports, it’s a very unfortunate circumstance for all concerned, a result not to be minimized or trivialized. The story is newsworthy, however, because it is an extremely rare event.
In 2007, there were 132,262 IVF cycles performed in the United States (Fresh, Frozen and Donor Egg, per the CDC) in which more than 300,000 embryos were placed into the intended recipients. Embryology laboratories have extremely rigorous procedures to maximally ensure public safety and the health of our patients and their children born of IVF.
The Ohio case is rarer than 1 in a million and I speculate that human error, not malintent, will prove to be the root cause. I have every confidence that each IVF program in the country will review their procedures and discuss this case to reinforce what we already know, that the work we do each and every day is very special and that the hundreds of thousands of patients we help each year are counting on us to do our best every day.”
-Alan Penzias, MD, Member, AFA Board of Directors
Legal:
“Unfortunately, due to the acknowledged negligence of the IVF Physician and clinic, this Ohio couple, by choosing to proceed with the pregnancy, is obligated to afford the other couple the legal rights to this little boy.  Any case, such as this that would go before a court of law, would likely grant full legal and physical custody to the other couple without any visitation to the Ohio couple.  They appear to be aware of this – such an unfortunate event for all parties involved.”
-Theresa Erickson, Esq., Member, AFA Board of Directors; Member, AFA Legal Advisory Council
Mental:
“As a psychotherapist and co-chair of The American Fertility Association, patients receiving treatments live in fear of this happening to them.  The AFA continues to encourage patients to become educated consumers and ask their treatment providers about their procedures for safeguarding their genetic materials. Programs are required to have in place strict guidelines that are overseen by numerous state and federal agencies requiring very specific procedures to be practiced and in place by each reproductive center.
These incidents are rare and patients should feel assured that the majority of centers follow these rigorous guidelines.  When these rare accidents do occur, it can be not only psychologically devastating to the couples involved in this mix-up but emotional damaging to the thousands of patients who are currently receiving or starting fertility treatments. We at the AFA hope that the media will allow these couples, the children involved, and the baby yet to be born to privately get the support that they need to cope with this emotionally difficult experience.”

This type of error can certainly be characterized by the national association as a “rare” error, but I am sure that neither Carolyn Savage nor Shannon Morrell can find much solace in this representation. Carolyn Savage will undoubtedly always wonder about the baby she brought into this world.

Making the decision to go to a fertility clinic in the hope of trying to conceive a child and/or have eggs tested for genetic factors must be a very difficult decision. All clinics and laboratories should have protocols in place to prevent these devastating errors from happening; causing devastating consequences to the parties involved. This is really a zero error tolerance business engaged in by fertility clinics. Providing an explanation such as that offered by the American Fertility Association is simply insufficient and lacks the very personal consideration due to these victims.

Become an educated consumer. Read, ask questions, be a persistent presence in the process of any medical procedure you undergo.

Once upon a time there was an insurance crisis…a lawsuit crisis…a medical malpractice crisis…a series of crisis manufactured by industries who have a need for consumers to have someone other than them to blame. The insurance industry, the healthcare industry, Associated Industries — the business of business organizations; they all have very distinct business reasons for keeping consumers mad at trial lawyers. These businesses know that government does not have the time or resources to hold them accountable for negligence; sometimes intentional; and so, they keep throwing gasoline on the fire of the propaganda created disdain for trial lawyers.

When I have the opportunity to give speeches or hear them given in connection with tort reform and tort law in general, the conversation usually finds itself leading to a discussion of medical negligence, medical malpractice. From there, depending on the group, we talk about doctors “fleeing” states; excessive malpractice premiums; and, inevitably, the “McDonald’s coffee case”.

What does it take to file a medical negligence lawsuit in “good faith”? To truly understand that, you must understand the elements the plaintiff is required to prove in any lawsuit:

• Negligence – someone acted improperly—a deviation from the acceptable standard of care.
• Causation—the someone’s improper action caused damages (in whole or in part)
• Damages – the injury flowing from the act of negligence

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St. Mary’s Hospital in West Palm Beach issued a statement relating to the wrong medication errors during the treatment of Tesome Sampson and her unborn child:

“On Sept. 4, 2008, a patient came to St. Mary’s in extremely premature labor. Due to a medication error, the patient was given medication to speed up her labor instead of medication that attempts to stop premature labor. Ultimately, the baby was born and suffered brain damage,” the statement said. “This was an unfortunate error that occurred despite the safeguards we have in place. . . . We apologized to the family for this deeply regrettable error.”

From all indications, this is the first time that St. Mary’s and its parent, Tenet Corporation, has acknowledges this error. Still, they characterize the error as almost normal negligence. They claim that their safeguards were in place and, presumably, they were appropriate. If that is the case, then they have a system in place, which permits colossal errors to occur without a system “catch” to cause someone to question, to investigate, and to stop a very serious error like this. In this case, a drug (Prostin) was administered to a pregnant woman. This is a drug that would never, never be given to a pregnant woman unless you wanted to force an abortion. This is not an oops sort of mistake, this is providing care you would almost never provide to this particular patient.

Hopefully, St. Mary’s risk management is approaching their system check with a more serious tone than their public explanation.

There is an old saying that if you have your health you have everything.  Anyone who has ever suffered a debilitating injury or lost a loved one to injury or disease knows this reality all too well.  We are also told by medical experts that an ounce of prevention is worth a pound of cure.  We are told to exercise, eat right, see a doctor for regular check-ups and indulge ourselves in life’s pleasures with moderation.

Regardless of our efforts to prevent injury and disease, inevitably we will require the services of a medical professional.  What is often overlooked is the important role of the patient in making sure the medical professional renders the very best of care.  This role is more important than we think.  For example, a 1999 study by the Institute of Medicine estimates that up to 98,000 people die in hospitals each year due to medical errors.  .  This exceeds the deaths from motor vehicle crashes, breast cancer and AIDS.

There was an excellent article on the CNN Health website advising patients to be proactive during a hospital stay to ensure that the very best care is received. The article suggests the following:

1.    Bring a list of the medications you are taking;
2.    Make sure the hospital gets your name right;
3.    Ask about every medication they give you;
4.    Make sure everyone washes their hands;
5.    If you think something’s wrong, don’t back down;

This is sage advice.  Many times, people admitted to a hospital feel helpless and confused and are hesitant to speak up when interacting with nurses and doctors.  We live in a culture that has for many years accepted the notion that what doctors say and do is not to be questioned.

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