The Life of a Medically Harmed Patient

It is time for me to tell my story. It has many layers and covers many issues, and that makes it complicated to tell. God willing, and with help from the Universe, I will tell my story in detail soon. For now, I will briefly summarize it:

I was working as an RN when I was violently assaulted by a patient that was hallucinating due to withdrawal from drugs and alcohol. The result was cervical (neck) spinal cord compression that eventually lead to right sided paralysis. Emergency surgery to relieve the spinal cord compression was successful in returning the movement on my right side. However, during surgery something went terribly wrong and I had a massive lung hemorrhage that included 100% of all lung lobes bilaterally and even my trachea. Major medical errors were made after this surgery that greatly increased the scarring of my lungs that the hemorrhage caused. I was told I would die if I caught a lung infection. That was four years ago. I have fought hard to survive, without any help from workers compensation, without any help from California’s medical malpractice system, and without any help from the medical insurance I had with my employment before the surgery (they refused to cooperate and Cobra my insurance) although I was left 100% disabled. Some wonderful people sent me their unopened inhalers that I needed to survive. Today I am preparing to begin evaluation for a lung transplant. The evaluation will begin this week.

All of the members of my facebook group ‘Medical Error Transparency Plan’, and my followers on Twitter  are very dear to me because even with your pain and suffering, you all hope to make this a better healthcare world for others. Thank you for being the kind of people that have compassion for others. It is a quality the industry lacks, but there are many very good and compassionate healthcare workers that have joined us to seek change. Let’s continue to stick together to find real solutions!

Buyer beware: no return, redo in hospital care

 

Guest Blog: By Kevin Kavanagh

Michael Hogue McClatchy-Tribune

Dr. Kevin Kavanagh

Obtaining the safest health care should be a top priority for everyone. A number of different rating systems act as a guide; but by the time you are sick, it is often too late to undertake a thoughtful search. All these systems rate hospitals differently and invariably give different results, making it all but impossible to select a provider on the day of an emergency.

There are three types of reports:

▪  U.S. News & World Report ranks mostly on the institution’s capabilities. Its scoring method places a weight of 27.5 percent on reputation and 30 percent on structure. Patient safety is only weighted 10 percent. In four of 16 specialties only reputation is used.

▪ Safety is the main factor for Consumer Reports, The Leapfrog Group rankings and Medicare’s hospital-acquired conditions penalty system.

▪ Finally, there are patient surveys which are largely decried by the industry as not truly reflective of quality. However, if the customers, who are also voters, are happy, politicians and federal oversight agencies also will be happy. In some respects, this is the score facilities have to worry about most.

A recent analysis revealed patterns across all ranking systems for high- and low-performing hospitals in Kentucky. As in previous years, Baptist Health Louisville, Baptist Health Lexington, St. Elizabeth Medical Center and Frankfort Regional Hospital appear to be the top performers.

The rankings also indicate that one should have concerns regarding St. Joseph East, which has fallen from a C to an F on the Leapfrog score and is receiving a penalty for hospital-acquired conditions, along with a 2.24 percent readmission penalty, over twice that of other regional institutions.

Similarly, the University of Louisville Hospital scored a C on the Leapfrog survey, has a high rate of MRSA bloodstream infections and is doing poorly as ranked on patient surveys.

 Bloodstream infections are only the tip of the MRSA iceberg. Overall, Kentucky has the nation’s second-highest rate of MRSA bloodstream infections with the University of Kentucky and the University of Louisville being worse than the national benchmark.

Only one hospital, Baptist Health Louisville, was ranked as better than the benchmark. The national benchmark is not the goal. It is set at the unacceptably high pre-intervention rate. Thus, achieving the benchmark should also be viewed as a failing grade.

The good news is that fewer Medicare hospital inspection reports found substantiated complaints.

However, several Kentucky facilities were cited in a U.S. Department of Justice settlement for false billing of non-Medicare approved insertions of cardiac devices. The U.S. attorney stated the settlements were heavily based on evidence-based medicine.

These hospitals included Baptist Health Lexington, Baptist Health Louisville, St. Joseph Hospital, St. Joseph Hospital East and St. Joseph Hospital London. St. Joseph London was also involved in a $16.5 million settlement for unnecessary heart procedures in 2014. One of its staff cardiologists is currently serving a 30-month federal prison sentence.

