Sunday, July 1, 2007

Prescription drugs present own problems

Saving money, including those with private or government insurance, is an appealing option. Thus the new emphasis on $4 generic drugs.

There are multiple large chain stores and an increasing number of independent drug stores who offer similar programs.
However, there are multiple issues to consider carefully with your doctor and/or pharmacist before using the $4 program.

If you shop for drugs at more than one pharmacy, it is possible that the dispensing pharmacy is unaware of other medications you are taking. This could result in "double dosing" or taking drugs that are not compatible.

Using one pharmacy for all of your prescriptions allows the pharmacy staff to review your medical conditions and the medications that you are currently taking prior to filling a prescription. If your medical condition requires several different medications, the possibility for the patient or caregiver to make an error can be increased.

Reading the label on the generically dispensed pharmacy labels becomes confusing. For example: the commonly ordered drug Novasc would be labeled Amlodipine Besylate and Soma would be labeled Simvistatin.

Further, different manufacturers may color their generic products differently.

Patients often take their medications by memory — for instances taking the "small pink pill" in the morning, a "triangular pill" midday etc. Some patients either can't or won't check the bottle before taking a pill, but they depend on the familiarity of shapes and colors.

The $4 drugs are very useful and safe if the patient knows what they are taking. When in doubt, call your pharmacy.


East Stroudsburg

Pharmacy error led to premature birth, suit says

Two years ago, Antoinette Lewis' baby was born prematurely. She claims her pregnancy complication was a result of a "misfilled" prescription received at a CVS Pharmacy and is suing the company for more than $50,000.

Lewis filed her suit individually and on behalf of her new born with the Jefferson County District Court on June 25. Judge Bob Wortham, 58th Judicial District, will preside over the case.

According to the plaintiff's original petition, on June 30, 2005, Lewis was pregnant when she had a prescription filled at the CVS on Avenue A.

"Defendant through its employees, agents, and servants, misfilled the prescription. Plaintiff subsequently suffered complications due to the misfilled prescription, was forced to deliver the minor plaintiff by C-section prematurely, and both suffered injuries due to the negligence of the defendant.

The suit goes onto to say Lewis presented CVS with a prescription for an antibiotic, and instead received Vytorin.

"Defendant failed to properly administer the correct medication, the plaintiff was pregnant, and the Vytorin caused complications with the pregnancy, and subsequently caused early delivery."

Vytorin is a cholesterol-lowering medicine distributed by Merck/Schering-Plough Pharmaceuticals. The official Vytorin Web site warns that the drug should not be taken by pregnant women.

"Vytorian is a prescription tablet containing two medicines, ezetimibe and simvastatin, and isn't right for everyone, including women who are nursing or pregnant or who may become pregnant, and anyone with liver problems," the site says.

Lewis alleges the pharmacy was negligent for failing to properly fill the correct medication, failing to recognize her symptoms, and "failing to engage in recognized and acceptable practices in the medical profession to limit the likelihood and probability of infection following the treatment provided by the defendant."

"Plaintiffs allege that the defendant violated the duty of care they owed to Lewis to exercise that degree of care, skill, and diligence ordinarily possessed and used by other members of the medical profession in good standing under the same or similar circumstances," the suit said.

Lewis is suing for physical pain and suffering in the past and future, mental anguish in the past and future, lost wages, loss of earning capacity, disfigurement in the past and future, physical impairment in the past and future, and past and future medical expenses.

Lewis is demanding a trial by jury and is represented by attorney Brett S. Thomas of the Roebuck & Thomas law firm.

Case No. A179-565
By David Yates

Vaad Refuah: Improving The Quality Of Hospital Care

Question: Where do you turn for help if someone is hospitalized? Answer: Vaad Refuah.

Mrs. Shapiro spent her last days in a hospital with constant attention from her devoted family. Her children took turns sitting by her bedside, wiping her brow and cooling her parched lips with ice. When she passed away, the family at least had the satisfaction of knowing that they had done everything possible to relieve her suffering and alleviate her pain. What they didn’t realize, however, is that despite their loving vigilance, Mrs. Shapiro was not receiving adequate medical care.

The chevra kadisha, while washing the body, discovered that yet another patient had passed away with Stage III or IV bedsores. These are deep, black craters usually in the sacrum, back or ankles where the skin, muscles, or bone have been eaten away. Mrs. Shapiro, along with 1 million other Americans, half of whom are over 70, was suffering from excruciating, but largely avoidable, decubitus (bed sores). Elderly patients who are confined to bed are at the highest risk due to their thinner skin and weaker circulation and immune systems. Had this family been aware of this potential problem, they would have made a simple request to the nurses to turn her every two hours and check her body for early signs of bedsores to prevent this painful complication.

Bedsores, unfortunately, are not the only problems that call for extra attention from the families of patients who are staying in a health care facility. At least one study shows that 5-6% of all patients acquire nosocomial infections in hospitals each year. These infections are usually highly resistant virulent strains. It is within the patient’s rights and responsibility to ask respectfully if the health care worker has washed his or her hands. There are also times when a family should discreetly ask that the patient be moved due to the danger of cross infection from a roommate. In addition, errors in prescription drugs for hospitalized patients have recently soared. If the patient was not informed that his doctor changed his medication, he should immediately request confirmation. The number of unnecessary surgeries and the resulting greater need for second opinions also warrants consideration.

How are the family members, who are already over-strained, worried, and tired, able to assume this role of guarding the patient from medical error without knowing the ‘ins and outs’ of the hospital process? To address this problem, a team of rabbonim, askonim, medical professionals and volunteer workers has created a patient advocacy group, Vaad Refuah. Vaad Refuah does not give medical advice. They only guide the patient and his family through the maze of health care bureaucracy in order to increase the quality of health care for all patients.

Mrs. Krausz, who supervises 14 volunteers who are on call through Vaad Refuah’s helpline, offers the following advice to all patients and their families:

Appoint a friend or family member to be a spokesperson to liaise with the hospital staff. Even a patient who can take responsibility for his own health care still needs a spokesperson to act as his advocate.

