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Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

  • 1.  Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-25-2020 16:30
    This story appeared in today’s Baltimore Sun. If facts are as described, words fail me!

    Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    https://www.baltimoresun.com/health/bs-hs-lawsuit-johns-hopkins-hospital-negligence-wrongful-death-20200724-gzsdwvyi2jf2hpl7ys7lgdbiim-story.html


    Sent from my iPhone

    David
    David L Meyers, MD FACEP
    410-952-8782


    Sent from my iPhone

    David
    David L Meyers, MD FACEP
    410-952-8782


  • 2.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-25-2020 16:37
    I am sadly not surprised that this critical information was not conveyed to the parents.  While the notion that the child's situation was found nearly instantly truly is shocking and heartbreaking, the failure to give patients/parents the complete records with those recommendations, this is not uncommon.

    Unless the parents or any patients assert in writing that they do NOT want to receive these kinds of records, the institution and treating physicians --and how many were there in the NICU?--should be obliged to provide them directly to those parties.  Anything less can endanger the patient, as in this case.


    Peggy Zuckerman
    www.peggyRCC.com






  • 3.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-25-2020 20:37
    I'd not make much of allegations.
    They are just that.
    Tom Benzoni





  • 4.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-26-2020 08:52
    While the allegations made are truly shocking and tragic, I am sure that the discovery phase of the suit will bring more clarity to the situation. Facts only become facts after rigorous investigation and objective analysis.
    JGK 





  • 5.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-27-2020 15:11
    Saying something would have been helpful here.
    Did no one read the NP note?  We used to be trained to write something like, "Ms. XXX note read, will inform family."  One wonders why Ms./Mr. XXX didn't tell the family her/him self.

    lots of gaps in the last leg of a "proper diagnosis".

    Clearly we in SIDM have a ways to go to get the message out of the steps in Diagnosis (including relaying results to the patient/family).






  • 6.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-27-2020 15:34
    The description in the news article makes it sound like a series of "never" events lining up through Reason's Swiss cheese holes. As Tom Benzoni pointed out, they are allegations only at this point, and Hopkins chose not to comment. Facts revealed in legal discovery may offer confirming or contradicting information. 

    But, unfortunately and tellingly, the information as described did not elicit a response from us like "no way that could happen!" Our reactions at best were "well maybe there's something we don't know" that might account for how this child died of a treatable cancer without finding individual or system fault. In fact, I would venture that many of us have seen or are aware of such situations in our professional lives. And a number of patients and family members I have spoken to agreed that this kind of scenario - not being told critical information until too late - happened to them or someone they  know. 

    How many similar cases are there each year? Failure to close the information loop is so common, it is one of THE major issues in DxE. Open Notes and policies encouraging patients to review them might be a way to prevent some of these, but this problem must be largely owned by us.

    David
    David L Meyers, MD FACEP

    Former Chief, Emergency Medicine; Sinai Hospital of Baltimore

    Society to Improve Diagnosis in Medicine
    Board member; Chair, Governance Committee; Board Liaison-Patient Engagement Committee

    Candidate, Master's degree in Bioethics; Berman Institute of the Johns Hopkins University 






  • 7.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-27-2020 15:43
    'How many similar cases are there each year? Failure to close the information loop is so common, it is one of THE major issues in DxE. Open Notes and policies encouraging patients to review them might be a way to prevent some of these, but this problem must be largely owned by us.'

    I agree that open notes and policies may offer a valuable feedback loop, but I would maintain that the information loop problem is owned completely by the health care providers.  For me it's like putting the onus to catch a breast lump on the patient ... "What do you mean you are not doing monthly breast exams?" 

    Just my two cents

    Carol E Gun, MD
    Occupational Medicine





  • 8.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-27-2020 23:45
    This case does not surprise me.  I work in primary care and often see hospital & ER discharge follow ups in my clinic. I always make the effort to get the records to review myself, and I can't count how many times I've found very important details not shared with the patient (or with me!)  

    As unpopular as this opinion may be, I really feel the information loop between inpatient and outpatient care has tanked with the advent of hospitalists.  There is just  no "hand-off" to primary care.  And the patient walks in with a pile of useless "discharge instructions" (like smoking cessation tips) but no mention of their diagnosis or test results.  

    Denise Bockwoldt, APRN





  • 9.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-28-2020 00:23
    My misdiagnosis journey/trek lasted 8 months, until the  anemia 'diagnosis' became 'tiny, scabbed-over stomach ulcer' to 'stressed, suburban housewife" to 'cirrhosis of the liver' to 'mass on kidney' to '10 cm tumor on kidney with multiple mets in lungs,too many to count."

