According to the legal profession, who six weeks later, reviewed my mother’s horrific drug overdose and subsequent death—not one red cent!
And not even one commitment by the hospital staff to improve the delivery of care to prevent others from suffering from the same mistakes!
A perfect storm of preventable medical errors on admission left my beloved mother in a stupor.
By the time she became reasonably alert three days later, she:
- Could no longer swallow properly, 2. Needed a walker to ambulate, 3. Became incontinent, and 4. Was clinically depressed. She had also acquired a Stage 2-3 bedsore that should have been prevented, but was neglected, causing her great pain.
The next day deeming her medically stable, the Hospital discharged her to a rehabilitation facility. Despite continually expressing a wish to die, my mother gave her best effort for four weeks, but she was simply too compromised to overcome so many challenges.
We then brought her home for hospice care. She died 12 days later surround by my sister, my husband and me.
What went so wrong December 3, 2012?
My mom was 3 months shy of her 90th birthday. She was successfully fighting, thriving and living on her own despite begin treated for cancer (7 rounds of chemotherapy and radiation therapy for multiple myeloma), the fracture of the right upper arm requiring surgery, a heart condition (aortic valve stenosis and atrial fibrillation, requiring a pacemaker), and a GI infection (three weeks of antibiotics for C. difficile).
In October 2012 she developed a cold and cough. Her oncologist suspended the daily oral dose of chemotherapy (Revlimid), so that she could fight that pesky cold. She began to experience serious back pain. After several visits to the local ER, one doctor finally ordered an X-ray of her spine where a T-12 compression fracture was diagnosed. Multiple myeloma had caused lesions in the bones and, coupled with age-related osteoporosis, had made her spine vulnerable.
Conservative measures, including physical therapy and a pain killer did not ease the pain. Even the smallest dose of Oxycodone resulted in tremors in her extremities. She then switched to Tylenol, which gave only partial relief.
Three more trips to the ER within a week led to the orthopedic surgery to stabilize her spine. The surgery on November 19 was done under local anesthesia, because her heart was not strong enough to withstand general anesthesia. She sailed through the procedure and was discharged to her home the following day.
In each of these situations, mom could come home to recover. She was fortunate to have an optimal environment: an outpatient oncologist and cardiologist, who kept her quality of life high. There was family close by for support and a nursing aide was available 5 hours a day from Monday to Friday. My older sister, recently retired, could travel from New York to help out for a few weeks.
Mom worked exceedingly hard, wanted to beat the odds, and was succeeding. In mid-October 2012, she visited her newborn 7th great-grandchild.
And then it all changed on Monday morning, December 3, 2012. The Tylenol failed to provide sufficient relief for her healing back and she was not strong enough to begin physical therapy. We brought her back to the ER. The examining hospitalist suggested the placement of a Fentanyl Patch. My husband, a psychiatrist who specializes in addiction medicine, suggested a milder but still potentially effective Buprenorphine patch, but was overruled. Mom agreed to be admitted overnight for observation and then released the following morning.
After the Patch was placed on her lower lower back she fell asleep just before 8PM. At 8 AM the next morning, Tuesday December 4, the nurse answered my call to my mother’s hospital room and told me that mom had received “too much medicine,” but her vital signs were stable. The doctor came on the phone and confirmed this to me. When I attempted to speak to my mom, she was barely rousable.
My sister arrived at the hospital 20 minutes later and called me in a panic. She had tried to waken and feed mom, but mom could not keep down her food. I tried to calm my sister down explaining what the nurse and doctor told me, and then suggested that she just let mom sleep.
At about 9 AM mom’s oncologist had arrived for routine rounds, but assessing mom’s condition, demanded of the nurse, “What have you done to my patient?” The nurse, clearly agitated, again said that they had given mom “too much medicine.” He asked the nurse the same question, “How much too much?” Then the truth came out and we learned she had been given TEN times the appropriate amount.
Fentanyl is a very powerful opiate. This woman, who stood 4’10” and weighed just over 100 pounds had been given the amount of Fentanyl one might prescribe for a 250lb. Hell’s Angel!
The oncologist turned to my sister and said, “Wow! They royally messed up!” With that my sister called me and I immediately called my husband, who then called the hospitalist to request that they give mom Narcan to reverse to effects of the pain killer and make her alert.
Again the hospitalist disagreed with that suggestion, because her vital signs were stable. He thought it was better to just let her sleep off the effects.
Twenty minutes later, I met with the hospitalist. He happily told me how as soon as he noticed the color of the patch (the patches are intentionally color-coded according to dose to prevent overdose errors), he “ripped” it off her back.
Once I learned the set of errors that allowed the overdose to happen in the first place, I was not impressed with the hospitalist’s attempt to be recognized as the hero. The usual starting adult dose for a Fentanyl patch is 25 mcg (micrograms). The doctor correctly decided to halve that dose to 12.5 mcg due to her size and medical condition, but he should have known better and not written the order as “12.5 mcg.” She received 125 mcg in error.
So what was the mistake?
The FDA, the pharmaceutical companies, the Physician’s Desk Reference, and even phone apps like Epocrates, as well as respected pharmacy journals have issued repeated warnings not to write the Rx as12.5 mcg, but only as 12 or 12.0 mcg. These warnings were issued in 2005, 2007, 2010 and every year since, because pharmacies often missed the decimal point and transcribe the prescription as 125 mcg.
Instead a trifecta of tragic errors occurred. 1. The doctor ordered the prescription wrong. 2. The hospital pharmacy filled the order, without taking into consideration my mother’s age, dosage amount. 3. The nurse never double checked or questioned the dose.