The spokesperson is invited to contact the Vaad Refuah helpline about how to avoid preventable complications and how to effectively intervene with hospital staff.

With polite respect, the spokesperson should try to resolve all care problems with the local nursing or care-giving workers.

Medical problems should be discussed with the doctor who is managing the case. In those instances where there is no managing doctor, the spokesperson should communicate with all the appropriate doctors who are involved in the case.

If any problems arise, the spokesperson should be in touch with Vaad Refuah. For Lutheran, NY Methodist, Long Island College, and Maimonides hospital, Vaad Refuah has established communication channels where, if necessary, they will intercede to help acquire the appropriate cooperation from the hospital. For patients in other hospitals, Vaad Refuah can advise the spokesman how to talk to the hospital and, where possible, the Vaad may be able to facilitate communication.

The Vaad will maintain a database of problems encountered in each hospital. The information collected will be provided to the management of each hospital to assist in effectuating needed improvement. Unclean conditions, employee neglect of duties, and other violations should all be reported to the Vaad. (Forms can be obtained at

Positive feedback, either general or relating to the actions of specific staff, should be reported to the Vaad, who will pass praise along to the hospitals. This will create a culture of caring in which the efforts of conscientious staff will be made known. Conversely, the Vaad will apply pressure on the hospitals to change by publicizing negative data when necessary.

All information given to the Vaad is kept in strict confidence. There is no need to fear retaliation from hospital employees.

The Vaad has thus far made several major changes in local Brooklyn hospitals. They have convinced hospital management to improve emergency room procedures, establish more hand washing stations, implement stricter hand washing compliance, improve the staff/patient ratio, provide more diligence in turning patients, and computerize bed availability tracking. Future plans include expanding the Vaad’s computerized patient satisfaction program to more hospitals, introducing more medical prevention practices, and educating the community and health workers about the most effective methods of communication.

The Vaad performs these services through its network of volunteers in order to help our local communities secure the best possible health care. For more information or to join the volunteer staff, call 1-877-REFUAH, 1-877-973-3824 or visit www.vaad

Vaad Refuah Meets Maimonides Trustees. On June 24, an historic conference took place in Borough Park between the Rabbinical board of Vaad Refuah and the Trustees of Maimonides Medical Center to tackle healthcare concerns facing the Borough Park/Flatbush/Bensonhurst communities.

The roster of esteemed attendees included: Rabbi Yisroel Tzvi Brody, Manchester Dayan; Rabbi David Eichenstein, Burshtyner Rebbe; Rabbi Shloime Gross, Belzer Dayan; Rabbi Shraga Hager, Kosover Rebbe; Rabbi Yakov Horowitz, Rav Telshe Minyan, Rosh Hayeshivah, Beis Meir; Rabbi Yechiel Kaufman, Rav D’khal Anshe Sefard; Rabbi Yakov Perlow, Novominsker Rebbe; Rabbi Yisroel Reisman, Rav Agudath Yisroel Madison Branch, Rosh Yeshivah Torah V’daas; Rabbi Yechiel Mechel Steinmetz, Skverer Dayan; and Rabbi Chaim Yakov Tauber, Bobover Dayan. The other participants were board members of Vaad Refuah, along with community representatives on the Maimonides Medical Center Board of Trustees including Abraham Biderman, Moshe Hellman, Andrew Kohen, Chaim Leshkowitz, Peter Rebenwurzel, Alfred Schonberger and Rabbi Aaron Twersky.

Concerned with the quality of healthcare our families receive at local hospitals as well as the need for the various community organizations to work together to ensure the best possible service within halachic parameters, the rabbonim initiated this meeting as a follow-up to a prior meeting held between the Vaad Rabbinical Board and Hatzoloh representatives. At the conference, attendees were updated on the efforts the Vaad has made to date on infection control, respiratory care patients, wound-care and decubiti (bed sores/pressure sores).

The Vaad has a close working relationship with the Bikur Cholims of Borough Park, Flatbush and Bensonhurst. It also meets regularly with Hatzoloh, sharing information of common concern and coordinating activities to maximize community efforts for the improvement in the quality of healthcare service delivery.

While the Vaad has made great strides in assisting individual patients and their families by helping them navigate hospital bureaucracy, advocating on their behalf and intervening to expedite their needs, effecting systemic changes is significantly more laborious and requires the close cooperation and assistance from the Hospital Board of Trustees.

The community representatives on the Maimonides Medical Center Board of Trustees expressed their eagerness to assist in this effort by collaborating with the Vaad in assuring that the Maimonides Administration continues to pay proper attention to community concerns, responds promptly to issues raised by the various community organizations, and implements needed changes in a timely fashion. The Vaad highly commended Maimonides Medical Center Board of Trustees for their commitment to partner in this vital mission.

Computerized Doctors' Orders Reduce Medication Errors

Doctors are famous for sloppy scribbling -- and handwritten prescriptions lead to thousands of medication errors each year. Electronics to the rescue: U.S. hospitals that switched to computerized physician order entry systems saw a 66 percent drop in prescription errors, according to a new review of studies.
Illegible handwriting and transcription errors are responsible for as much as 61 percent of medication errors in hospitals. A simple mistake such as putting the decimal point in the wrong place can have serious consequences because a patient's dosage could be 10 times the recommended amount.

Drugs with similar names are another common source of error, such as the pain medication Celebrex and the antidepressant Celexa, or the tranquilizer Zyprexa and the antihistamine Zyrtec.

"These medication errors are very painful for doctors, as well as the patients. Nobody wants to make a mistake," said Tatyana Shamliyan, lead review author and a research associate at the University of Minnesota School of Public Health.

The University of Minnesota researchers looked at 12 studies that compared medication errors with handwritten and computerized prescriptions from in-hospital doctors. Nearly a quarter of all hospital patients experience medication errors, a rate that has increased from 5 percent in 1992, according to the study.

