Welch Company
San Francisco, CA
S U M M A R Y
DIARY: April 16, 2004 10:45 AM Friday;
Rod Welch
Meeting at Kaiser with the doctor preparing to start treatments.
1...Summary/Objective
2...Recovery Progress CA 15-3 Cancer Marker Rises from 60 to 70
3...CA 15-3 Cancer Marker Continues Strong Rise Consistent with Pathology
4...Rise in CA 15-3 Cancer Marker Attributed to Trauma of Biopsy
5...Treatment Scheduled to Recover from Cancer in Neck Lymph Nodes
6...Cancer Cells Reported in Biopsy of Lumps in Neck Treatment Scheduled
7...Chemotherapy Prescribed Surgery Not Effective for Lymph Node Cancer
8...Surgery Not Prescribed for Lymph Node Cancer Chemotherapy Scheduled
9...Rosalie's Assistant Stephanie Introduced
10...Tumor Board Report Not Submitted to Patient Verbal Explanation
11...2nd Opinion Verify Scope of Problem and Treatment Planning
12...Cancer Neck Only Evidence of CT Scan Shows Distant Metastasis
13...CT Scan Shows Evidence of Distant Metastasis Carcinoma Only in Neck
14...Medical Tests Analysis Erroneous Incomplete Cursory Limited Time
15...Separate Signal from Noise in Documents Case Study Not Enough Time
16...Case Study Not Enough Time to Study Test Reports Discover Variances
17...CT Test Reporting Variance Language Terminology Scope Cause Errors
18...Medical Mistakes Case Study Patient History for Millie
19...Case Study Limited Time Weakens Health Care Diagnosis Treatment
20...Medical Tests Require Careful Review for Effective Diagnosis Study
21...Distant Metastasis Cancer Neck Only Evidence of CT Scan Shows
22...Chemotherapy Cleared to Start Avastin Trials
23...Treatment Proceeds Diagnosis Cellulitus Changed to Radiation Reaction
24...Redness Breast Diagnosis Changed from Cellulitus to Radiation Reaction
25...Radiation Reaction Redness Breast Diagnosis Changed from Cellulitus
26...Blood Tests Causing Painful Condition on Right Arm
27...Port to Support New Treatments Administered Intravenously
..............
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CONTACTS
SUBJECTS
Meeting Doctor Examination Clear Patient for 1st Treatment Taxol Bev
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 67 0000. ref SDS 65 0000.
040502 -
040503 -
040504 -
040505 -
040507 - ..
0406 -
0407 -
0408 - Discussion
0409 -
040901 - Recovery Progress CA 15-3 Cancer Marker Rises from 60 to 70
040902 - CA 15-3 Cancer Marker Continues Strong Rise Consistent with Pathology
040903 -
040904 - Follow up ref SDS 67 SM6M, ref SDS 65 SM6M.
040905 -
040906 - There were no new blood tests reported today on CA 15-3.
040908 - ..
040909 - 040318......... 70 H............. 040211, ref SDS 65 SM6M
040910 - 040205......... 60 H............. 040211, ref SDS 61 SM6M
040911 - 031205......... 62 H............. 031205, ref SDS 60 SM6M
040912 - 030915......... 66 H............. 030913, ref SDS 58 SM6M
040913 - 030708......... 68 H............. 030710, ref SDS 57 SM6M
040914 - 030503......... 54 H............. 030508, ref SDS 53 SM6M
040915 - 030403......... 45 H............. 030403, ref SDS 53 SM6M
040916 - 030220......... 46 H............. 030220, ref SDS 52 5E6L
040917 - 030106......... 37 H............. 030109, ref SDS 50 SM6M
040918 - 021202......... 41 H?............ 021204, ref SDS 46 SP5G
040919 - 021102......... 36 H?............ 021113, ref SDS 45 Y65I
040920 - 021023......... 33 H?............ 021023, ref SDS 44 SQ5I
040921 - 020930......... 33 H?..29........ 021002, ref SDS 43 SQ5I
040922 - 020917......... 36 H?............ 020924, ref SDS 42 SQ5I
040923 - 020717......... 59 H?............ 020726, ref SDS 41 YN5K
040924 - 020629......... 75 H ............ 020705, ref SDS 39 UX6I
040925 - 020608........ 67 H ............ 020614, ref SDS 35 0001
040926 - 020603........ 108 H ............ 020607, ref SDS 33 X67F
040927 - 020511........ 117 H ............ 020603, ref SDS 32 PJ4J
040928 - 020419......... 81 H ............ 020430, ref SDS 28 7N5H
040929 - 020321......... 85 H ............ 020405, ref SDS 17 6T8K
040930 -
040931 -
040933 - ..
0410 -
0411 -
0412 - Analysis
0413 -
041301 - Rise in CA 15-3 Cancer Marker Attributed to Trauma of Biopsy
041302 -
041303 - Follow up ref SDS 67 GJ5M, ref SDS 65 GJ5M.
041304 -
041305 - There was no further discussion today on CA 15-3.
041306 -
041307 -
041308 -
041309 -
041310 -
0414 -
SUBJECTS
Cancer Cells Detected in Biopsy of Lumps in Neck Taken on 040303 by
Trial on New Cancer Treatment Double Blind Test Alternative Approach
Treatment Relapse Patient Approved Begin Taxol Bevacizumab (Avastin)
Treatment Relapse Testing Indicates Swelled Lymph Nodes in Neck is O
Treatment Cancer and Trial on New Cancer Treatment Double Blind Test
Approves Clears Millie for Receiving Cancer Treatments Enrolled in A
Treatment Patient Approved Begin Taxol Bevacizumab (Avastin) Chemoth
Avastin Patient Randomized Approved 1st Taxol Bevacizumab Treatment
1910 -
191101 - ..
191102 - Treatment Scheduled to Recover from Cancer in Neck Lymph Nodes
191103 - Cancer Cells Reported in Biopsy of Lumps in Neck Treatment Scheduled
191104 - Chemotherapy Prescribed Surgery Not Effective for Lymph Node Cancer
191105 - Surgery Not Prescribed for Lymph Node Cancer Chemotherapy Scheduled
191106 -
191107 - Follow up ref SDS 67 8R6M, ref SDS 65 8R6M.
191109 - ..
191110 - Treatments begin on 040420, advised by Rosalie in a call on 040407.
191111 - ref SDS 68 3S6L
191112 -
191113 - Stephanie Aguilar came into the exam room prior to the doctor
191114 - arriving and reported that Millie has been randomized by the folks
191115 - managing the trial, and she has been selected to receive the
191116 - bevacizumab, ref OF 10 QR4J, also, called VEGF and Avastin, per
191117 - planning on 040318. ref SDS 65 BK8M
191119 - ..
191120 - Stephanie seemed very pleased with this announcement. He hugged
191121 - Millie, and noted that others on the staff are pleased that Millie
191122 - will receive the new treatment. She indicated that the past few
191123 - patients placed in the trial at the Kaiser Walnut Creek facility
191124 - were not selected to get the new drug.
191125 -
191126 - [On 040420 Stephanie visited Millie briefly in the Chemotherapy
191127 - treatment center. ref SDS 74 014F
191129 - ..
191130 - A colleague, also, stepped into the examination room and was
191131 - equally effusive about Millie having been placed in the group to
191132 - receive bevacizumab.
191134 - ..
191135 - When the doctor finally arrived for the meeting, he, too, was very
191136 - pleased that Millie will be treated with the new drug.
191138 - ..
191139 - The doctor reviewed results of CT test shown below, and commented that
191140 - the swelled lymph nodes in the neck are the only indications of
191141 - cancer. ref SDS 0 WE7N
191143 - ..
191144 - The doctor examined lumps in the neck and commented that they feel
191145 - bigger, than when he made a similar examination on 040318. ref SDS 65
191146 - 565L which aligns with the CT test results. ref SDS 0 7U6O The doctor
191147 - used an ordinary ink pen and drew a circle around each of the two
191148 - lumps in Millie's neck. He then used an instrument, that seemed
191149 - similar to a rolled cloth measuring tape, commonly found in a sewing
191150 - kit, to measure the diameter of each swelled node.
191152 - ..
