When It Comes to Care and Transition Management, We’ve Got to Get the Basics Right First

I recently read an article on patient safety in the mainstream media that is one of the best articles intended for laypeople that I’ve read in a long time. The article appeared in The Washington Post on April 29 and online in Kaiser Health News on May 2, under the headline, “Hospital Discharge: It’s One of the Most Dangerous Periods for Patients.” Written by KHN’s Jordan Rau, it looks at the point of inpatient hospital discharge as a key moment of danger for patients, and it illustrates the issue with a devastating opening case study.

As Rau writes, “Within two weeks of Joyce Oyler’s discharge from the hospital, sores developed in her mouth and throat, and blood began seeping from her nose and bowels. Her daughter traced the source to the medicine bottles in Oyler’s home in St. Joseph, Missouri. One drug that keeps heart patients like Oyler from retaining fluids was missing. In its place was a toxic drug with a similar name but different purpose, primarily to treat cancer and severe arthritis. The label said to take it daily. ‘I gathered all her medicine, and as soon as I saw that bottle, I knew she couldn’t come back from this,’ said the daughter, Kristin Sigg, an oncology nurse. ‘There were many layers and mistakes made after she left the hospital. It should have been caught about five different ways.’”

On the one hand, it was tremendously fortunate for Joyce Oyler that her adult daughter, Kristin Sigg, was an oncology nurse. On the other hand, as Sigg noted, it was already too late for her to turn the situation around for her mother; the accumulated dosage of the toxic drug had already taken its toll on Oyler.

“Oyler’s death in October 2013 shows how a fatal mistake can slip by multiple checkpoints,” the KHN/Washington Post article notes. “The 66-year-old retired safety manager left Heartland Regional Medical Center in St. Joseph after being treated for congestive heart failure... She returned home as a hospital nurse telephoned the local Hy-Vee Pharmacy with eight new prescriptions. One was for the diuretic metolazone. But the medications a pharmacy technician wrote down did not include metolazone. Instead it listed methotrexate, which can damage blood cell counts, organs and the lining of the mouth, stomach and intestines. The drug is so potent that the Institute for Safe Medication Practices includes it among eight ‘high-alert’ medications with consequences so ‘devastating’ that they warrant special safeguards against incorrect dispensing.” Ultimately, “[A] jury awarded Oyler’s family $2 million in damages from the pharmacy. The judge lowered the award to $125,000 because of Missouri’s cap for non-economic damages in medical malpractice cases.” And Heartland Regional Medical Center ended up paying Oyler’s family $225,000.

Could this story get even worse in its details? Well… yes, it could. As the article goes on to note, “[T]he error could have been caught right away as Oyler began getting care from Heartland’s home health care agency. Medicare requires home health agencies to examine details of a patient’s medications to ensure all the drugs match the prescriptions ordered, are being taken in the right dose and frequency, and don’t have negative interactions.” What’s more, “Less than a year before, Missouri state inspectors had cited the agency for inadequately reviewing medications for three patients, and the agency had pledged to make improvements, records show. Still, neither of two agency nurses who visited Oyler at home stopped her from taking the wrong drug.”

“Why they didn’t catch it was beyond me,” her husband, Carl, was quoted in the article as saying. “They had a printout from the hospital,” with every medication correctly listed. “It was all there,” he said. Tragically, no one caught the error until Sigg found it herself. Thus, “After 18 days, her family took her to North Kansas City Hospital, where doctors determined that the methotrexate had irreparably damaged her bone marrow’s ability to create blood cells. She died three days later of multiple organ failure.” As her husband noted, “By the time we got her into the emergency room, essentially she had no blood cell count. It was irreversible. It was a gruesome, slow, painful way to die.”

Care management and population health: let’s get the basics right first—and simultaneously

This terrible patient safety sentinel event, so excellently articulated by Jordan Rau’s Post/KHN article, speaks to a core issue facing patient care leaders nationwide. And that is this: even as hospital and medical group leaders move forward quickly—and they absolutely must do so—to put in place great population health management and care management programs, robustly data analytics-driven—they must also map and address the current deficiencies in their care transition processes. What happened to Joyce Oyler, sadly, is incredibly common in practice, if rarely as devastatingly fatal as in this circumstance.

But the reality is clear: the processes by which patients are discharged from inpatient hospitals remain absolutely fraught with errors, miscommunications, and indeed, complete breakdowns of communication and care management. Obviously, by the time Oyler’s daughter, a skilled oncology nurse, discovered what had happened to her mother, it ended up being too late for her, and she died as the result of a pharmacy dispensing error. Who knows what might have happened had a skilled, aware care management/case management nurse caught this error the day it happened? Certainly, Oyler would have become ill; but one day versus two weeks might have made all the difference, and Oyler might have been alive today.

One of the good things that we’re hearing about, in that context, is that, as the leaders of innovative patient care organizations move forward to build population health and care management initiatives, they are in fact uncovering all the gaps in communication, in hand-offs, in transitions, that occur all the time in the U.S. healthcare system. That is a necessary element in all this, and yes, it does require that patient care leaders work along several dimensions at once—mapping their current care transition processes, using data to identify gaps and points of breakdown, continuously improving clinical and care management performance, and, at the same time, expanding dramatically their work to broaden their oversight and management of the care and health status of patients. Because, had a strong system involving discharge management and oversight, care and case management, data analytics, and some kind of alerting system, been in place, and used well, in this case, Joyce Oyler would still have been alive today. And healthcare IT leaders—CMIOs, CIOs, and everyone who works with them—can absolutely be heroes in all this, as they work with clinician leaders in their organizations, and beyond, to put in place the systems that will prevent sentinel events like this one from happening in the first place. We owe it to the Joyce Oylers of the world to master the basics of such transitions as hospital discharge, while at the same time, building broader, more comprehensive systems of care and population health management. So yes, it is a bit like refueling a plane while still in mid-air. But it’s what will be required of the leaders of patient care organizations nationwide—with no excuses for not being able to achieve such feats.