Читать книгу The Coming Healthcare Revolution: Take Control of Your Health - Sheldon Cohen M.D. - Страница 7

Patients are often transferred from unit to unit within the hospital: regular room to intensive care; intensive care to regular room; acute care hospital to the rehabilitation unit; emergency department to intensive care or regular room; and so on. Medication errors occur during these transition points. This is a common occurrence and the cause of many medical errors.

Case in point:

A woman was walking her dog down a residential side street and noticed a neighbor lying unconscious on her garage floor. She rushed in, was unable to revive her, and called the paramedics who transported her to the closest hospital emergency department. Examination revealed a seventy-five year old unconscious woman with a bruised head. An emergency CT scan of the brain revealed a collection of blood under the lining of the brain known as a subdural hematoma. This hematoma was very small, so her physicians elected watchful waiting rather than surgery. The patient regained consciousness, but was very restless and agitated, a state that persisted over the next few days. She also had some difficulty in walking, lost strength in one of her extremities and required the use of a walker. She was rational, but stated she “Was jumping out of my skin.” This persisted until her physician prescribed a tranquilizer in an attempt to calm her. The anxiety improved, but the patient then became confused and disoriented. This worried her physicians who ordered further tests thinking that perhaps the hematoma had enlarged or other cerebral pathology had developed, or there were undiagnosed medical problems. There were no new findings identified. Thinking that perhaps the confusion and disorientation was due to the tranquilizer prescribed to calm his patient, the physician discontinued it. Indeed, within two days the patient’s problem had resolved. All this time the rehabilitation transfer was not possible because this requires a clear mind and a cooperative patient, neither of which was possible while she was having her symptoms. Different physicians and a new healthcare team attended to her in the rehabilitation unit. They started her on rehabilitation, but after a day or two they found her to be confused and disoriented making progress impossible. They called her hospital physician to tell him what had happened. In the meantime, she was in the rehab unit for a full week and could not make any progress due to her altered mental state. When her physician arrived, he discovered why the patient had relapsed. Somehow—and no one could tell him how—the medication that he had discontinued because it caused her confusion and disorientation had been restarted. He never found out why. This medical error caused considerable delay, set back the patient’s progress and could have resulted in serious consequences.