As exemplified by these DOJ settlements, overutilization of medical care is becoming an increasing problem and is unacceptably high in Kentucky by a number of measures. For example, according to the Center for Disease Dynamics, Economics & Policy, we have the highest rate of antibiotic usage in the nation, 1.4 prescriptions per Kentuckian per year — a rate double California’s.

One may argue that overutilization is physician dependent and not the fault of hospitals, but let’s not forget the massive employment of physicians by hospitals and that almost all physicians are members of a hospital staff. This is analogous to the banking industry saying it was not responsible for the financial collapse, since it was the loan officers’ fault.

Nurses are key to patient safety. Hospitals achieve Magnet designation by undergoing a rigorous survey by the American Nurses Credentialing Center. This important designation has been achieved by Baptist Health Lexington, Baptist Health Louisville, Frankfort Regional and St. Elizabeth Medical Center. The University of Kentucky lost this designation in 2011 and has applied to regain it.

The Joint Commission accredits hospitals, but almost all receive its Gold Seal of Approval. For example, St. Joseph East scored low on several ranking systems but has a Gold Seal from The Joint Commission. Not achieving this designation would be a sign of major problems.

Substantial quality improvements are needed in our health-care system in Kentucky and nationwide. Until this takes place, one should preemptively study and evaluate treatment options. As the old saying goes, “Let the buyer beware,” for in health care, there is little opportunity to return or redo the service.

Kevin Kavanagh of Somerset is a physician and board chairman of Health Watch USA.

Hospital	Leapfrog Group® Hospital Safety Score(sm) (1)	Consumer Reports Hospital Safety Score (2)	CMS penalty for hospital acquired conditions (HACs) (3)	CMS readmission penalty (4)	MRSA Score, National Benchmark = 1.00 (5)	Patient Survey (6)
Year of measure	2014 to 2015	2014 to 2015	2016	2016	2014
Baptist Health, Lexington	A to A	59 to 60	No	0.19%	0.88 (No Difference)	****
St Joseph Hospital, Lexington	C to D	56 to 50	No	0.86%	1.19 (No Difference)	**
St Joseph East	C to F	65 to 47	Yes	2.42%	0.00 (No Difference)	***
University of Kentucky	C to B	41 to 47	No	0.43%	2.17 (Worse)	***
Frankfort Regional	B to A	51 to 46	No	0.71%	Not Available	***
Georgetown Hospital	N/A to C	66 to 53	No	0.35%	Not Available	***
Pikeville Medical Center	A to A	54 to 36	No	0.35%	0.62 (No Difference)	****
Jewish Hospital-Shelbyville	D to B	52 to 52	No	0.98%	Not Available	***
St. Joseph-Mount Sterling	B to B	59 to 64	No	0.40%	Not Available	****
St. Elizabeth Florence	A to A	53 to 52	No	0.86%	1.51 (No Difference)	***
St. Elizabeth Med. Ctr. (Edgewood) (+)	A to A	54 to 58	No	0.77%	0.67 (No Difference)	****
St. Elizabeth Fort Thomas	A to A	54 to 55	No	0.25%	0.00 (No Difference)	***
Norton Hospital(s)/Healthcare (++)	C to C	48 to 46	No	0.17%	1.24 (No Difference)	***
Jewish/St. Mary’s Healthcare (+++)	C to C	43 to 45	Yes	0.47%	1.07 (No Difference)	**
Baptist Health, Louisville	B to B	61 to 63	No	0.00%	0.38 (Better)	****
University of Louisville Hosp.	C to C	40 to 37	Yes	0.02%	4.00 (Worse)	**

(1) The Leapfrog Hospital Safety Score(sm) grades hospitals on data related to patient safety.

(2) Consumer Reports, Hospital Safety Data; higher is better, scale 1 to 100

(3) Centers for Medicare & Medicaid Services, hospital acquired condition penalty, up to a 1% penalty on all Medicare payments.

(4) CMS readmission penalty, up to a 3% penalty on all Medicare payments.

(5) Rates of MRSA bloodstream infections. The National Benchmark is 1.00 and is the starting point not the goal. Thus, a value of 1 shows no improvement.

The percentage is the penalty or bonus applied to the facility’s entire Medicare payments.