Medication errors include prescribing the wrong drug or incorrect dosage or administering a drug at the wrong time or not at all. "Most errors typically go undetected unless they led to an adverse event," said review co-author Robert Kane.

In addition to improving patient safety, computerized systems make life easier for pharmacists. "They don't have to decipher the chicken scratch," said Karl Gumpper, director of the pharmacy informatics and technology section of the American Society of Health-System Pharmacists, based in Bethesda, Md. Pharmacists frequently have to call the prescribing doctor or interview the patient because of problems in deciphering handwriting.

Currently, only about 9 percent of hospitals have computerized prescription systems. Some hospitals have stand-alone systems, while others have computerized prescriptions as part of an electronic medical record system.

Each year, more health systems implement computerized order entry systems and more will do so as electronic medical records become more common. "It's a growth industry," Kane said.

A small handful of institutions, including Brigham and Women's Hospital in Boston and Vanderbilt University Medical Center in Nashville, have been leaders in integrating computerized prescriptions, experts say.

It takes 12 to 36 months to implement computerized prescribing system, Gumpper said. Currently, no industry standard system exists. Some hospitals use systems created in-house, while others use commercial products created by companies such as Epic Systems, based in Verona, Wis. or McKesson Corp., based in San Francisco.

Some systems guide doctors through the prescription process, asking questions that might help avoid errors. Some even use voice recognition.

There are two reasons why more hospitals have not switched to electronic prescription systems, says Arthur Levin, director of the Center for Medical Consumers in New York. First, "Physicians, like most of us, don't like change," he said. In addition, electronic prescription systems are costly and difficult to integrate into the complex, sometimes-chaotic hospital structure.

Regardless, in hospitals with a computerized prescription system, the number of medication errors dropped, especially among adult patients. However, the rate of one type of error --prescribing the wrong drug -- did not decrease, and in five studies, the number of adverse events from drug errors did not decrease.

Each year, more than one-half million patients sustain injuries or die in hospitals from adverse events, according to the study.

In hospitals with a higher number of medication errors -- more than 12 percent -- computerized systems made the biggest improvement, the researchers found.

Medical schools in the United States rarely address penmanship. It is the same in Russia, says Shamilyan, who studied there. However, at least one medical school in the United States, Indiana University in Indianapolis, teaches penmanship to students in hopes of avoiding errors.

As nearly every industry becomes more computerized, Levin says the doctor's prescription pad should go the way of scarification used in the 19th century for bloodletting. "Written and verbal orders should be a no-no," he said.

Reference; Shamliyan TA, et al. Review of the evidence: impact of computerized physician order entry system (CPOE) on medication errors. Health Services Research online, 2007.

Note: This story has been adapted from a news release issued by Center for the Advancement of Health.

Call Kurtis: Medical Board Investigation

An 82-page report shows the medical board is still failing to protect all of us from doctors who abuse alcohol and drugs.

Linda, Becky, Tina, Ken-- just some of the faces of people who believe they're living the consequences. If you looked beneath the clothes of some patients you would see something horrifying. They blame damages on a doctor who battled a dangerous addiction, and on the state's significant errors.

We know of more than 30-patients who say plastic surgeon Dr. Brian West made medical mistakes while treating them. The medical board knew Dr. West had a drinking problem, and had two drunk driving convictions. The first, after crashing his car in 2000 on the way to the hospital to treat a patient. The state had the power to take away his license to practice.

Instead, they let him enroll in the medical board's alcohol diversion program, a secret program where they're supposed to keep an eye on substance abusing doctors with random alcohol and drug tests in an effort to protect patients.

We learned, the state wasn't giving doctors those tests as often as required, and the testing was done on days doctors could anticipate. In November, with the Dr. West case in front of him, the head of the medical board admitted his agency failed.

While in the program, Dr. West cut into Becky Anderson so many times, she never looked or felt the same. Tina Minasian ended up with permanent scars from a body tuck that went wrong. Ken Mickulecky says his late wife Sharon was left with a massive flesh eating infection that kept her from getting the cancer treatment she needed.

“He put his finger without a glove in my wife's wound. When he came into examine her, she said smells like he's got alcohol on his breath. I said, no, doctors wouldn't do that,” said Ken.
Back in November Medical Board Executive Director Dave Thornton admitted the diversion program's problems of the past, but claimed they have been fixed.

“If your doctor is an alcoholic, and is in the program, he's not gaming the system. The system is working now the way it’s supposed to be working and the way it should have been working all of these years,” said Thornton.

Fast forward to a state audit that was just released. The audit states that what he says is not true. Although there have been some improvements, many doctors in diversion are still given drug and alcohol tests on days they can anticipate.

The report shows during the audit 13 doctors failed their tests. Yet, only three of them were immediately removed from practice.

“These are doctors who retain their license to practice medicine who are allowed to practice medicine, are chemically dependent. This board is supposed to be monitoring doctors, it doesn't,” said Julie D'angelo Felmeth, who has audited the program twice.

D'angelo Felmeth says there have been five audits in 27 years and each one shows the same exact issues with diversion-- A program she says has no room for error.

“They've had decades to fix these problems, which have been repeatedly identified for them and the problems and the programs have never been a priority to the medical board,” said D'angelo Felmeth.

In fact, a member of the board's executive committee even admitted it during a meeting last week. The problematic program caught the attention of state lawmakers in 2005 who passed a law stating the diversion program needs to be fixed by July of next year, or it'll go away.

Earlier this year State Senator Mark Ridley-Thomas, the head of the legislative committee that oversees the medical board, drafted a bill to keep the diversion program going for an additional two years.

“Ultimately saving doctors is better than disposing of them,” said Senator Ridley-Thomas.

We showed him our investigation, and he admitted what the state allowed to happen here is upsetting.

“It should be long before you get there, this problem is dealt with,” said Senator Ridley-Thomas.

He points out, his bill to extend the program was drafted before the latest audit, but instead of killing his legislation he says he'll beef it up, to hold the medical board accountable.

“Shape up this program, or it will not longer exist,” said Senator Ridley-Thomas.