191153 - The doctor indicated the report shows that cancer is limited to the
191154 - neck area. ref SDS 0 IG9K While this is not expressly stated in the
191155 - report, the findings appear to show there has been some expansion of
191156 - lymph nodes in the neck, since the prior report received on 040318,
191157 - per above. ref SDS 0 7U6O
191159 - ..
191160 - What are implications from rate of growth for lymph nodes in the neck
191161 - -- normal, below or above average?
191162 -
191163 -
191164 -
191165 -
191166 -
1912 -
SUBJECTS
Treatment Patient Approved Begin Taxol Bevacizumab (Avastin) Chemoth
2203 -
220401 - ..
220402 - Rosalie's Assistant Stephanie Introduced
220403 -
220404 - Follow up ref SDS 67 WW7I.
220405 -
220406 - Prior to meeting with the doctor, Stephanie Aguilar came into the
220407 - examination room and introduced herself. Earlier, in a letter on
220408 - 040410 Rosalie explained that Stephanie is Rosalie's assistant.
220410 - ..
220411 - In her letter, Rosalie provided a backup up email address for
220412 - contacting the protocol team.
220413 -
220415 -
220416 -
220417 -
220418 -
2205 -
SUBJECTS
Tumor Board Hearing Today Report Not Submitted to Patient Verbal Exp
2503 -
250401 - ..
250402 - Tumor Board Report Not Submitted to Patient Verbal Explanation
250403 - 2nd Opinion Verify Scope of Problem and Treatment Planning
250404 -
250405 - Follow up ref SDS 67 AW6M, ref SDS 65 AW6M.
250407 - ..
250408 - The doctor reported that he presented Millie's case to the Tumor Board
250409 - this morning, in accordance with Millie's letter on 040409,
250410 - ref SDS 69 HS3O, and Debra's call later that day, ref SDS 69 7K4G, and
250411 - further in accordance with notice to Millie on 040414 about the
250412 - hearing today. ref SDS 70 HS3O
250414 - ..
250415 - Millie requested a copy of Tumor Board procedures, and the report
250416 - showing what was reviewed, findings and recommendations.
250417 -
250418 - Published procedures were not submitted.
250420 - ..
250421 - The doctor did not submit any written reports he may have
250422 - submitted to the board showing what records were reviewed to guide
250423 - recommendations.
250425 - ..
250426 - Results of Tumor Board Hearing have not yet been published...
250427 -
250428 - The doctor said that the Tumor Board suggested radiation may be
250429 - helpful in Millie's case, since it apears from testing that at
250430 - this time cancer recurrence is localized to the neck.
250431 -
250432 - [On 040517 doctor submits pathology report on biopsy for
250433 - left breast taken on 040419, ref SDS 73 789F, and it
250434 - diagnoses metastatic disease consistent with inflammatory
250435 - carcinoma. ref SDS 77 7D6F
250437 - ..
250438 - [On 040614 doctor reports Millie has been diagnosed with
250439 - IBC, ref SDS 78 6T5G, and changed to the most severe cancer
250440 - treatment level of stage IV. ref SDS 78 6M9H
250442 - ..
250443 - Millie asked for the actual published report.
250445 - ..
250446 - The doctor said the Tumor Board will submit a written report; the
250447 - doctor will submit a copy to the patient along with published policy
250448 - and procedures that guide Tumor Board hearings and disposition, per
250449 - Millie's request. ref SDS 0 F46M
250450 -
250451 - [On 040517 doctor submits written report on findings and
250452 - conclusions of Tumor Board hearing to support Team Care practice
250453 - in Millie's case. ref SDS 77 MB7G
250454 -
250455 -
250456 -
250457 -
250458 -
250459 -
2505 -
SUBJECTS
PET Scan Findings Show Previous Metastatic Lymphadenopathy No Longer
Metastasis New Nonspecific May be Post Treatment Trauma Inflammatory
CT Scan Performed for Comparison with PET Scan to Evaluate New Metas
CT Scan Findings Show Previous Metastatic Lymphadenopathy No Longer
Axilla and 18 MM Referenced CT Report 040410 Received 040416 Says 18
CT Scan Findings Show 2 New 1 CM Masses in Area of Prior Surgery for
Distant Metastasis Not Reported in CT Test on 030508
CT Scan Findings Show 1 CM Masses Increased to 1.5 CM 50% Growth
CT Scan Test Ordered Instead of PET Scan Test and Compare with Origi
CT Scan Test Shows No Evidence Progression Distant Metastasis Stable
CT Test 040410 Shows Cancer Lymph Nodes No Increase Size Growing No
3713 -
371401 - ..
371402 - Cancer Neck Only Evidence of CT Scan Shows Distant Metastasis
371403 - CT Scan Shows Evidence of Distant Metastasis Carcinoma Only in Neck
371404 -
371405 - Follow up ref SDS 67 LK5L, ref SDS 65 LK5L.
371406 -
371407 - The doctor used a computer in the examination room, which was
371408 - running the Windows 2000 operating system. This is new capability
371409 - from prior visits, reflecting improvements on information management
371410 - planned for release in 2001, reported by Jeanne Bradly on 000121.
371411 - ref SDS 4 CG61
371413 - ..
371414 - The doctor found on Kaiser's computer the report for the CT test on
371415 - 040410, which was ordered on 040402 by Rosalie, as a condition of the
371416 - Avastin trial protocol. ref SDS 67 LK5L Today, the doctor printed the
371417 - report and submitted it to Millie during the meeting. The report
371418 - shows...
371419 -
371420 - [On 040811 received CT test after 3rd treatment cycle.
371421 - ref SDS 79 WV7H
371423 - ..
371424 - Patient
371427 - ..
371428 - Personal Physician:
371431 - ..
371432 - 68/F Radiology Report Exam 1 of 1
371433 - Page 1
371435 - ..
371436 - CT of the head, neck, chest and abdomen and pelvis (digital)
371438 - ..
371441 -
371442 - ** A D D E N D U M E X I S T S B U T N O T F I N A L I Z E D**
371444 - ..
371445 - History
371447 - ..
371448 - Breast CA
371450 - ..
371451 - Findings
371453 - ..
371454 - The ventricles and sulci are symmetrical and normal. There is no
371455 - abnormal contrast enhancement. There are no abnormal high or low
371456 - attenuating lesions seen. There are no parenchymal or
371457 - extra-axial hemorrages seen.
371459 - ..
371460 - The skull base and nasopharynx are normal. There is no
371461 -
371462 - ** A D D E N D U M E X I S T S B U T N O T F I N A L I Z E D**
371463 -
371464 - hypopharyngeal mass. The sinuses are clear. There is no cervical
371465 - adenopathy aside from the 1.3 mm left posterolateral retro
371466 - sternocleidomatoid node and a 14 mm left scaline node.
371468 - ..
371469 - Compare 040307:
371471 - ..
371472 - There are 18 mm nodes in both axili, unchanged from prior study,
371473 - post op changes are seen on the left. There is stable left
371474 - apical interstitial septal change. The lungs are otherwise
371475 - clear, free of infiltrates or masses. There are no pleural
371476 - effusions. There are no hilar or mediastinal masses seen.
371477 -
371478 - [On 040811 CT test after 3rd treatment cycle seems to indicate
371479 - 18 mm nodes in axili are now about 9 mm. ref SDS 79 RU45
371480 -
371481 -
371482 -
3715 -
SUBJECTS
Case Study Medical Mistakes Diagnosis CT PET Tests IBC Pulmonary Emb
7703 -
770401 - ..
770402 - Medical Tests Analysis Erroneous Incomplete Cursory Limited Time
770403 - Separate Signal from Noise in Documents Case Study Not Enough Time
770404 - Case Study Not Enough Time to Study Test Reports Discover Variances
770405 - CT Test Reporting Variance Language Terminology Scope Cause Errors
770406 -
770407 - Neither the term "axili" nor the number "18" seem to appear in the
770408 - prior report received during the meeting on 040318. ref SDS 65 LK5L
770409 - Therefore, in order for "18 mm nodes" to be "unchanged," as reported
770410 - today, ref SDS 0 EH47, descriptions in the prior report must be
770411 - different, but intended to mean the same thing.
770413 - ..
