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2013 YP Award Essay 6
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2013 Winner - Essay 6

The Doctors Company Foundation Young Physicians Patient Safety Award

I helped Ms. G from the wheelchair to the cold examining table. She was an 88-year-old woman with a history of coronary artery disease, congestive heart failure, type 2 diabetes mellitus, and obesity. She was my first patient on the oncology service. She had previously been evaluated by a local oncologist, who diagnosed her with an aggressive form of stomach cancer. She was told that she would not be a suitable candidate for surgery or chemotherapy.


I introduced myself to Ms. G and her family as the third-year medical student who would be part of the team taking care of her. I explained that I would be asking her several questions about her medical history and performing a physical examination before the supervising physician, Dr. M would be joining us. I listened intently as Ms. G told me her story.


Ms. G became a widow at the age of 30 and raised her four children as a single mother with three jobs. She was proud to be the head of her family. Though she had multiple medical problems, she had always “bounced back” from every medical obstacle. When she started to develop abdominal pain, Ms. G dismissed her symptoms for 6 months before she presented to the emergency room with coffee-ground emesis and a hematocrit of 18. An upper endoscopy demonstrated a large mass in the lesser curvature of her stomach. She remained in the hospital for 12 days and then was discharged to a skilled nursing facility. While in the hospital, the oncologist informed Ms. G that the mass was a gastric adenocarcinoma with signet ring cell features. She was told that though the cancer had not spread, her disease was very aggressive and that hospice was the only realistic option. Ms. G went on to say that life had never been too kind to her, but she was a fighter and that she wanted to fight until her last breath. I was inspired by her determination and believed that maybe we, the large academic teaching hospital, would be able to provide her some hope to treat her cancer. Ms. G and her family came to clinic that day for a miracle.


Though I had only been doing clinical rotations for a few months, I knew how rare it was for outside hospital records to be complete; however, to my surprise Ms. G’s family came prepared with consult notes, imaging and pathology reports, and CDs with all of the imaging studies from her hospitalization. After stepping out of the examining room and presenting to Dr. M, we headed back into Ms. G’s room.


Ms. G, her family and I were all anxiously awaiting to hear what Dr. M had to say. Dr. M stated that the best course of action for Ms. G would be to focus on the quality of her life. Dr. G emphasized that hospice care would provide her with home health services to keep her comfortable for the remainder of her life. Ms. G and her family had a few questions. Then it was time to move on to the next patient in the next room.


Dr. M asked the family to request that the tissue blocks be sent from the community hospital to the pathology department for review. I completed my 2-week rotation in the oncology clinic and never heard about Ms. G. Two months later, I was doing my pathology elective and reviewing tissue blocks and slides. Ms. G’s story popped into my head and I asked the pathology resident if she could help me locate the results for Ms. G’s specimen. The pathology report read, “high–grade diffuse large b-cell lymphoma.” This was not gastric adenocarcinoma. I emailed Dr. M about these findings and he was shocked to see that this was not stomach cancer but rather lymphoma, a curable disease. Dr. M had never been notified about these results.


Dr. M contacted Ms. G and her son picked up the phone. He said that Ms. G had passed away from a massive upper GI bleed three weeks ago. When I learnt about Ms. G’s death, I was overwhelmed with guilt, frustration, and remorse.


How could a top institution allow simple information flow to prevent patient care? I could not stop thinking that Ms. G had a potentially curable cancer but she never had the chance to fight for her life simply because her pathology results were never sent to Dr. M. In my investigation to find the holes in this process, I learned that the computer system and electronic medical records in the hospital did not have built in capabilities to communicate any results to the ordering physician. Additionally, the availability of pathology results is highly variable, especially if the pathologist is waiting for the tissue block to be sent from an outside facility. Each department claimed that the other department was responsible for ensuring appropriate follow up. This lack of accountability and coordination in every step captures the breakdown of information flow needed for patient safety.


The Centers for Medicare & Medicaid Services emphasizes that health information systems have three major outcomes: quality, safety, and costs. Hospitals must provide health care providers with the tools needed to deliver and access medical information in a timely manner to provide necessary medical care. Each institution must take the initiative to continuously evaluate and assess how information is transmitted to and from providers to provide meaningful patient care. Unless implementation of such policies is enforced, the goals of providing optimal care through the use of electronic health records will not be achieved. Doctors are expected to honor the Hippocratic oath and execute their duty towards their patients by providing appropriate medical care. Every effort should be made by hospitals to help clinicians uphold this responsibility. All processes have some design flaws, but the health care system is slow to react to these issues. Although many of these mistakes may be inconsequential, some may be the difference between life and death.


*Please note that all pieces of possible identifying information (names, dates, locations, etc.) have been changed for purposes of privacy.

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