That message went out two years ago, and the program still has major problems putting patients at risk.

“Let me simply say there's a new sheriff in town. And the chair of this committee will push for accountability, and that's essentially what we're doing now,” said Senator Ridley-Thomas.

Knowing this is the fifth audit in 27 years, and all of the same concerns keep coming up. Audit after audit some might question why should this program be extended for another two years.

“That's a legitimate question. This is a program under strict scrutiny. Either they perform as intended, or there is no defense for continuation. It requires a significant time on task to straighten some of these things out,” said Senator Ridley-Thomas.

That bill is still being talked about at the capitol. It has to pass the State Senate and Assembly by September, or the program is set to go away next July. It's supported by the medical board and the California Medical Association, which historically contributes a large amount of money to the campaigns of state lawmakers.

At the Beverly Hills Surgical Institute in Long Beach, Dr. West still practices, and has always refused to comment on this issue. The state has a case against him for what happened to several patients. It will be the fall before a judge decides if he should lose his license.
by Kurtis Ming

Physician order entry system reduces error

The incidence of medication errors can be reduced by implementing a computerized physician order entry (CPOE) system, according to a review of several studies conducted by researchers at the University of Minnesota.

The review, recently published in the online journal Health Services Research, analyzed 12 studies conducted between 1990 and 2005 that compared the number of handwritten and computerized medication errors made by hospital physicians. Medication errors, which include prescribing the wrong drug, ordering an inaccurate dosage, or administering a drug at the wrong time, dropped by as much as 66 percent in United States hospitals that switched to a CPOE system. Illegible handwriting and transcription errors account for more than 60 percent of medication errors.

Patient safety is our final goal, said Tatyana Shamliyan, lead review author and a research associate at the University of Minnesota School of Public Health.Evidence from these studies show that computerized systems can reduce mistakes, but unfortunately less than 50 percent of hospitals have implemented these systems. There is a lot of work to be done in the future.

The rate of medication errors experienced by hospitals has skyrocketed from only 5 percent in 1992 to nearly 25 percent today. The review found that of these hospitals, CPOE systems were most beneficial when the rate of medication errors was more than 12 percent.

The Institute of Medicine has already identified medication errors as a major threat to patient safety and has endorsed electronic prescribing of medication as an effective method in correcting the problem.Medication errors are a central aspect of improving hospital safety. CPOE can help that process, says Robert Kane, M.D., review co-author.

Hospitals would be short-sighted not to use it. Kane also notes that CPOE systems can be combined with existing computerized medical records, creating a central location for physicians to efficiently enter and view past and present patient prescriptions and medical history.

While the review found that the number of medication errors dropped as a whole, the incidence of one type of error, prescribing the wrong drug, did not decrease. In five of the twelve studies, the number of adverse events from drugs errors did not decrease. More than one-half million patients suffer injuries or death from adverse events, causing up to $5.6 million annually per hospital, according to the review.

When Minority Patients Have Insurance And A Medical Home, Their Health Care Improves

Providing minority patients a "medical home" in which they have a regular doctor or health professional who oversees and coordinates their care would help eliminate racial and ethnic health disparities and promote more health care equity, says a new report from The Commonwealth Fund. The report, based on a 2006 survey of more than 2,830 adults, shows that linking minority patients with a health care setting that offers timely, well-organized care where they can routinely seek physicians and medical advice can help them better manage chronic conditions and obtain critical preventive care services.
According to the report, Closing the Divide: How Medical Homes Promote Equity in Health Care, in 2006 nearly one-half of Hispanics and more than one of four African Americans were uninsured at some point during the year. In contrast, 21 percent of whites and 18 percent of Asian Americans lacked coverage. In addition to being the groups most likely to go without health insurance, African Americans and Hispanics are least likely to have a regular doctor or source of care. While health insurance coverage is an important determinant of whether people can obtain essential care, the authors say insurance alone cannot eliminate racial and ethnic disparities in health.

"Insurance coverage helps people gain access to health care, but the next thing you have to ask is 'access to what?'" says lead co-author Anne Beal, M.D., senior program officer at the Commonwealth Fund. "We found many disparities in care; however, disparities are not immutable. This survey shows if you can provide both insurance and access to a true medical home, racial and ethnic differences in getting needed medical care are often eliminated," she adds.

According to the report, patients have a medical home when they:

* Have a regular provider or place of care
* Report no difficulty contacting a provider by phone
* Report no difficulty getting advice or medical care when needed on weekends or evenings
* Always or often find office visits well-organized and efficiently run

Although there are many places that are already functioning as models of such care, what most limited a health setting from being designated a medical home in this survey was the ability to dispense medical advice or care after hours or on weekends, according to the report. Only two-thirds of adults who have a regular provider or source of care report that it is easy to get care or medical advice after hours. Among all groups surveyed, Hispanics have the hardest time seeking care or advice after hours, and they are least likely to have a medical home.

The survey shows that, when they have a medical home, the vast majority of adults of all races say they can always get the care they need when they need it. Nearly three-quarters of adults with a medical home report getting the care they need compared with only 52 percent of those with a regular provider that is not a medical home and 38 percent of adults without any regular source of provider.

Key survey findings on the role of a medical home in eliminating health care disparities:

* Racial/Ethnic Disparities Are Still Common.
* African Americans and Hispanics are less likely to be insured, and less likely to have a regular doctor or source of care.
* Hispanics are least likely to have a medical home; only 15 percent of Hispanics report having a medical home compared with 28 percent of whites, 34 percent of African Americans and 26 percent of Asian Americans.

Preventive Care Is More Routine.

* Minority adults with a medical home experienced no disparities in receiving preventive care reminders, which significantly improve rates of routine screening for conditions such as heart disease and cancer. For example, eight of 10 adults who received a preventive reminder had their cholesterol checked in the past five years compared with half of adults who did not get a reminder.
* Two-thirds (65%) of adults who have a medical home receive preventive reminders, according to the survey.

Chronic Care is Better Managed.