770414 - Variance in terminology, quality, and scope of medical test reports,
770415 - ranging from thorough and comprehensive to cursory and neglegent,
770416 - including lack of notice about symptoms and diagnoses buried within
770417 - long paragraphs cause doctors with hectic schedules to rely solely on
770418 - first impressions from reading a summary with the gist of findings,
770419 - rather than actual findings. Busy doctors with limited span of
770420 - attention, and in some cases inattention, and sloth, cited 010908
770421 - discussing the "fools gold" of "expediting," ref SDS 6 YF5O, overlook
770422 - critical details that influence care. Practitioners with limited time
770423 - for study and analysis due to a hectic schedule caring for many
770424 - patients, and managing a department, reported on 020321, ref SDS 12
770425 - MK4J, get frustrated when small, complex details that seem
770426 - inconsequential later explode into major problems, reported on 921127.
770427 - ref SDS 2 0674
770429 - ..
770430 - [On 040517 lessons learned doctors do not have enough time to read
770431 - complex medical test reports and correlate clinically with complex
770432 - patient history. ref SDS 77 VG6U
770434 - ..
770435 - [On 050517 case study cognitive overhead shows culture resists due
770436 - diligence to collaborate, communicate, investigate, study,
770437 - analyse, and verify accuracy that levearages experience for taking
770438 - effective action, because people do not have time to think.
770439 - ref SDS 91 PY4U
770441 - ..
770442 - [On 060628 testimony before US Congress reports national security
770443 - intelligence analysis cursory, incomplete, inaccurate; warns
770444 - leadership to spot check bibliography. ref SDS A9 SY3O
770446 - ..
770447 - A color coded scheme might be considered to provide alerts in test
770448 - reports for overcoming limited span of attention to expand situational
770449 - awareness (see NWO, ref OF 29 08XX) of clinical correlations during
770450 - the "fog of war," as described in NWO. ref OF 28 159O
770451 -
770452 -
770454 - ..
770455 - Medical Mistakes Case Study Patient History for Millie
770456 - Case Study Limited Time Weakens Health Care Diagnosis Treatment
770457 - Medical Tests Require Careful Review for Effective Diagnosis Study
770458 -
770459 - Examples of limited time influencing analysis in medical management,
770460 - causing meaning drift, compounding mistakes, bumbling, conflict,
770461 - crisis, and calamity...
770463 - ..
770464 - 1. Meeting productivity poor, example
770465 - in other fields; communication
770466 - collaboration cognitive overhead
770467 - avoids investing time to review
770468 - documents for accurate understanding
770469 - people rely on official view of
770470 - reality that emerges from repeating
770471 - guess and gossip over time in
770472 - meetings and correspondence........... 920123, ref SDS 1 9054
770474 - ..
770475 - 2. Doctors scheduled to see
770476 - patients every 15 minutes
770477 - do not have time for analysis
770478 - to review the record.................. 000207, ref SDS 5 0788
770480 - ..
770481 - 3. Emergency pulls doctor from
770482 - examination; diverts attention
770483 - and compresses time to understand
770484 - critical details causing errors
770485 - due to stress......................... 020726, ref SDS 41 YT6L
770487 - ..
770488 - 4. Doctors do not have time to
770489 - perform Kaiser requirements for
770490 - "ping pong" method to review
770491 - feedback from patient that
770492 - verifies accurate and complete
770493 - communication......................... 020402, ref SDS 15 KG4H
770495 - ..
770496 - 5. Doctors invest a lot of time
770497 - sending email to other doctors
770498 - so there is not enough time to
770499 - communicate with
770500 - patients.............................. 020708, ref SDS 40 EY9N
770502 - ..
770503 - 6. PET test on 021218 reports findings
770504 - of new mild diffuse increased uptakes
770505 - at region of left supraclavicular,
770506 - left upper chest, and, also, left axilla;
770507 - not enough time to align and correlate
770508 - clinically with increased discomfort
770509 - under left arm, clincial finding of
770510 - inflammation on left breast, and
770511 - patient reports stiff neck fits
770512 - diagnosis for IBC..................... 030109, ref SDS 50 L66M
770514 - ..
770515 - 7. Emergency meeting with doctor requested
770516 - to evaluate recurrence inflammation left
770517 - breast rising discomfort left
770518 - axillary.............................. 030606, ref SDS 54 7C6W
770519 - rising cancer marker.................. 030606, ref SDS 54 NE7L
770520 - doctor defers biopsy testing to
770521 - diagnose symptoms
770522 - of IBC................................ 030606, ref SDS 54 P97J
770524 - ..
770525 - 8. CT scan test on 030626 finds
770526 - persistant dermal (skin)
770527 - thickening left breast; notes
770528 - invasion of dermal lymphatics
770529 - from known breast cancer can
770530 - present similarly; left axillary
770531 - adenopathy nodes measuring 1.5 cm
770532 - increase 50% from prior study,
770533 - but not expressly stated;
770534 - findings attributed to radiation
770535 - treatment a year earlier; test
770536 - report recommends correlate
770537 - clinically; not enough time to
770538 - separate signal from noise by
770539 - correlating symptoms reported
770540 - on 030109 and PET test findings
770541 - that cite all three elements of
770542 - IBC diagnosis delayed until
770543 - 040614................................ 030710, ref SDS 57 VM7I
770545 - ..
770546 - 9. Not enough time to review
770547 - test reports to prepare for
770548 - meeting............................... 030710, ref SDS 57 7C6W
770550 - ..
770551 - 10. Biopsy and PET scan tests deferred
770552 - again to evaluate recurrence of
770553 - breast cancer so that treatment
770554 - can start in time to be
770555 - effective............................. 030710, ref SDS 57 WS3M
770557 - ..
770558 - 11. Patient requests PET scan and other tests
770559 - to evaluate treatment of rising symptoms
770560 - which later were discovered to be IBC;
770561 - Kaiser defers testing
770562 - again................................. 030915, ref SDS 58 7C6W
770564 - ..
770565 - 12. CT test on 031031 described by
770566 - doctor as "great" prognosis for
770567 - patient during progress review
770568 - meeting at Kaiser..................... 031205, ref SDS 60 LK5L
770570 - ..
770571 - 13. 2 lymph nodes increased 50% in prior
770572 - CT test on 030710, not reconciled in
770573 - follow up test on 031031 without
770574 - any treatment......................... 031205, ref SDS 60 GJ69
770576 - ..
770577 - 14. CT scan recent tests on 030710 and
770578 - 031031 doctor cannot find reports
770579 - in medical chart to check for errors
770580 - and omissions from prior work on
770581 - 031205 to diagnose and treat cancer
770582 - relapse; Kaiser's computer system
770583 - out of service temporarily for
770584 - repairs; doctor will investigate
770585 - later................................. 040227, ref SDS 62 YE4F
770587 - ..
770588 - 15. CT test errors and omissions not
770589 - enough time to research doctor cannot
770590 - find test reports in patient's
770591 - medical chart nor on Kaiser's
770592 - computer system....................... 040318, ref SDS 65 ZE5O
770594 - ..
770595 - 16. Accuracy and precision paramount
770596 - for medical practice shown by
770597 - requirements for audits of
770598 - Kaiser's medical
770599 - records............................... 040402, ref SDS 66 6E4K
770601 - ..
770602 - 17. Doctor failed perform follow up examinations
770603 - for surgery; limited time and computer
770604 - glitch prevent doctors from
770605 - implementing team care
770606 - requirements.......................... 040419, ref SDS 73 XU75
770608 - ..
770609 - 18. Primary care physician cites Kaiser policy
770610 - on proactive management to order biopsy
770611 - for accurately diagnosing red rash in this
770612 - case on the left) breast, first noticed
770613 - on 030109; but invariably results are
770614 - negative, so this time the policy was
770615 - ignored to save time and money; it
770616 - turned out the patient has IBC
770617 - which some authorities
770618 - say has 18 months
770619 - survival.............................. 040504, ref SDS 76 WI8F
770621 - ..
770622 - 19. Medical test reporting erroneous,
770623 - cursory, and misleading; language
770624 - variance and burying notice of symptoms
770625 - in long narrative on findings; busy
770626 - doctors only have time to read analysts'
770627 - impressions that summarize the gist
770628 - of findings, overlook diagnosis that
770629 - requires investigation and timely
770630 - treatment............................. 040416, ref SDS 0 PTSX
770632 - ..