The damage was done—my mother received ten times the dose of one of the strongest of pain killers, continuously for over 12 hours. The medical care she was aiming for was put on hold. Her multiple myeloma was worsening, she was becoming more anemic, her bones were deteriorating, and now she couldn’t improve enough to take chemotherapy. And she developed an extremely painful bedsore, which the hospital did not try to prevent and then neglected altogether, until we raised a stink about it..
By early afternoon my younger sister had arrived from New York City and the two of us met with the oncologist. Her doctor was genuinely sorry and dismayed about what was happening and informed us of our even more limited and narrow options. If we did nothing, my mom would die within the week. If we gave her a blood transfusion and a drug called Aredia to fight the Hypercalcemia (a result of bone destruction caused by multiple myeloma), we could give her about 4 more weeks. With aggressive physical therapy, she might have regained her strength, allowing her to resume chemotherapy to combat her multiple myeloma.
When we came to the ER only the morning before, mom had told the doctor, “Do everything you can to help me feel better.” Clearly she was not ready to die—then. Although I held the medical power of attorney, my sisters and I all faced the same terrible choice together. Could we really just let her go and she would never know what happened?
Based on our mother’s wishes, we unanimously told her doctor to treat her. The hospital moved her to the Oncology Unit, where that evening she received both the blood transfusion and Aredia. And still my mother was in a stupor.
By 6 pm Tuesday evening, a nurse told us that our mother had received a serious overdose of medicine, as if we hadn’t known about it. We endeavored to remain calm.
Wednesday passed by in a blur of our mom becoming alert for 1-3 minutes at a time, before lapsing back into a deep sleep. She awoke around 4 am Thursday on December 6, utterly confused, having no idea where she was. She was so weak and incapacitated that it was evident that she would need to be placed in a full time rehabilitation facility. The hospital social worker helped us and arranged the discharge for Friday December 7.
At the rehab, my sisters helped my mom settle in to her room. I met with the admitting physician and insisted on reviewing the medication list because I had lost all trust in the hospital. Sure enough, the hospital had sent a wrong transfer list of medications, including an Rx for Oxycodone, which we had made clear she could not take, because of serious side effects.
We then settled mom in the lounge area for a bit of soup. She looked at us and, for the first time, she asked to die. Shocked, we tried to make her laugh and said, “Look—you survived the hospital’s attempt to kill you—c’mon there’s some fight left, right?
And for four weeks she tried to survive, though she suffered every day of that time. She fell repeatedly, had pain that could not be relieved by meds and became very depressed. Her bedsore deteriorated despite excellent care. She just wanted to go home. Mom had an advanced medical directive, but in meeting with the social worker signed an even more detailed one that included no more IV’s or treatments. Throughout the month she asked to die every day.
We brought her to our home on Saturday Jan. 5. She was very weak and despondent. I explained her options to her and she asked for hospice care. “Enough! I am done,” she said very clearly. Hospice intake began on Sunday Jan 6, 2013. On January 17, she died just before 9 am.
We then began the process of initiating a lawsuit against the hospital for neglect, pain, suffering and damages. In attempting to gather all essential files it became clear the hospital was stonewalling and withholding critical information.
In finding an attorney to represent her case, the advice from some was very frank. “Your mom lived for only 6 weeks…your mom was already a sick old lady…, the medical record clearly shows hospital negligence, but no clear causation for the overdose contributing to her death…juries don’t assign much value to such cases…”, ad nauseum.
These comments disgust me. Not just as her daughter, but as the administrator of her estate, I have both a moral and fiduciary responsibility to my two sisters, to her 7 grand children and 7 great-grand children. I must be mom’s advocate. She can no longer speak for herself.
Before mom was discharged from the hospital my husband and I met with the head of nursing and the lead clinical coordinator. My husband told them they have serious systemic errors that must be fixed. They lack a stopgap system to prevent such commonly known medication errors concerning pain killers. They have no explicit mindset, policies and procedures, or staff training for caring for the needs of the geriatric population. We wanted to know what procedures the hospital would put into place to ensure that no one suffered the way my mom has from an eminently preventable series of disastrous errors. The hospital administrators reassured us that they would respond in writing to our concerns. To this date, they never have.
In the meantime, my formal complaint to Maryland’s Office of Health Care Quality about the hospital’s treatment of my mother, has led to the citing of deficiencies and the requirement of a Plan of Correction to prevent the reoccurrence of those deficiencies. We do not know if the hospital has submitted a plan, if it has been approved, and when the hospital must correct these deficiencies.
In 2013 America, suing for malpractice is legally intended to try to quantify, in financial terms, my mom’s neglectful care, pain and suffering. It only happens for obvious cases nowadays, not for my mom’s case for which the payout wouldn’t cover the legal bills. And arbitration before suing for trial only occurs if both sides agree. It is voluntary and no longer mandatory.
But what happened to my mom is not about money and suing for malpractice. It’s about a healthcare system that doesn’t carry out some of the basic steps of good patient care, a system that is broken. A system that lets down its patients and the community, a community that expects and needs the best of care, not a system that causes pain and suffering, and shortens a life. So I ask again, how much is my mother’s pain and suffering worth? And how and where can we find justice for her pain and suffering?
On April 13, 2013 she would have turned 90. She would still have been sick. She would still have been old. But I am 100% certain that without the egregious errors inflicted on her, she would have been alive.
Written by Sue Cohen and Peter Cohen