* Adults with a medical home are better prepared to manage chronic conditions such as diabetes or hypertension. Only 23 percent of adults with a medical home report their doctor or doctor's office did not give them a plan to manage their care at home compared with 65 percent who have no regular source of care.
* Forty-two percent of hypertensive adults with a medical home report that they check their blood pressure and it is well controlled compared with 25 percent of those without a medical home.

Having Health Insurance Matters.

* More than half of insured adults received a reminder from a doctor's office to schedule preventive visits compared with only 36 percent of uninsured adults; when African American and Hispanic patients are insured, they are just as likely as white adults to receive reminders to schedule needed preventive care.

Community Health Centers and Other Public Clinics Are Important Providers of Care to Vulnerable Patients.

* Although they care for a large proportion of uninsured, low-income, and minority adults, patients report that community health centers (CHCs) or other public clinics are less likely to have all four characteristics that comprise what the survey defined as a "medical home." Twenty-one percent of CHCs or public clinics have all four indicators of a medical home, compared with 32 percent of private doctors' offices.
* The main reason CHCs and other public clinics do not function as medical homes is because patients say they have more difficulty getting medical advice or care in the evenings or weekends. Since these safety net providers play a critical role in the care of vulnerable patients, the authors say it is important to find ways to support CHCs and public clinics becoming medical homes.

Promoting standards for the medical home through public reporting of performance and rewarding providers that meet these performance benchmarks would go a long way toward improving the way care is delivered and eliminating disparities, say Commonwealth Fund authors.

"We know the medical home is a promising model of care for narrowing health care disparities and providing patients with much higher quality care in terms of prevention and chronic disease management," says Fund Executive Vice President Stephen C. Schoenbaum, M.D. "Adopting policies to encourage practitioners to embrace this model would improve care for everyone, particularly those in safety net settings," he adds.


The survey was conducted by Princeton Survey Research Associates International from May 30 through October 19, 2006. The survey consisted of 25-minute telephone interviews in English or Spanish among a random, nationally representative sample of 3,535 adults at least 18 years of age living in the continental United States. The report restricts the analysis to the 2,837 respondents ages 18-64. The sample was designed to target African American, Hispanic, and Asian households and it classifies adults by insurance status and annual income. The survey has an overall margin of sampling error of +/- 2.9 percentage points at the 95 percent confidence level.

The Commonwealth Fund is a private foundation working toward a high performance health system.

Note: This story has been adapted from a news release issued by Commonwealth Fund.


A COURT clerk's mistake is why Dickson Tan Yong Wen ended up getting the extra strokes.

This was revealed in a joint statement by the Law and Home Affairs ministries yesterday.

'Unfortunately, when the warrant of commitment was prepared by the Court Officer (that is, court clerk who assisted the judge with the administrative aspects of the case), the Court Officer erroneously reflected on the warrant of commitment an additional three strokes to one of the charges,' the statement said.

Tan was found guilty of abetting an illegal moneylender. He was convicted and sentenced on 28Feb.

The statement said that prison officers followed proper procedures when administering the caning on 29Mar this year.

This included verifying with the prisoner that the number of strokes of caning as specified in the warrant of commitment was correct.

Tan also did not raise any objection to number of strokes when he was interviewed during his admission process to prison on 1 Mar.

On the day of the caning, statement said, Tan acknowledged on the Inmate's Events Sheet that eight strokes was correct. And just before he was caned, Tan confirmed once again to the prison officers and the Medical Officer that the number of strokes were correct.

The Subordinate Courts has since taken various steps to tighten the processes. These efforts include checklists for Court Officers in preparing warrants of commitment and layers of additional checks for warrants of commitment, the statement said.

It also added that the Government regrets the error.

'The Government has also offered to refer the case to mediation. In negotiations so far, Tan's settlement sum has escalated from an initial amount of $150,000 to $3m (out of which he said he would donate $2.7m to charity), made on a without prejudice basis. This could not be accepted by the Government.'

The statement also said the court officer had resigned over the incident.
By Tay Shi'an

A $962,120 medical bill error

The patient didn't have to pay, but it's still a useful lesson for others, an economist says.
Helen Dorroh White thought she was doing the right thing when she called a health insurance company to question a nearly $1-million medical bill. Instead, she said, no one seemed to care.

White, a Glendale lawyer, was closing the financial affairs for a deceased client when she came across the insurance statement. It showed a $962,120 bill for her client, Dusanka Mlinarevich, who spent four days at Glendale Adventist Medical Center after suffering minor injuries in a fall at her Burbank home last year.

That struck White as odd, she said, because the hospital had told her the bill was $48,106.

Concerned about the discrepancy, White called the health insurance company, Long Beach-based SCAN Health Plan.

"My first question was, 'Is this some kind of typo or some mistake?' " said White, 73. A customer service representative paid little heed, White said, and insisted that the amount was correct.

"She didn't even bat an eye," White said.

Fearing fraud, White wrote a letter to the U.S. attorney's office and contacted The Times.

After inquiries from a reporter, SCAN's vice president of marketing, Sherry Stanislaw, said the company found a computer glitch that was producing erroneous claim reports for customers.

Actual billings and payments were not affected, Stanislaw said. She confirmed that Glendale Adventist's bill was for $48,106 and said that SCAN paid a negotiated rate of $4,350 and that Mlinarevich, who died in August at age 78, was assessed a $150 co-payment.

Because patients are responsible only for co-payments and deductibles, few consumers ever take a close look at their medical bills, said Devon Herrick, a healthcare economist and senior fellow at the National Center for Policy Analysis.

To help keep rising healthcare costs in check, more consumers should do what White did, Herrick said. "Most insurance companies will agree that they'd want their enrollees to scrutinize their bills."

SCAN said the computer glitch was being investigated. Stanislaw conceded that her customer representative should have heeded White's concerns and contacted a supervisor. The company is sending White a new claim statement, she said.

White wasn't completely pleased.