770633 - 20. Tumor Board re-hearing new evidence
770634 - biopsy diagnosis IBC very rare, very
770635 - aggressive cancer major change patient
770636 - profile doctor fails to update findings
770637 - and recommendations on treatment
770638 - plan.................................. 040517, ref SDS 77 4R59
770640 - ..
770641 - 21. Family history of blood clot problems
770642 - reported to doctor.................... 040812, ref SDS 80 MG5K
770644 - ..
770645 - 22. Doctor orders patient continue on clinical
770646 - trial for bevacizumab (Avastin) with documented
770647 - side effects of blood clots causing pulmonary
770648 - embolism with severe risks
770649 - of death.............................. 040812, ref SDS 80 W35K
770651 - ..
770652 - 23. Manufacturer discloses recent deaths
770653 - from pulmonary embolism (blood clots)
770654 - that cause heavy chest, difficult
770655 - breathing, and coughing on the
770656 - Avastin drug trial.................... 040812, ref SDS 80 MG4G
770658 - ..
770659 - 24. Patient suffers increased side
770660 - effects of difficult breathing,
770661 - coughing, nose bleeds on Avastin
770662 - (bevacizumab) trial................... 040812, ref SDS 80 RZ4I
770664 - ..
770665 - 25. Accuracy medical practice requires less
770666 - precision than engineering for diagnosis
770667 - and treatment ignores conflicts, errors,
770668 - omissions in pathology reports on
770669 - medical tests......................... 040812, ref SDS 80 T761
770671 - ..
770672 - 26. Pulmonary embolism symptoms rise bleeding
770673 - nose, chronic cough, shortness of breath,
770674 - heavy chest; Kaiser continues treatment
770675 - bevacizumab and Taxol with documented
770676 - side effects pulmonary embolism, because
770677 - numerous CT tests show no findings of
770678 - pulmonary embolism; patient seeks 2nd
770679 - opinion on 041018 at UCSF; on 041103
770680 - Kaiser orders emergency CT test; next day
770681 - on 041104 diagnoses pulmonary embolism ends
770682 - treatment with bevacizumab and Taxol; patient
770683 - treated for life with warfarin (Coumadin);
770684 - on 061020 Kaiser discloses treatment
770685 - delayed 6 months because PE requires
770686 - special method of CT test using
770687 - thin-slice technology................. 041005, ref SDS 81 RZ4I
770689 - ..
770690 - 27. Medical chart patient history review
770691 - to prepare for 2nd opinions reveals
770692 - errors and omissions case
770693 - study................................. 041014, ref SDS 82 T49J
770695 - ..
770696 - 28. Doctor Benz at UCSF Cancer Center
770697 - noted importance of accurate patient
770698 - history for 2nd opinion on diagnosis
770699 - and treatment; ignored written record,
770700 - and relied on hurried, cursory note
770701 - taking to construct chronology of
770702 - patient history by asking an elderly
770703 - traumatized patient about details
770704 - of events covering 3 years of
770705 - treatment for cancer.................. 041018, ref SDS 83 EN63
770707 - ..
770708 - 29. Doctor Benz at UCSF Cancer Center
770709 - requests documentation of CA 15-3
770710 - cancer marker, which UCSF ignores
770711 - for patient diagnostics; demonstrates
770712 - strong commitment to accuracy in
770713 - medical practice...................... 041018, ref SDS 83 L16Q
770715 - ..
770716 - 30. Doctor Benz at UCSF Cancer Center
770717 - read from patient's letter to verify
770718 - accuracy on scope of work for 2nd
770719 - opinion............................... 041018, ref SDS 83 LX3U
770721 - ..
770722 - 31. Stanford Cancer Center relied on
770723 - written record to construct accurate
770724 - chronology of patient history for
770725 - preparing 2nd opinion................. 041019, ref SDS 84 WR9F
770727 - ..
770728 - 32. Doctor Guardino at Stanford Cancer
770729 - Center performed due diligence by
770730 - directing an aide to authenticate
770731 - conversation on the date of a biopsy
770732 - that diagnosed IBC by leaving the
770733 - room during a meeting and going to
770734 - another locatoin to check
770735 - documentation......................... 041019, ref SDS 84 BV92
770737 - ..
770738 - 33. Chemotherapy treatment confusion and
770739 - errors by Infusion Clinic illustrate
770740 - requirement for high degree of
770741 - precision following
770742 - protocols............................. 041021, ref SDS 85 NG7B
770744 - ..
770745 - 34. Analyst for CT test called and
770746 - alerted the doctor about pulmonary
770747 - embolism to ensure serious condition
770748 - not overlooked; why didn't the
770749 - analyst for PET scan test on 030109,
770750 - and later CT test on 030710 also
770751 - call the doctor to alert about
770752 - finding 3 symptoms of IBC,
770753 - similar to collaboration and
770754 - support to alert of pulmonary
770755 - embolism?............................. 041104, ref SDS 86 RZ4I
770757 - ..
770758 - 35. Patient rushed to emergency treatment
770759 - elevated temperature required for
770760 - cancer patients; IBC symptoms rising
770761 - rapidly; examination showed IBC not
770762 - rising, symptoms are expected side
770763 - effects of antibiotics to treat
770764 - cellulitus, but not disclosed to
770765 - the patient by doctor................. 041202, ref SDS 87 0001
770767 - ..
770768 - 36. Patient history doctor cannot find
770769 - reasons for ending treatment with AC
770770 - assumes no problems giving additional
770771 - AC treatments because nothing
770772 - written in medical chart.............. 041230, ref SDS 88 XQ84
770774 - ..
770775 - 37. Doctor cannot find patient history in
770776 - medical chart and on Kaiser's computer
770777 - required to diagnose and prescribe
770778 - treatment in Emergency
770779 - Room.................................. 050212, ref SDS 89 VC8H
770781 - ..
770782 - 38. Mistake avoided treatment prescription
770783 - doctor patient partnership with Zan
770784 - in Pharmacy using feedback from
770785 - patient to authenticate conversation
770786 - with doctor........................... 050415, ref SDS 90 KX49
770788 - ..
770789 - 39. Medical chart entered in computer improves
770790 - legibility and timely access to reduce
770791 - medical mistakes at
770792 - Kaiser................................ 050520, ref SDS 92 HX6J
770794 - ..
770795 - 40. Meeting productivity rises, SDS
770796 - work product provides precision
770797 - access for timely, accurate patient
770798 - history enables understandings of
770799 - complex record; attitudes change
770800 - when doctors can work quickly and
770801 - accurately to save lives, time,
770802 - and money............................. 050826, ref SDS 94 V15F
770804 - ..
770805 - 41. Pathology reports on biopsies missing
770806 - from medical records for Millie's
770807 - 2nd opinion process................... 050907, ref SDS 96 FB6X
770809 - ..
770810 - 42. Medical records for another patient
770811 - distributed incorrectly for
770812 - Millie's 2nd opinion
770813 - process............................... 050907, ref SDS 96 028E
770815 - ..
770816 - 43. Nuclear medicine department cannot
770817 - find Millie's PET scan files for
770818 - 2nd opinion process................... 050907, ref SDS 96 FA57
770820 - ..
770821 - 44. Computer notification failed pathology
770822 - slides not prepared for 2nd opinion
770823 - process............................... 050907, ref SDS 96 4R89
770825 - ..
770826 - 45. 2nd opinion reports patient history
770827 - shows no metastatic cancer, when
770828 - CT test and biopsy reports and team
770829 - care physicians have reported for
770830 - 4 years that patient has metastatic
770831 - cancer with regional disease, and no
770832 - evidence of distant
770833 - metastasis............................ 050907, ref SDS 95 555G
770835 - ..
770836 - 46. Doctor preparing 2nd opinion does
770837 - not have time to review summary
770838 - of critical details on patient
770839 - history because the case is too
770840 - complex............................... 050907, ref SDS 95 D05G
770842 - ..
770843 - 47. Medical staff afraid of reprisals to
770844 - notify doctor of hospital requirements
770845 - for Coumadin treatment of patients
770846 - with pulmonary emboli; requests
770847 - patient present hospital policy
770848 - to the doctor......................... 051006, ref SDS 97 5F62
770850 - ..