(6) CMS patient survey results, scale is 1 to 5 stars. This data is from Hospital Compare, http://www.medicare.gov/hospitalcompare/

(+) Listed as: St. Elizabeth Healthcare – Edgewood/Grant/Covington

(++) Listed as Norton Hospital, Norton Hospitals, or Norton Healthcare

(+++) Listed as Jewish Hospital, Jewish Hospital & St. Mary’s Healthcare or Sts. Mary’s & Elizabeth Hospital; Consumer Reports only lists Jewish Hospital. CMS combines the data from Jewish and St. Mary’s Healthcare; The Leapfrog Group(sm) surveys the hospitals separately and reports a safety score for both Jewish and Sts. Mary’s & Elizabeth Hospital.

Read more here: http://www.kentucky.com/opinion/op-ed/article54997560.html#storylink=cpy

 

Advocates Respond to ‘Law ignored, patients at risk’

 

Stop the Medical Harm! Tell the FDA and NIH to Enforce the Law!

 

A recent article by Charles Pillar, Law Ignored, Patients at Risk,

http://www.statnews.com/2015/12/13/clinical-trials-investigation/ alerts us to an alarming violation of a federal law, https://www.gpo.gov/fdsys/pkg/PLAW-110publ85/pdf/PLAW-110publ85.pdf#page=82, that requires public reporting of clinical trials, including some that involve, “…life and death problems.” Even more alarming, the article states our government agencies, the NIH and FDA, are not enforcing the law.

 

What do we do when our top government healthcare agencies do not follow, nor enforce, a law designed to deliver timely and safer healthcare, and this failure can result in patient harm and death? For starters, we can ask them to look into this failure, correct it, and let us know what corrections have been implemented.

 

Patient advocates across the country are informing others of this failure, and gathering signatures on this letter, which will be sent to all the agencies listed.

 

Letter:

 

Loretta E. Lynch

Attorney General

U.S. Department of Justice

950 Pennsylvania Avenue, NW

Washington, DC 20530-0001

 

HS Secretary Sylvia Mathews Burwell

U.S. Department of Health & Human Services

200 Independence Avenue, S.W.

Washington, D.C. 20201

 

Daniel R. Levinson, Inspector General

Office of Inspector General

U.S. Department of Health and Human Services

330 Independence Avenue, SW

Washington, DC 20201

 

NIH Director Dr. Francis Collins

National Institutes of Health

9000 Rockville Pike

Bethesda, Maryland 20892

 

Dr. Stephen Ostroff, M.D.,

FDA Commissioner

Food and Drug Administration

10903 New Hampshire Ave

Silver Spring, MD 20993-0002

 

Attorney General Loretta E. Lynch,

 

Patient advocacy groups across the U.S. are very concerned with the disregard for human life, patient safety, transparency, and accountability the NIH, and the FDA, have shown by not enforcing timely reporting of federally funded clinical trials.

 

A recent article by Charles Piller, Law Ignored, Patients at

Risk http://www.statnews.com/2015/12/13/clinical-trials-investigation/ alerts us to an alarming violation of a federal law, https://www.gpo.gov/fdsys/pkg/PLAW-110publ85/pdf/PLAW-110publ85.pdf#page=82, that requires public reporting of clinical trials, including some that involve, “…life and death problems.” Even more alarming, the article states our government agencies, the NIH and FDA, are not enforcing the law.

 

Charles Piller writes, “The federal government has the power to impose fines on institutions that fail to disclose trial results, or suspend their research funding. It could have collected a whopping $25 billion from drug companies alone in the past seven years. But it has not levied a single fine.”

 

Attorney General Loretta Lynch, we are asking that you take immediate action to correct the violation of law that is occurring, both as a failure to report clinical trial data, and also as a failure to demand accountability with the power the law, and the people, have entrusted you. We also ask that you issue a public report on how you will correct these urgent issues of patient safety.

 

Thank you in advance for the resolution of these urgent issues.

 

Sincerely,

 

Suzan Shinazy

Medical Error Transparency Plan, Founder

https://www.facebook.com/groups/Medicalerrortransparencyplan/

suzan1111@hotmail.com @Suzan Shinazy

 

To sign on to this letter, please leave your name, organization (if any) city, and state in the comment section below, or contact me privately at suzan1111@hotmail.com. Thank you!

Petition to Mandate Medical Error Reporting!

 

This petition is not active at this time.