"It is easy to blame the computer. Well, who programs the computers?" she asked. "The last I checked, computers didn't program themselves."
By Daniel Yi, Times Staff Writer

Why King-Harbor must die

We must admit that the patient can't be saved -- and move on.
FOR FOUR YEARS, Los Angeles County officials have been dithering and bickering over what to do about Martin Luther King Jr.-Harbor Hospital.

Those who believe it must be closed argue that patients are dying because of substandard care and that there is little indication that anything — including downsizing by 80%, firing hundreds of staff members and changing the hospital's ownership and leadership — has worked to overcome its staggering problems. Opponents counter that King-Harbor served 47,000 emergency room patients in South Los Angeles last year and that, even with all its flaws, a bad hospital is better than no hospital at all.

So how are we to know whether the benefits of closure outweigh the risks of keeping the hospital open? As the state Department of Health Services, the federal government and the Los Angeles County Board of Supervisors all contemplate the possible demise of King-Harbor, how are we to determine whether the time has indeed come?

This much we know: There are no perfect hospitals. A seminal study by the Institute of Medicine conducted in 1999 found that 44,000 to 98,000 patients die from medical mistakes in the United States each year — the equivalent of a commercial jet crash every day. The average hospitalized patient suffers one medication error daily, according to another report from the institute, and patients in intensive care units experience nearly two mistakes in their care each day.

Until recently, we approached problems of poor quality and safety by admonishing doctors, nurses and hospitals to try harder, underscoring these exhortations with threats of malpractice lawsuits. But eventually it became clear that that was not enough. As Albert Einstein observed, we cannot solve our problems with the same thinking we used when we created them.

What we've learned in recent years is that most errors are not committed by incompetent doctors or slacker nurses but by well-trained, committed caregivers working in environments that are simply too complex for any human to get it right every time. This epiphany has led us to embrace what is known as "systems thinking" — in which we aim to create systems and structures that anticipate errors on the part of fallible workers and catch those errors before they cause harm.

By implementing relatively simple system fixes — such as double-checking before administering dangerous medications, marking surgical sites on patients' skin with indelible ink to ensure that we don't operate on the wrong body part, implementing computerized prescribing systems and limiting resident work hours (to less than 80 a week) and the number of patients assigned to each nurse (to no more than five) — we have begun to move the safety needle in the right direction.

Evidence is emerging that medical errors are decreasing and that hospital death rates in the last five years have fallen. Certain problems once felt to be inevitable, such as hospital-acquired infections, can be all but eliminated by widespread implementation of a series of safe practices, including religious attention to hand-washing and the use of other sterile techniques.

But even as we chalk up some safety victories, there remain problems so stubborn that they can't be solved by changing procedures and implementing new systems. The question is — because even the best hospitals will commit terrible, even lethal, errors every year — how do we know when a hospital is so bad that it should be deemed unfit for patients?

This question has been brought into sharp focus by the extraordinary saga of King-Harbor. What is so shocking about the story is not that the initial reports in 2003 showed scores of safety problems, although the breadth and depth of the problems far exceeded the usual litany. Nor is it the tale of a resource-poor hospital serving indigent patients struggling to make ends meet; those problems exist everywhere. Nor is it that the organizational chart of King-Harbor needed reshuffling — reorganizations of failing enterprises, guided by consultants, are a dime a dozen (not counting the price of the consultants, of course).

No, King-Harbor's problems are distinguished by their intractability. Other hospitals have had highly public errors or sustained withering press coverage but used these traumas to create a platform for improvement. Boston's Dana-Farber Cancer Institute, for instance, was transformed after a chemotherapy overdose there killed a Boston Globe healthcare columnist. Johns Hopkins Hospital in Baltimore, often rated as the nation's finest, was nearly brought to its knees by the error-related death of a young girl, but it used the tragedy as a springboard to develop a world-class safety program.

And other resource-poor county hospitals — such as San Francisco General and Harbor-UCLA — manage to provide high-quality care even in the face of budget woes and enormous caseloads.

But at King-Harbor, highly public disasters involving quality and safety have not managed to upend the status quo. Regulators have issued stern threats to yank funding or certification — but have then lowered the bar again and again. Leaders have been fired, organizational charts have been reshuffled and consultants have come and gone, and yet the shocking revelations — including numerous deaths from medication errors and lapses in monitoring — keep on coming.

When a patient can literally lie dying on the ER waiting room floor — a janitor mopping up around her — at a hospital whose every move is being scrutinized by the media and legislators, we know that the problems cannot be fixed by a better computer system, a few new bylaws or more intensive personnel training. The troubles run far deeper than that.

We physicians are socialized to believe in the possibility of redemption and healing — that the tumor can be excised, the obese patient will finally stick with that diet, the baby will emerge from the womb hale and hearty. This is mostly a good thing, but it can take us down dark alleys. For example, our "never say die" attitude sometimes leads us to over-treat patients with terminal illnesses, flogging them with another course of chemotherapy long after realistic hope is gone.

We now teach young doctors to recognize when cure is impossible and, at those times, to help guide patients and families toward what we have come to call a "good death." When offering this "palliative care," we focus on keeping the patient comfortable while encouraging loved ones to honor the past, come to terms with the present and make appropriate plans for the future.

With that in mind, we can never forget what King-Harbor represented at its christening: a shining light emerging from the dark shadows of the '60s riots. We must recognize the service of those committed, competent caregivers (and there were and are some) who struggled to provide high-quality care in a dysfunctional environment. We have to empathize with the patients who may be inconvenienced, or even harmed, when their local hospital — bad as it was — is no longer down the street.

But how can we stay silent in the face of overwhelming evidence that this hospital cannot ensure a decent level of safety, knowing that no patient with a choice would dare cross its threshold? How can we continue to focus on cure when hope has long since vanished? Surely, the resources being poured into that one last change in the organization chart, one more consultant engagement or one more staffing surge could better be used to ramp up the capacity of other hospitals' ERs and clinics to absorb King-Harbor patients.