770851 - 48. Pulmonary emboli treatment with
770852 - Coumadin ended rather than paused
770853 - for surgery; conflicts with
770854 - policy to treat cancer patients
770855 - for life after diagnosis of
770856 - pulmonary emboli...................... 051007, ref SDS 98 OG5J
770858 - ..
770859 - 49. PET scan test on 051005 omits
770860 - comparison CT test on 050530 that
770861 - reported swelling right axillary
770862 - requires monitoring................... 051007, ref SDS 98 OG5J
770864 - ..
770865 - 50. Mastectomy surgery reduces palliation
770866 - prospects and benefits, and also reduces
770867 - ability to treat patient for IBC relapse;
770868 - surgery removes blood vessels and
770869 - capillaries in breast tissue, which
770870 - may slow delivery of chemotherapy
770871 - drugs and immune system nutrients
770872 - to infected area, 2nd opinion
770873 - consultation.......................... 051011, ref SDS 99 G65S
770875 - ..
770876 - 51. Palliation does not justify
770877 - mastectomy surgery for patient
770878 - NED 2nd opinion consultation
770879 - Doctor Bailey......................... 051011, ref SDS 99 G66W
770881 - ..
770882 - 52. Due diligence analysis requirements
770883 - for "Time Out" to evaluate need
770884 - for surgery, scope, schedule,
770885 - tasks, and risks were not performed
770886 - by medical team....................... 051019, ref SDS A0 O95W
770888 - ..
770889 - 53. Surgeon's analysis on necessity for
770890 - operation showing alignment with
770891 - patient history missing from medical
770892 - records required for due diligence
770893 - to avoid mistakes; not corrected
770894 - prior to surgery because not
770895 - enough time........................... 051021, ref SDS A1 QV4H
770897 - ..
770898 - 54. Pulmonary emboli treatment with
770899 - Coumadin initiated by Kaiser's
770900 - Coagulation Treatment Clinic to
770901 - comply with policy that cancer
770902 - patients are treated for life after
770903 - diagnosis of pulmonary
770904 - emboli................................ 051026, ref SDS A2 PO7J
770906 - ..
770907 - 55. Pulmonary emboli treatment with
770908 - Coumadin ended permenantly by
770909 - primary care physician, because
770910 - diagnosis originally occurred
770911 - during treatment with Avastin
770912 - (Bevacizumab) on 041104, and
770913 - pulmonary emboli is a side
770914 - effect of treatment
770915 - with Avastin.......................... 051121, ref SDS A3 RZ4I
770917 - ..
770918 - 56. PET scan test 060120 omits
770919 - comparison prior test because
770920 - Kaiser cannot find report for
770921 - test on 051005........................ 060126, ref SDS A4 XF3K
770923 - ..
770924 - 57. Test reports never requested by
770925 - patients nor distribued by doctors
770926 - for patients to review in order
770927 - to be prepared for productive
770928 - meetings.............................. 060428, ref SDS A5 NL4N
770930 - ..
770931 - 58. PET scan test on 060414 fails to
770932 - compare with prior test on 060120
770933 - that reported findings of likely
770934 - esophagitis; did prior findings
770935 - disappear, worsen, was it a mistake,
770936 - what happened?........................ 060428, ref SDS A5 OX62
770938 - ..
770939 - 59. Esophagitis - doctor did not have
770940 - time to read findings in PET scan test,
770941 - and so did not know the test report
770942 - shows "likely esophagitis," because
770943 - this is not mentioned in the analysts'
770944 - summary impression; doctor did not
770945 - have time to read patient's letter
770946 - asking about diagnosis and
770947 - treatment............................. 060428, ref SDS A5 PR9J
770949 - ..
770950 - 60. Read medical test findings - case
770951 - study doctors do not have enough
770952 - time to read findings and correlate
770953 - clinically with compelx patient
770954 - history that discovers symptomatic
770955 - trends in time for proactive
770956 - management; there is only enough
770957 - time to read summaries and rely
770958 - on 1st impression from the
770959 - gist of findings...................... 060428, ref SDS A6 VG5L
770961 - ..
770962 - 61. CT test finds new nodes in right
770963 - paratrcheal region that may support
770964 - prior findings of esophagitis on PET
770965 - scan test on 060120, but terminology
770966 - differences prevent practitioners
770967 - from making mental connections;
770968 - notice buried in findings; doctor
770969 - did not have time to read; summary
770970 - impression does not mention findings
770971 - of new nodes.......................... 060523, ref SDS A7 4O8P
770973 - ..
770974 - 62. CT test compared with prior CT study
770975 - 1 year earlier on 050530, rather than
770976 - with PET scan test a few weeks earlier
770977 - on 060414 which requested contrast CT
770978 - study of new findings possible
770979 - cancer lymphadenopathy................ 060523, ref SDS A7 006P
770981 - ..
770982 - 63. Doctor unable to access computer files
770983 - to evaluate report of esophagitis in
770984 - PET scan test on 060120, and later
770985 - report of nodes in right paratracheal
770986 - in CT test on 060505.................. 060623, ref SDS A8 463H
770988 - ..
770989 - 64. MRI test on brain omitted comparison
770990 - with prior test on 020617 because
770991 - analyst could not find the prior
770992 - report................................ 060711, ref SDS B0 QPRT
770994 - ..
770995 - 65. Doctor discovers cancer status change
770996 - for expanding treatments from biopsy
770997 - on 040419 was available during past
770998 - 2 years by computer access using
770999 - functions which require training
771000 - and experience to
771001 - use................................... 060711, ref SDS B0 SW7O
771003 - ..
771004 - 66. Millie patiet history show high risk
771005 - for recurrence of pulmonary
771006 - emboli................................ 060722, ref SDS B1 6G6O
771008 - ..
771009 - 67. Research indicates 10% of patients
771010 - suffer recurrence for pulmonary
771011 - emboli, and 45% of patients who
771012 - have recurrence die................... 060722, ref SDS B1 BI5J
771014 - ..
771015 - 68. Family genetic disposition to pulmonary
771016 - emboli discovered when Millie's son
771017 - was hospitalized suffering
771018 - recurrence............................ 060722, ref SDS B1 3D9T
771020 - ..
771021 - 69. Genetic disposition for pulmonary
771022 - emboli reported to Kaiser for
771023 - review of decison removing Millie
771024 - from treatment with Coumadin for
771025 - pulmonary emboli...................... 060724, ref SDS B2 NL5Q
771027 - ..
771028 - 70. Communication mistakes case study
771029 - supports Kaiser's good reputation
771030 - for strong doctor patient
771031 - parternship........................... 060809, ref SDS B3 QN6G
771033 - ..
771034 - 71. Doctor Benz at UCSF 2nd opinion
771035 - consultation misled by Kaiser's false,
771036 - medical chart saying patient treated
771037 - with warfarin for pulmonary embolism;
771038 - reliance induced by improved legibility
771039 - beginning on 050520, ref SDS 0
771040 - G57M, using computer
771041 - technology............................ 060821, ref SDS B4 PM4N
771043 - ..
771044 - 72. Primary care and 2nd opinion doctors
771045 - do not have enough time to think and
771046 - plan treatment strategy, establish
771047 - criteria for selecting chemotherapy
771048 - treatment agents, nor to list pool
771049 - of drugs available to
771050 - patient............................... 060825, ref SDS B5 K36G
771052 - ..
771053 - 73. Doctor does not comment on report of
771054 - genetic disposition for pulmonary
771055 - emboli in relation to Millie's
771056 - risk factors of pulmonary
771057 - emoboli............................... 060825, ref SDS B5 9W4L
771059 - ..
771060 - 74. Patient reports chronic fatigue,
771061 - difficult breathing common
771062 - side effects of chemotherapy, and
771063 - symptoms of pulmonary
771064 - emboli................................ 060929, ref SDS B6 B56N
771066 - ..
771067 - 75. Patient requests CT scan to evaluate
771068 - pulmonary emboli and distant
771069 - metastatic disease.................... 060929, ref SDS B6 DY5M
771071 - ..
771072 - 76. Doctor orders CT test for pulmonary
771073 - emboli; specifies date of test that
771074 - made original diagnosis on 041103
771075 - to compare same location.............. 060929, ref SDS B6 DY7G
771077 - ..
771078 - 77. Doctor asks patient to obtain from her
771079 - son's doctor the report on coagulapathy
771080 - showing genetic disposition for blood
771081 - clots which was reported to Kaiser
771082 - on 060724............................. 060929, ref SDS B6 NU4N
771084 - ..