    Had I been given a few sheets of paper about my tests and recommendations from the ER doctor and pathology department, my cancer may have been found far sooner

    The ER doctor indicated I should be seen by a hematologist and rheumatologist.

    There was no ulcer, per the pathology report, and no accompanying H. pylori.  
     
    I never had the opportunity to read either of the above reports. I must assume the internist never read the pathology report or dismissed it.  Had I had these two papers, I could have asked, "Which hematologist should I see? or "What else could it be, now that we know there is no ulcer?" 

    This failure to inform the patient about EVERYTHING that is his data must stop.  It is unethical,  wasteful of resources, and costly in all human terms to the patient.  This is not hard.  Just give every patient the information that has been produced about his situation as soon as it is available.

    To do otherwise is a clear disservice to patients everywhere.


    Peggy Zuckerman
    www.peggyRCC.com





  • 10.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin's death

    Posted 07-29-2020 13:09
    Hi Denise,

    I agree that most of the hospital discharge information is not detailed enough to be useful to the patient. One thing I noticed (as a nurse) is that nurses "used to" print out test reports, blood work results, and so on and give them to the patient on request. Then interpretation of HIPAA led to restrictions placed on printing patient test results. Patients and family members may be faced with looking over the shoulder of a provider at the computer screen (I took photos of the screen when my husband was hospitalized) to see results. In many situations patients are told they have to get copies of their inpatient reports from Medical records (but they are not available for xx number of days after discharge). The records are supposed to be sent to an outpatient doctor but as you mentioned this is not always done automatically. The main factor is that this information is not available to the patients during or after hospitalization unless there is a portal available for inpatients.  Very frustrating as many times this information is being used to make medical decisions and true participatory medicine includes the patient having the same information as the rest of the team. 
    Marge

    ------------------------------
    Marge Benham-Hutchins
    Texas A&M University Corpus Christi
    ------------------------------



  • 11.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin's death

    Posted 07-29-2020 16:14
    Are litigation risks part of the problem. Different States have different rules. Should there be one rule?

    Rob Bell, M.D.


    Sent from my iPhone





  • 12.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-27-2020 16:15

    David,

    Without knowing the details, but using the general scenario to sharpen our collective thinking.....  One could say that this tragic error falls in the category of a critical physical exam finding, test or imaging result not being followed up and also shared with the patient.  These errors happen way too frequently. I would argue that this type of error is not just a "failure to communicate" error.  At the heart of the problem is the EHR.    Current EHR's were mostly designed for documentation with the purpose of maximizing billing.  The EHR is thus perceived to be pure drudgery for most clinicians because ultimately they are drudgery and are often not about patient care.    50 years ago Larry Weed began the discussion of patient engagement along with his creation of the Problem Oriented Medical Record.  The POMR is not understood by todays doctors and it should be.  Currently, (as opposed to 50 years ago) problem lists are mostly out of date past medical history lists.  Dr. Weed defined a "problem"  which is a symptom or complaint until there was a basis for the diagnosis. Once there is a basis for a diagnosis, a diagnosis can be listed in the problem list.   A finding such as "cystic mass in right adrenal gland" would have been a problem in any medical record created by Dr. Weed's team.  If you were a student, resident, nurse or physician and you did not chart a problem in one of the records for Dr. Weed's patients you would be eviscerated on rounds the next morning.  Dr. Weed was a tough teacher and enforced thoroughness and reliability.  He put a primacy on a thoroughness rigor over evaluation of medical students based on their exam scores. The meticulous building of a problem list is at the core of patient centered medicine.  The problem list would always be reviewed with the patient at discharge.   An abnormal finding or key problem result not being communicated to the patient begins with it not being recorded as an active problem. 

    Of course the elephant in the room is that most problem lists are not up to date and many doctors never look at them.  The care team can review them and the patient should have access to them.  Until we enforce thoroughness in our behavior through well maintained problem lists and 100% review with patients of their problem list at every visit and discharge.....we are going to have a broken system. 

    Best

    Art

     

     

    Art Papier MD

    CEO VisualDx

     

    Associate Professor of dermatology and Medical Informatics

    Universiyt of rochester

     






  • 13.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-27-2020 16:24

     

    Thanks Art. It's also about diffusion of responsibility. If a task doesn't explicitly fall to some named individual, it belongs to no one.