King-Harbor is on life-support, and has been for years. The disease is a cancerous culture, and one more course of chemo won't help. It is time to orchestrate a "good death" — to focus on healing the community and making plans to care for the patients of South L.A. once this hospital is gone.
By Robert M. Wachter, ROBERT M. WACHTER is a professor of medicine at UC San Francisco and the author of "Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes" and the forthcoming "Understanding Patient Safety."

Error gave woman HIV, but Navy turns its back on her

WINTER SPRINGS - Richelle Starnes' cell phone alarm beeps to interrupt her three times a day. It's her reminder: Take the medication.

Richelle is 26, a forward on the semipro Orlando Falcons soccer team, and the ring is a reminder she has HIV.

Now, however, she has enough pills to last into mid August. After that? That's a question she's wrestling with the Navy over.

It's the Navy that has been treating Richelle since she was 10. That's when she learned she was infected with HIV, an infection she and her family blame on the Navy. But as Richelle has become an adult, the Navy says it no longer will pay for her pills.

* * *

Richelle's parents and older sister were living near San Francisco in 1979 when her mother Kathy became pregnant. Her father was a radioman on a submarine. But soon after Kathy became pregnant, a painful lump on her side and bleeding sent her to a Navy doctor. He sent her home, missing signs she had an ectopic pregnancy, that a fertilized egg had implanted not in her uterus but in a fallopian tube.

A few days later, the tube burst. Kathy was rushed to the nearest hospital, not a Navy facility. She needed immediate surgery and a blood transfusion. The couple was told the Navy doctor would be reprimanded.

A year later, Richelle was born. It would be a decade before the family knew anything was wrong, that in an era before blood was tested for HIV, the blood Kathy had received was tainted.

* * *

Brown spots appeared on her mother's thighs in 1990. By then, the family was in Maryland, and her mother was sent to the National Naval Medical Center in Bethesda. Doctors saw the blood transfusion on her mother's medical charts and ordered an HIV test.

Richelle's parents told her and her older sister over ice cream. Richelle remembers crying, that her mother's pill case beeped when it was time to take medication, and being told she and her sister would have to be tested.

Dr. Richard Moriarty, then a Navy doctor, remembers thinking she didn't look like a child with HIV. A day after her 10th birthday, he told her family. Richelle was positive.

* * *

Some people didn't understand. In a home economics class, one classmate refused to cook in her kitchen. Another time, kids said they didn't want her swimming in a lake. When she went to college, her school and soccer coach knew, but she didn't initially tell friends.

She waited a semester, then told her soccer team. There were never any questions. But when she told her roommate, their relationship soured. By the end of the semester, Richelle was sleeping on friends' floors.

* * *

In graduate school, Richelle knew she wanted to study HIV policy and said so in introductions. Someone asked why, just making conversation.

"Because I'm HIV positive, " she said.

Her frankness impressed a classmate, Jeff Starnes.

They didn't know each other well, but in 2003 Richelle's mom died of complications from AIDS. Jeff sent Richelle a card.

They started dating, but Jeff was hesitant to kiss her. He went with Richelle to her doctors in Bethesda and asked a lot of questions.

They also went parasailing and hot air ballooning and to New York, where they saw the musical Rent. Her mom had wanted to do some of the same things, but never got the chance. Later, Jeff had another question. Would she marry him? She said yes.

But trouble started soon after. For years, Richelle had flown to Maryland to see her doctor and get medication. She'd participated in research studies and talked to medical students about her disease. With regular medication, her viral load - the amount of HIV in her blood - is undetectable.

* * *

In 2005, the Navy told Richelle she'd need to get treatment elsewhere. Her case did not satisfy the "compelling criteria" for a special designation that would extend her care, the Navy wrote.

Working through two congressmen, she's managed to get her care extended - one year at a time.

She and Jeff moved to Florida, where he works in law enforcement. Through artificial insemination and months of planning, they had a baby, Braden, last July. As a precaution, doctors had them feed the newborn tiny syringes of antiviral medication for weeks. Tests show he is HIV-free.

On June 22, she got her decision on care for this year. The Navy will let her see their doctors but will no longer pay for hospitalization or for her medication, which costs thousands of dollars a year.

"They can't make what they caused right, " Richelle said. "They can't bring my mother back. They couldn't promise me a future. What they could do was take care of the medical side of it."

The doctor and nurse who treated her as a child agree, and wrote the Navy. That promise was one reason the family never thought of suing and doesn't have a lawyer now.

The Navy reviewed the decision again at the request of Richelle's U.S. representative, Tom Feeney. Assistant Navy Secretary William A. Navas Jr. said he was sympathetic to the situation, but the program under which she got treatment was "not intended to provide lifelong care."

Without help from the Navy, Feeney, a Central Florida Republican, said he will look at writing a personal bill for Richelle, one Congress could pass to grant her care.

Amite mayor held liable in malpractice suit

Also doctor, town’s chief sued for not treating patient
AMITE — A Tangipahoa Parish jury found that an Amite family physician’s failure to treat a diabetic patient’s rising blood sugar levels led to the ailing man’s dementia and institutionalization for the last three years of his life.

That same jury handed down an $814,079 award on June 22 for damages against Dr. Reggie Goldsby, who also is mayor of the town, for the pain and suffering of the late Marion Hendry and his only daughter, Tanya Hendry Sparks, court records show.

In 2000, Sparks, acting on her father’s behalf, filed a medical malpractice complaint in the 21st Judicial District Court against Goldsby and Hood Memorial Hospital in Amite. After that, she filed a lawsuit seeking damages in 2003 against Goldsby, his liability insurance company and the hospital.

The hospital was dropped from the suit before trial, Sparks’ attorneys said.

According to court records, Marion Hendry entered Hood Memorial Hospital in Amite for treatment of a swollen hand on March 13, 2000.

Eleven days later, he suffered from dementia and dehydration and his health had declined so severely that he was unresponsive. As a result, Hendry’s daughter had him transferred to another hospital, North Oaks Medical Center in Hammond, court records show.

Hendry, a retired high school teacher and former assistant superintendent for the Tangipahoa Parish School System, never recovered from his dementia and died three years later in an assisted living facility, said Hendry’s attorneys, Charles Moore and Patrick Boryles.