771085 - 78. Pulmonary emboli diagnosed by CT
771086 - test patient begins treatment
771087 - again, previously ended on 051007
771088 - despite policy to treat cancer
771089 - patients with PE for life due to
771090 - elevated risk for recurrence and
771091 - that 45% of patients who suffer
771092 - recurrence die........................ 061002, ref SDS B7 MI5I
771094 - ..
771095 - 79. CT Test 060929 for pulmonary emboli
771096 - doctor orders comparison with prior
771097 - test on 041103 that reported same
771098 - problem; analyst fails to perform
771099 - comparison, compares only to recent
771100 - tests which were not ordered and
771101 - do not demonstrate patient history
771102 - on pulmonary emboli................... 061012, ref SDS B8 2935
771104 - ..
771105 - 80. Mistakes avoided communication
771106 - collaboration coordination Oncology
771107 - and Coagulation Treatment Clinic
771108 - reliance on computer fails to notify
771109 - staff to balance Coumadin (Warfarin)
771110 - treatment for pulmonary emboli with
771111 - capecitabine (Xeloda) treatment for
771112 - cancer; team care feedback doctor
771113 - patient partnership avoided small
771114 - problem cascading out of
771115 - control............................... 061020, ref SDS B9 TZ4I
771117 - ..
771118 - 81. Doctor relied on computer system for
771119 - automatic notification to pharmacy and
771120 - Coagulation Treatment Clinic, and did
771121 - not specify nor follow up to verify
771122 - that prescription on 061002 for Coumadin
771123 - (warfarin) to treat pulmonary embolism
771124 - should be balanced with capecitabine
771125 - (Xeloda) treatments for cancer
771126 - ordered on 060711..................... 061020, ref SDS C0 YQ7L
771128 - ..
771129 - 82. Kaiser discloses CT test pulmonary
771130 - embolism different from testing for
771131 - cancer explains delay discovering
771132 - pulmonary embolism with CT test on
771133 - 041103 for symptoms beginning on
771134 - 040517................................ 061020, ref SDS C0 S56G
771136 - ..
771137 - 83. Communication documentation records
771138 - management doctor cannot find patient's
771139 - letter 061013 asking about severity
771140 - pulmonary embolism, enlarged right
771141 - ventricle patient status for exercise
771142 - return to gym restore
771143 - fitness............................... 061020, ref SDS C0 VJ49
771145 - ..
771146 - 84. CT test 060930 doctor not aware of
771147 - findings enlarged right ventricle
771148 - heart disorder diagnosed in findings;
771149 - hectic schedule not enough time
771150 - to read test findings cannot
771151 - remember reading patient's letter
771152 - asking about severity; Kaiser
771153 - cannot determine severity of
771154 - pulmonary embolism comparing with
771155 - original findings on 041103; cannot
771156 - compare right and left ventricle
771157 - for impact on pulmonary
771158 - embolism.............................. 061020, ref SDS C0 VJ4J
771160 - ..
771161 - 85. Cellulitus complications lymphedema
771162 - diagnosed 060217 compounded by trauma from
771163 - broken finger on 060914 patient treated
771164 - in Emergency Room; hospitalized 5 days
771165 - temperature rising during cancer treatments,
771166 - left arm engulfed with inflammation, red
771167 - rash and excessive swelling diagnosed as
771168 - side effect from loss of lymphatics removed
771169 - on 051021 for mastectomy surgery which
771170 - was not disclosed to patient for approving
771171 - surgery balanced against risks of
771172 - what can go wrong due to
771173 - side effects.......................... 061027, ref SDS C1 714I
771175 - ..
771176 - 86. Medical chart mistakes patient history
771177 - problems diagnosed, communications,
771178 - medications, examinations doctor
771179 - progress notes errors and
771180 - omissions............................. 061110, ref SDS C2 FE4I
771182 - ..
771183 - 87. Mistakes compound in electronic medical
771184 - chart stored on Kaiser's computer, started
771185 - 050520, ref SDS 0 G57M, cannot be corrected
771186 - because Kaiser "locks down" the record
771187 - after doctor meets with patient; compound
771188 - mistakes, e.g., on 060821, ref SDS 0 S16H,
771189 - because lock down prevents feedback
771190 - loops called out in Kaiser's Healthwise
771191 - Handbook from correcting
771192 - medical chart......................... 061208, ref SDS C3 N54K
771194 - ..
771195 - 88. Medical chart shows metastatic breast
771196 - cancer (IBC) lung and lymph node;
771197 - chest wall recurrence conflicts with
771198 - patient history no diagnostic support
771199 - representation........................ 061208, ref SDS C3 G25K
771201 - ..
771202 - 89. Biopsy avoid diagnose IBC spread to
771203 - right breast repeat mistake failing
771204 - diagnose IBC left breast for 18 months,
771205 - prescribe treatment for antibiotic
771206 - testing for ring
771207 - infection............................. 061208, ref SDS C3 KT7J
771209 - ..
771210 - 90. Payment authorization to start treatment
771211 - doctor not enough time to sign document
771212 - for 3 weeks; treatment delayed while
771213 - medical management reacts to
771214 - crisis................................ 070118, ref SDS C4 YF8U
771216 - ..
771217 - 91. Treatment delayed because not enough
771218 - time to resolve policy conflict between
771219 - Kaiser Medicare because work delayed
771220 - 3 weeks until crisis forced problem
771221 - into span of attention in order to
771222 - avoid proactive
771223 - management............................ 070119, ref SDS C5 YF8U
771225 - ..
771226 - 92. Laboratory blood test scope incomplete
771227 - for baseline start new chemotherapy
771228 - treatment on clinical study
771229 - UCSF.................................. 070122, ref SDS C6 LY30
771231 - ..
771232 - 93. Treatment delayed because complex
771233 - referral authorization requirements
771234 - not enough time for doctors and
771235 - staff to resolve...................... 070124, ref SDS C7 YF8U
771237 - ..
771238 - 94. CT test history of breast cancer omits
771239 - context of pulmonary embolism and Cor
771240 - Pulmonale heart disorder enlarged
771241 - right verntircle
771242 - verntircle............................ 070202, ref SDS C8 0Z6O
771244 - ..
771245 - 95. CT test comparison test 060505 omits
771246 - context other related tests, and
771247 - missing comparison nodules in
771248 - right paratrachael.................... 070202, ref SDS C8 0136
771250 - ..
771251 - 96. Blood test diagnostic differences between
771252 - UCSF Kaiser collaborration clinical study
771253 - drug trial increases risk medical
771254 - mistakes requires coordination
771255 - plan to calculate common
771256 - results .............................. 070301, ref SDS C9 Q659
771258 - ..
771259 - 97. Medical Chart shows 4 times daily
771260 - instead of 3 times daily for
771261 - prescribed medication; typing error
771262 - not corrected because there
771263 - is no feedback loop in
771264 - the communication
771265 - process............................... 070302, ref SDS D0 FN5M
771267 - ..
771268 - 98. Blood tests verify ANC high enough for
771269 - safe treatment with strengthened immune
771270 - system that resists infection and
771271 - progression of cancer, not enough time
771272 - for communication and collaboration to
771273 - coordinate scheduling blood
771274 - tests ordered by the
771275 - doctor................................ 070308, ref SDS D1 1M6H
771277 - ..
771278 - 99. Quality control errors failure to
771279 - perform protocol requirements treatment
771280 - cetuximab clinical study
771281 - drug trial............................ 070308, ref SDS D1 FF41
771283 - ..
771284 - 100. Cancer treatment not scheduled for
771285 - cetuximab weekly infusions on clincial
771286 - study................................. 070315, ref SDS D2 1M6H
771288 - ..
771289 - 101. CT test history of breast cancer omits
771290 - context of pulmonary embolism and Cor
771291 - Pulmonale heart disorder enlarged
771292 - right verntircle
771293 - verntircle............................ 070329, ref SDS D3 GH5L
771295 - ..
771296 - 102. CT test comparison test 060505 omits
771297 - context other related tests, and
771298 - missing comparison nodules in
771299 - right paratrachael.................... 070329, ref SDS D3 0136
771301 - ..