     

    Karen Cosby M.D. Program Officer Gordon and Betty Moore Foundation 650-213-3160

     






  • 14.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-27-2020 16:29

    Karen,

    Completely agree!  Discipline and consistency would be part of insuring non-diffusion of responsibilities.

    Best!

    Art

     






  • 15.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-27-2020 17:15
    Art,

    Is the message that there are simple things to correct to be able do a better job.

    Does SIDM have a recommendation as to how to deal with a patient so that accurate information is obtained regarding symptoms and problems?

    And then do you run up against extra time that is money to someone?

    Should HCPs have the right to refuse using a computer system that frequently produces errors?

    Will AI help, or even confuse the situation?

    Rob Bell, M.D.







  • 16.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-27-2020 19:10
    This type of error is why I believe that all records should be Open Notes.  The patient should have access to results and notes right away.  They or their families are more likely to notice if something remarked on has gone without follow up.  Our healthcare  processes should exist without dependence on them but that extra review by interested parties is another level of safety. 
     







  • 17.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-27-2020 19:22

    I would love to say something about this event but I cannot since I work at the defendant institution.  That being said, these sorts of errors often get blamed on individuals but are system problems.  The example given earlier in the thread regarding Dr. Weed's approach, while notable for  his attempts to reduce such errors, still rely on individuals and hence blame individuals (getting "eviscerated on rounds the next day").  While individuals are part of the system, focus on individuals mostly leads to failure in safety efforts.  There are many opportunities to close the loop that are missed.  Wish I could say more.


    Slainte,

    Bradford D. Winters, Ph.D., M.D., FCCM
    Associate Professor
    Anesthesiology and Critical Care Medicine and Surgery
    Division Director, Critical Care Medicine
    Co-Director, Surgical Intensive Care Units and Burn ICU
    Core Faculty Armstrong Institute for Patient Safety and Quality
    The Johns Hopkins University School of Medicine






  • 18.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-27-2020 19:29
    Some clinics give a copy of the note at the end of the visit. At least a summary of all tests, findings, diagnoses, and recommended follow up could and should be done at discharge from hospital. Transparency is key. Less likely to miss something like this.

    Paul F. Treder, APNP

    Sent from my iPhone




  • 19.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-27-2020 23:55
    Could periodic instruction on how to use Open Notes help? But would that consume someone's time and not be accepted? 

    Also,what do other advanced countries do with access to doctors notes, symptoms, problems and results of investigations?

    Are there things to be learnt from overseas practice?

    Rob Bell, M.D.







  • 20.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-27-2020 19:30

    Open Notes is clearly a way to decrease the likelihood of an event like this from happening in the future but it is not enough to eliminate it.  A large problem with Open Notes is that most patients do not read their notes.  I am a big fan of Open Notes but it only will mitigate.  Communicating results to patients will also mitigate but also will not totally fix the problem.  Patients may hear or see abnormal test results but that does not mean they do the needed follow up.    We recently published on risk factors for failure to follow up abnormal creatinine tests and patients who saw their abnormal results on the patient portal (verified electronically) were only slightly more likely to follow up.   There needs to be a closed loop system where these abnormal results are tracked to resolution.    Malpractice attorneys and some physicians like to consider mere documentation that patients were notified of their results good enough but it is not.

     

    Michael H. Kanter, MD, CPPS

    Professor and Chair

    Department of Clinical Science

     

    98 S. Los Robles Avenue, Pasadena, CA  91101

    Work phone: (626) 564-3643 | tieline 8+338 | Mobile phone: (626) 243-8674

    michael.h.kanter@kp.org | https://medschool.kp.org | @michaelkantermd

    Pronouns: he/him

     

    Vanessa Papatsos, Executive Assistant

    vanessa.papatsos@kp.org | Work phone: (626) 564-3608 | Mobile phone: (626) 660-8604

     

     

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  • 21.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-27-2020 19:39

    Hopkins actually has open notes (MyChart in EPIC).  patients can access their charts through the web.  but as Dr. Kanter pointed out,  they are uncommonly accessed and I suspect patients aren't always sure what to do with the information.