Hello,

Please read and consider signing and sharing this petition calling for a ‘Medical Error Transparency Plan’. This petition is on the White House’s  ‘We The People’ page. We need 100,000 signatures within 30 days to get a response from the Obama Administration.

Here’s some more information about this petition:

Mandate Reporting of All Medical Errors to an Independent Oversight Committee, and to the Patient or Their Next of Kin.

We call on President Obama to mandate a national ‘Medical Error
Transparency Plan’. Medical errors are known to be the third leading
cause of death, and medical errors also create a high number of disabilities.
Patient’s human rights are being violated by the current lack of
transparency. We call for mandatory reporting of medical errors by anyone
that has knowledge of, or reasonably suspects, that a medical error has
occurred. Reporting must be to an independent oversight committee as well as
to the patient, or to the deceased / incapacitated patient’s healthcare
representative.

You can view and sign the petition here:

http://wh.gov/iBlpa

Here is a link to a facebook page that promotes the petition and also where patients can tell their stories:
https://www.facebook.com/groups/Medicalerrortransparencyplan/

Thank you very much for your time and help in improving patient safety while decreasing medical errors.

Suzan Shinazy RN
suzan1111@hotmail.com
661-340-8955

An RN’s Real Education

This post is dedicated to my mother, Shirley June Holderness.  I watched her die from medical errors in the southern California town of Loma Linda.  She fought valiantly for seven weeks to live, before succumbing to septic shock from the hospital acquired infections that the physicians refused to treat. She had just had her 66th birthday.

My mother was admitted to the hospital due to a heart attack. She had a stent placed and her heart function returned to completely normal functions.  It was the infections she caught in this hospital, and the refusal to treat the infections that killed her. On admission to the hospital, my mother was tested for infection in her blood, urine and sputum; these test reveled that she did not have any infection. The three infections she caught in the hospital were MRSA, Acinetobacter baumannii  and yeast. Later,  her records revealed the physician ignored the lab results and refused to treat these infections for days before she went into septic shock and was put on life support, and even then the physician refused to give her the correct antibiotics for 12 more hours.

As an ICU RN I knew the mistakes they were making.  I begged for the correct treatment, and when the physicians refused,  I tried to transfer my mother out of there.  My mother’s regular physicians did not practice at this Loma Linda hospital, and they wanted her transferred to a hospital they practiced at. The physicians at the  Loma Linda hospital would not cooperate, they would not speak to my mother’s own physicians, or give them her medical chart, which is necessary before transferring. 

As if that wasn’t enough, when my mother died from this Loma Linda’s hospitals errors, I had to get the county coroners office to subpoena my mothers body and records out of the hospitals morgue. The hospital did not notify the crematory to come and pick up her body, although they had been given all the details several times and it was also noted in her chart.  I called the crematory the next day and was told the hospital never notified them, but they said they would send drivers to pick her body up immediately.  About an hour later, the crematory called me and apologized, “I do not know how to tell you this because it has never happened to us before, but the hospital refused to allow our drivers to pick up your mothers body. Our drivers told us that two physicians were in the morgue fighting over who was going to sign the death certificate.”  The hospital did not cooperate with my request either, so I had to call an attorney and get the county coroners involved. Even with the county coroners subpoena, it took three days for them to get my mothers records.

 I pursued a lawsuit in spite of many California attorneys telling me that this particular hospital, an ‘icon of the community’,  had the largest defense team in California, and ‘…they will make sure you spend more than you can ever recover…’ due to California’s outdated laws from the ’70′s.  My mother’s own physicians, that had known her a long time, told me I needed to pursue a wrongful death lawsuit. I spent a lot of money, only to discover what all the attorneys tried to tell me was true. The medical industry lets you down because the legal industry already has.  I didn’t have enough money to continue. The attorney did not charge, but I had to pay for legal experts and other costs, and they are very expensive. California’s CAP laws are responsible for many cases of poor care, deaths and disabilities being swept under the rug, and by no means does this outdated law bring about improvements in patient safety.

I still have my mothers medical records with proof all of this happened, and will gladly share them in the right situation.

My real education as a nurse began the day my mother was admitted to this Loma Linda, California, hospital.

I  had the highest respect for my mother’s life, although the medical and legal community did not. She taught me to respect everyone’s life, and that is why this nurse will speak for the patients.

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