771302 - 103. Doctor ordered CT test for pulmonary
771303 - embolism and enlarged right ventricle
771304 - life threatening issues ignored by
771305 - Medical Imaging test department
771306 - without notice nor consideration of
771307 - patient history....................... 070330, ref SDS D4 B74K
771309 - ..
771310 - 104. Treatment Keflex antibiotics prescribed
771311 - by Kaiser for Cellulitis should defer to
771312 - UCSF maintain control clinical
771313 - study................................. 070330, ref SDS D4 V66M
771315 - ..
771316 - 105. Blood tests to evaluate immune system
771317 - strong enough for safe treatments schedule
771318 - changed from protocol requirements for
771319 - testing prior to treatment, to test
771320 - during treatment, results received after
771321 - treatment show sudden reversal; blood
771322 - counts ANC NEUTS too low for safe
771323 - treatment............................. 070426, ref SDS D5 P560
771325 - ..
771326 - 106. Doctor reports CA 15-3 56 "stable"
771327 - referral coordination fails; doctor
771328 - patient partnership collaboration fails;
771329 - mistake occurred because patient history
771330 - weeks earlier reporting CA 15-3 36 and
771331 - then only a few days earlier reporting
771332 - decline to 29, both well below 56, and
771333 - submitted to the doctor through Kaiser's
771334 - email system, were not entered into
771335 - the Kaiser's computer program Medical
771336 - Chart for patient case
771337 - management............................ 070516, ref SDS D6 RH9H
771339 - ..
771340 - 107. Emergency care failure Cellulitis patient
771341 - suffers rising pain, chills, temperature
771342 - risk to Stage IV cancer patient, rapidly
771343 - spreading inflammation and lymphedema
771344 - treatment delayed for staff
771345 - meeting............................... 070607, ref SDS D7 8I89
771347 - ..
771348 - 108. Blood test unnecessary duplication error
771349 - reading Medical Chart misunderstand clinical
771350 - trial protocol; nurse assigned not experienced
771351 - with patient history; not enough time
771352 - to verify accuracy; cost containment
771353 - less important than drawing blood
771354 - which seems fast and easy for
771355 - nurse................................. 070809, ref SDS D8 CN76
771357 - ..
771358 - 109. Doctor submits report on blood test for
771359 - 071017 omits section on Neutrophils,
771360 - Lymphocytes, Bands, etc., used to
771361 - calculate ANC for evaluating safety
771362 - of patient receiving chemotherapy
771363 - treatments; doctor fails to submit
771364 - ANC composite number, requested
771365 - by patient............................ 071023, ref SDS D9 JM41
771367 - ..
771368 - 110. Speciality doctor fails to comment on
771369 - advisability of patient returning to
771370 - work during treatment in clinical
771371 - trial despite request by primary
771372 - care physician for
771373 - review................................ 071023, ref SDS D9 V63L
771375 - ..
771376 - 111. Blood test mistake Magnesium omitted from
771377 - order for labs to start new cycle of treatment;
771378 - conflicts with clinical trial
771379 - specification......................... 080117, ref SDS E0 4F9G
771381 - ..
771382 - 112. CT scan report for on test 080212 omits
771383 - patient history recurrent pulmonary embolism,
771384 - enlarged right ventrical (cor pulmonale),
771385 - enlarged heart, esophigitis; fails to
771386 - perform comparison with prior test
771387 - findings.............................. 080215, ref SDS E1 IX4F
771389 - ..
771390 - 113. CT scan test 080212 findings conflict with
771391 - prior test on 071210 erroneous unit of
771392 - measure substituting "cm" for "mm" 10
771393 - fold mistake; likely typographical
771394 - error; failure reconcile prior
771395 - report................................ 080215, ref SDS E1 EO8F
771397 - ..
771398 - 114. Communication conflicts UCSF proposes using
771399 - conversation to order same day examination
771400 - of Cellulitis for cancer
771401 - patient............................... 080304, ref SDS E2 6T41
771403 - ..
771404 - 115. Patient notifies Kaiser that UCSF recommends
771405 - same day examination for Cellulitis
771406 - recurrence............................ 080304, ref SDS E2 UZ47
771408 - ..
771409 - 116. UCSF submits confirmation letter to
771410 - patient and to Kaiser that does not
771411 - specify same day examination
771412 - conveyed in earlier
771413 - telephone call........................ 080304, ref SDS E2 B18J
771415 - ..
771416 - 117. Kaiser schedules examination for
771417 - following day despite notice that
771418 - UCSF recommends urgency
771419 - requires same day
771420 - examination........................... 080304, ref SDS E2 UZ89
771422 - ..
771423 - 118. Infusion Clinic medical chart shows
771424 - incorrectly blood tests on 6-week cycle
771425 - which is actually 4-week cycle; causing
771426 - confusion and delay despite excellent
771427 - support by Infusion Clinic
771428 - staff................................. 080306, ref SDS E4 NK5L
771430 - ..
771431 - 119. Blood test order delivered to the wrong
771432 - Lab due to communication mistake
771433 - causing delay giving
771434 - treatment............................. 080306, ref SDS E3 JT4F
771436 - ..
771437 - 120. Blood test mistake Magnesium omitted from
771438 - order for labs to start new cycle of treatment;
771439 - conflicts with clinical trial
771440 - specification......................... 080404, ref SDS E5 O059
771442 - ..
771443 - 121. Collaboration failure referral coordination
771444 - blood test at UCSF on 080306 sent to Kaiser
771445 - on 080307 was not evaluated for emergency
771446 - care at Kaiser on 080409; Kaiser compared
771447 - blood test on 080409 with data on 071017
771448 - because nobody entered 6 months of test
771449 - data in Kaiser computer; if data is
771450 - not in the computer it does not
771451 - exist................................. 080409, ref SDS E6 439L
771453 - ..
771454 - 122. Chemotherapy Orders received 2 weeks later
771455 - on 080515 reduced dose Carboplatin withheld
771456 - notice change conflicts with planning to
771457 - maintain full dose to optimize
771458 - recovery.............................. 080501, ref SDS E7 PVUQ
771460 - ..
771461 - 123. Blood draw delayed by reliance on verbal
771462 - coordination causing mistakes submitting
771463 - orders and blood vials for laboratory
771464 - work to the Infusion
771465 - clinic................................ 080529, ref SDS E8 4E5J
771467 - ..
771468 - 124. Replacement medical team did not receive
771469 - agenda for meeting; relied on verbal
771470 - coordination of written instructions
771471 - causing numerous errors
771472 - and delays............................ 080529, ref SDS E8 4E69
771474 - ..
771475 - 125. Medical Chart missing reports on prior
771476 - laboratory blood tests corrected
771477 - during meeting with
771478 - patient............................... 080529, ref SDS E8 L255
771480 - ..
771481 - 126. Chemotherapy Orders received 1 week later
771482 - on 080605 again shows reduced dose
771483 - Carboplatin with handwritten
771484 - notation of error .................... 080529, ref SDS E9 PVUQ
771486 - ..
771487 - 127. Chemotherapy Orders received 1 week
771488 - later on 080605 prescribes 2 Neupogen
771489 - treatments per week when Carboplatin;
771490 - received conflicts with verbal instruction
771491 - for patient to get 1 Neupogen treatment
771492 - which was implemented; did not cause
771493 - patient to miss chemotherapy
771494 - treatment due to low blood
771495 - counts................................ 080529, ref SDS E9 PWSY
771497 - ..
771498 - 128. UCSF requested referral coordination to
771499 - submit "certificate" from Kaiser surgeon
771500 - on suitability of Power Port for Millie's
771501 - blood draws, and cancer treatments;
771502 - patient notified primary care physician,
771503 - who notified the surgeon of UCSF requirement
771504 - for "certificate" of suitability for use;
771505 - Kaiser surgeon annoyed by request for
771506 - "certificate" that conflicts with medical
771507 - documentation practices; UCSF received
771508 - "certificate" provided at great time,
771509 - expense, and annoyance, and advised the
771510 - "certificate" request was a mistake; UCSF
771511 - requirement was for xray report produced
771512 - routinely for port surgery at no extra
771513 - time nor expense; UCSF coordinated
771514 - directly to obtain xray report
771515 - in about 10 minutes................... 080710, ref SDS F1 EE4O
771517 - ..