A medical examination board, a panel of doctors who determine whether medical personnel are at fault in malpractice complaints, found that Goldsby failed to treat Hendry, a known non-insulin dependent diabetic, for his rising blood sugar levels while under his care at Hood. That failure likely led to his failing health and dementia while at Hood, the board decided in April 2003, court records show.

The board found that Goldsby failed to follow “standard practices of care” in treating Hendry, according to court records.

However, the medical examination board did not link Goldsby’s mistake to Hendry’s permanent disability and dementia. Instead, a trial jury was charged in 2003 with determining whether Goldsby caused Hendry’s injuries, Moore said.

After a four-day jury trial and two hours of deliberations on June 22, the jurors found that Goldsby’s breach in care led to Hendry’s declining physical and mental health and eventual death on Nov. 28, 2003.

Goldsby did not return telephone messages seeking comment. His attorney, James Strain, also did not return calls, but his staff said Strain was in Shreveport Tuesday and Wednesday working on another case.
Advocate Florida parishes bureau

Are doctors' malpractice premiums unfair?

Insurance companies have said for years that they're paying more and more in medical malpractice claims as they push for caps on lawsuits, like the cap approved in Idaho. But a new study shows claims have been decreasing for seven years while the insurance premiums continued to rise. Report author Jay Angoff with the American Association of Justice says it looks like the insurance companies are overcharging doctors.

"The amount they project that they're going to be paying out in the future has decreased by 48 percent over the last four years, yet rates have been going way up," Angoff told SVO. "This makes no sense."

The insurance industry has criticized the report, saying it doesn't take into account all insurance company liabilities, and that profits are low in the malpractice sector compared to other insurance categories. Angoff based his report on company filings with state governments.

Angoff says doctors don't have time to do their own investigations of insurance company claims and don't seem to suspect anything is amiss.

"They believe what the insurance companies tell them about malpractice claims going up, when in fact, they're going down, and therefore they accept these rate increases."
By Gary Stivers

Pa. physicians fearing boost in malpractice insurance fees

Pennsylvania's doctors, especially high-risk surgeons and physicians from the east who pay higher medical malpractice rates, worry that a state-mandated change in insurance could result in an overnight 25 percent increase in their premiums.

Any doctor who does the majority of his work in Pennsylvania is required by state law to carry at least $1 million in liability insurance. The first $500,000 is covered by the doctors through the private insurance market. The next $500,000 in coverage is purchased through the state's MCARE program, which charges doctors an assessment, then pays claims out of that group fund.But the state Department of Insurance is mulling a change that would require doctors to purchase the first $750,000 on the open market -- either through a private insurer, or through doctor-run organizations known as risk-retention groups and insurance exchanges.

The hope is that the state has recovered from what physicians groups billed a medical-malpractice crisis three years ago, and that there are enough insurers underwriting enough products to drive down costs organically.

Doctors say that's not the case yet.

"I believe that it could destabilize the medical malpractice marketplace," said Dr. Lewis Sharps, a spinal surgeon from Chester County, "and reactivate the crisis we faced from 2002 to 2004."

Dr. Sharps has a unique vantage point: In addition to being a high-risk surgeon, he's also the CEO of a medical insurer called the Positive Physicians Insurance Exchange.

His company paid for an actuarial analysis of what might happen if the shift takes place -- an orthopedic surgeon whose med-mal insurance was $60,000 annually would see the payment jump to $75,000.

"It's a very significant concern," Dr. Sharps said. "Many physicians don't even know this is going on."

What's going on is this: The Insurance Department is analyzing the state's marketplace to determine whether there's enough underwriting capacity to shift med-mal liability away from the state and into the private market. The shift, as a side effect, could save Pennsylvania about $70 million of the roughly $120 million that is now spent on MCARE abatements, which are financed by cigarette tax money.

High-risk specialists get full abatements in their MCARE assessments, meaning the extra $500,000 in coverage costs them nothing, wiping out what otherwise would be a bill of tens of thousands of dollars. Lower-risk doctors get a lesser abatement.

The insurance commissioner is supposed to issue a decision by this week regarding the shift, and changes, if they are authorized, would go into effect in January, without legislative authorization.

By law, the insurance commissioner reviews the marketplace capacity every two years -- the last time this happened, in 2005, then-Commissioner Diane Koken announced that there would be no change in the 50-50 split.

Doctors fear that this year could be different, because two years of relative calm on the med-mal front have led to more stable rates and new carriers. In the last three years, for example, about 30 new carriers have begun offering services in the state -- though that's not necessarily reflective of a fully healthy market, since most of those carriers do only a sliver of business here.

State Rep. Todd Eachus, D-Luzerne County, viewed as an ally of the medical community, said it's too early for the Insurance Department to declare the marketplace healed. That's because the full effects of the raft of med-mal reforms enacted in 2004 won't be known for another year or two.

"I really don't want anyone meddling with the Legislature's work at this point," the representative said. "It was a difficult debate. There was a lot of finger-pointing" among legislators, lobbyists, the medical community and attorneys. Mr. Eachus has sent a letter to the governor, asking him to delay the shift.

Doctors also hope to prod the state Legislature and the governor to reauthorize the state's MCARE abatement program, which expires annually. Much of the would-be cost of the state's insurance assessment is defrayed by the abatement fund.

Historically, renewal hasn't been a major political issue, in large part because of the persistence of the state's many doctors and surgeons' lobbying groups. In recent years, they've sought reductions in their medical malpractice premiums, a medical school loan repayment program, caps on "pain and suffering" jury awards and a change in litigation rules forbidding "jury shopping" -- the practice of moving a case from county to county in search of a jury more sympathetic to a given malpractice plaintiff.

Some legislators have complained of "doctor fatigue," while many doctors say the state hasn't gone far enough to make Pennsylvania an attractive place in which to practice, thanks to high med-mal rates and lower-than-average service reimbursements from insurance companies.
By Bill Toland, Pittsburgh Post-Gazette