    Slainte,

    Bradford D. Winters, Ph.D., M.D., FCCM
    Associate Professor
    Anesthesiology and Critical Care Medicine and Surgery
    Division Director, Critical Care Medicine
    Co-Director, Surgical Intensive Care Units and Burn ICU
    Core Faculty Armstrong Institute for Patient Safety and Quality
    The Johns Hopkins University School of Medicine






  • 22.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-28-2020 08:40

     

     

    July 28, 2020

    8:33 AM

     

    From an outsiders point of view, it clearly looks like the mantra for physicians is that they are the ultimate judge of what is important to someone other than themselves - the patient -  and that many believe there is a no need to question their evaluation.  Hence the lack of records disclosure to the patient.  A typical human condition.

     

    The challenge is to get both the clinician (team) and the patient (and family) to take responsibility for each and every patient.  Not easy to do!  So thinking of this as a "system" problem; if the medical "industry" each had a stake in the outcome (financial obligation to cover costs), would it not work more astutely to fix things early?  As it stands today, the more billings (services), the more income.  Some medical institutions have implemented a patient insurance program, accepting the downstream responsibility.

     

    Next, take the autonomy of the physician and blow it up; it is a concept long outdated.  All other critical industries are moving (have moved) to Team environments - meaning the evaluation and decisions are shared.

     

    Is this like getting Congress to pass term limits.

     

       Nelson Toussaint

     

    TAMARAC LLC

    860-844-0199

    ntoussaint@tamarac.com

     






  • 23.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-28-2020 14:39
    Yes, but what are the hazards of teams? 

    Which organization should lead the way?

    Does medicine need good leadership/.

    Rob







  • 24.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-29-2020 08:53

     

     

    July 29, 2020

    8:50 AM

     

    Rob

     

    Teams are not leaderless.  The leader must have the mindset to solicit the ideas, knowledge and opinions and share reasoning for going down a path.  The leader remains responsible to reach a decision.  Team members must also take some responsibility.  Many elements of medicine already function in this manner.

     

    Patients and Families are Team Members.

     

    One weakness of Teams is that it slows down decision making.  So, in a crisis, the leader has to take the burden and act accordingly.  That does not mean that a decision is not modifiable as more becomes known.

     

       Nelson

     

    TAMARAC LLC

    860-844-0199

    ntoussaint@tamarac.com

     






  • 25.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-29-2020 12:15
    I've truly enjoyed the back-and-forth on this article and the issue of patient communication. I wanted to make a comment on one piece of Dr Toussaint's earlier email.

    His assertion - that the clinician is part of the team and the patient is not - is part of the problem. While he correctly noted that the responsibility lies with both parties, the power right now lies solely with the medical team (and corporate management where it exists). Once this antiquated concept is replaced by every healthcare professional trained to view patients (and caregivers) as an essential team member, this gap in communications may narrow.  There are steps that have to be taken, which SIDM's PEC members attempted to address when HHS asked for input on their update of the definition of Health Literacy

    It is the healthcare professional's job to include the patient in their diagnostic reasoning, to use plain language terms to improve communication, to explain what tests are being ordered, why they're being ordered, when the results are expected, and what to do if the patient doesn't see or learn about the results. Patients have to be trained to share their full history, to keep records, to share their goals, to follow up, to ask their questions, and to express their concerns. The healthcare professionals role then is to honor their goals, address their concerns, answer the questions, and do so with the shared goal of improving the health of the patient before them. Until this communication circle is common practice and completed for every patient, we will not be able to reduce diagnostic error sufficiently for SIDM to no longer be a needed voice. 

    There's one more gigantic piece of the puzzle that's required: compensation for the healthcare professional that motivates them to do all this. If Medicare, Medicaid, and insurance companies will compensate healthcare professionals for better communication and greater diagnostic reasoning time, the corporatization of healthcare will bend in that direction.

    So perhaps we need to begin at the medical school and residency training level while simultaneously urging CMS to change their latest, and overly complex, compensation plan. The last part, the part that will keep those more concerned with the bottom line and less concerned with patient care honest, is the diagnostic error reporting tool that many of our fantastic researchers are working on, like Traber Giardina. 

    Best,
    Helene 

       
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        Website 
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        Facebook





  • 26.  RE: Fwd: The Baltimore Sun: Maryland family files lawsuit against Johns Hopkins Hospital alleging negligence led to 2-year-old twin’s death

    Posted 07-29-2020 12:41
    Agree with Helene re the importance of integrating the patient and family into the team - outcome clearly more important to them than to anyone else!

    Re reimbursement for actions - you do not go far enough.  We need to get rid of our piecemeal fee-for-service model where doing things to patients is paid at a much higher level than spending time with them.  Global payments that emphasize keeping people well would work much better.
    Ed

    Edward P Hoffer MD, FACP, FACC