771518 - 129. Coordinating documentation Chemotherapy
771519 - Orders chemothearpy treatments and
771520 - Neupogen treatments delayed due to
771521 - hectic schedule....................... 080605, ref SDS F0 JO9Q
771523 - ..
771524 - 130. Communication failure CT Department did
771525 - not receive and/or did not have time to
771526 - be prepared for performing CT test with
771527 - new Power Port technology by reviewing
771528 - manufacturer's Instructions for Use and
771529 - to arrange for qualified medical
771530 - professionals to perform the
771531 - work.................................. 080711, ref SDS F2 7K8I
771533 - ..
771534 - 131. Infusion Clinic in Oncology Department
771535 - cannot spare experienced medical
771536 - professional for 30 minutes to support
771537 - CT Department on 080718 perform test
771538 - using new Power Port technology for
771539 - the first time ordered by Oncology
771540 - Department............................ 080715, ref SDS F3 PQ6P
771542 - ..
771543 - 132. CT test using power injection procedure
771544 - for contrast medium medical professionals
771545 - did not have time to be prepared by
771546 - reviewing manufacturer's instructions
771547 - for use............................... 080718, ref SDS F4 2U8V
771549 - ..
771550 - 133. CT test failed using Power Port for
771551 - high pressure injection of contrast
771552 - medium; patient suffers extravasation
771553 - with contrast medium overflowing
771554 - the port into chest, shoulder and
771555 - upper arm; bleeding from surgical
771556 - wound where Power Port was
771557 - implanted a week
771558 - earlier............................... 080718, ref SDS F4 LK3R
771560 - ..
771561 - 134. Medical Chart at UCSF missing CT test due
771562 - to delays reading scans at Kaiser and
771563 - changes to personnel causing problems
771564 - for referral coordination
771565 - requesting report..................... 080724, ref SDS F5 TG96
771567 - ..
771568 - 135. INR test omitted from labs because
771569 - patient failed to submit an agenda to
771570 - remind hospital Infusion Clinic staff
771571 - about scope of work, and because test
771572 - was performed at 0745 earlier than the
771573 - usual time of 0800 causing another nurse
771574 - to perform the work who was not familiar
771575 - with requirements for Millie's
771576 - blood tests starting a new
771577 - treatment cycle every
771578 - 4 weeks............................... 080724, ref SDS F6 IU8H
771580 - ..
771581 - 136. CT test reports with omissions interpreted
771582 - as showing disease is not worsening or
771583 - is too negligible to
771584 - report................................ 080912, ref SDS F7 HI8N
771585 - appears conflicting for CT test on
771586 - 081107 indicating omissions are actually
771587 - mistakes; severe medical problems occurred
771588 - in locations that were ignored by the
771589 - analyst reviewing CT scans for
771590 - prior tests........................... 081113, ref SDS G9 HW8M
771592 - ..
771593 - 137. Communication glitch finding swelled
771594 - lymph node left supraclavicular at UCSF
771595 - on 080821, and at Kaiser on 080829, delayed
771596 - tessting 2 months that required
771597 - changing treatment.................... 081016, ref SDS F8 J34X
771599 - ..
771600 - 138. FNA Biopsy to test for cancer scheduled
771601 - 081023 1050 at Kaiser conflicted with
771602 - Millie getting cancer treatment at
771603 - UCSF on 081023 until
771604 - 1330.................................. 081021, ref SDS F9 4Q4C
771606 - ..
771607 - 139. FNA biopsy to test for cancer requires
771608 - 2 meetings; conflicts with patient
771609 - history doing prior work with
771610 - only 1 visit.......................... 081021, ref SDS F9 YR6O
771612 - ..
771613 - 140. FNA Biopsy to test for cancer scheduled
771614 - in Surgery Department conflicts with
771615 - patient history performing FNA biopsy
771616 - in Kaiser Head and Neck
771617 - Department............................ 081021, ref SDS F9 03GE
771619 - ..
771620 - 141. Referral for FNA biopsy of lump does not
771621 - specify location of lump, conflicts with
771622 - letter to Kaiser submitting prescription
771623 - from UCSF specifying FNA biopsy in
771624 - left suprclavicular................... 081021, ref SDS F9 PQ7T
771626 - ..
771627 - 142. Referral for FNA biopsy of lump does not
771628 - specify check for status change; conflicts
771629 - with letter to Kaiser submitting UCSF
771630 - prescription.......................... 081021, ref SDS F9 WO31
771632 - ..
771633 - 143. CT test request on 080827 cover neck
771634 - evaluate possible spread of new cancer
771635 - reported on 080821; CT test on 080911
771636 - does not report cancer in neck (left
771637 - supraclavicular); review of CT scans
771638 - for test on 080911 shows test did not
771639 - include the neck, so findings yielded
771640 - false negative, reported during
771641 - meeting at Kaiser..................... 081022 ref SDS G0 516F
771643 - ..
771644 - 144. FNA biopsy at Kaiser cannot check for
771645 - status change triple negative ER PR
771646 - HER2 neu; requires core
771647 - biopsy................................ 081022, ref SDS G1 4Q61
771648 - 5 letters from UCSF indicate conflict
771649 - requesting FNA biopsy rather than core
771650 - biopsy to test for status
771651 - change................................ 081022, ref SDS G2 NI7S
771653 - ..
771654 - 145. Doctor Johnson requests again list of therapies
771655 - which UCSF plans for treateing Millie's cancer
771656 - as chronic disease, which requires proactive
771657 - case management having treatments targeted to
771658 - Millie's cancer lined up in time to be effective,
771659 - because Millie's cancer has mutated into
771660 - aggressive disease that has narrowing
771661 - tolerance for delay starting treatment,
771662 - and Kaiser has no more agents for
771663 - Millie's complex patient
771664 - profile.............................. 081024, ref SDS G3 BO9F
771666 - ..
771667 - 146. Muga test ordered by Kaiser on 081106 1030
771668 - conflicts with work plan patient on vacation
771669 - until 081107, and already scheduled
771670 - for tests until
771671 - 081111................................ 081105, ref SDS G4 WO72
771672 - No evident alignment of Muga test and
771673 - screening requirements for sunitinib
771674 - clinical study; not enough time to
771675 - collaborate with referral
771676 - health care provider
771677 - UCSF.................................. 081105, ref SDS G4 6138
771678 - Possible mixup from difficulty reviewing
771679 - patient history associating sunitinib
771680 - clinicial trial treatment using Cytoxan
771681 - with heart damage exposure from prior
771682 - treatments with Adriamycin Cytoxan
771683 - (AC) where heart damage seems to occur
771684 - from Adriamycin which is not part
771685 - of sunitinib treatment plan, and
771686 - Cytoxan is not associated with
771687 - heart damage.......................... 081105, ref SDS G4 WI5L
771689 - ..
771690 - 147. Blood test ordered at Kaiser for CT test
771691 - on 081107; turned out this was reviewed
771692 - earlier on 081024 and decided to use
771693 - blood test at UCSF on 081023 but nobody
771694 - could find the record in Kaiser's
771695 - computer of the work on
771696 - 081024 so rework was
771697 - performed............................. 081106, ref SDS G6 ED6H
771699 - ..
771700 - 148. Muga test ordered on 081103 scheduled
771701 - for 081111 duplicates echocardiogram
771702 - test scheduled the day before on
771703 - 081108 and ordered weeks
771704 - earlier on 081024 was
771705 - cancelled............................. 081106, ref SDS G7 WH9N
771707 - ..
771708 - 149. Core biopsy evaluate status change scheduled
771709 - previously changed on 081027 from 081107 to
771710 - 081117 with Doctor Wong was changed by
771711 - Doctor Daamen back to 081107 at 1600 (4pm)
771712 - with Doctor Kahn; schedule assistant later
771713 - notifies patient schedule changed again
771714 - for Doctor Wong on 081107 1000 because
771715 - Doctor Kahn is not available and sees
771716 - nothing scheduled at 1600; calls back
771717 - and advises mistake occurred using
771718 - computer - core biopsy scheduled
771719 - for 081107 1600 with Doctor
771720 - Khan.................................. 081106, ref SDS G5 IP7L
771722 - ..
771723 - 150. CT test on 081107 was compared with
771724 - test on 080718, rather than the most
771725 - recent test on
771726 - 080911................................ 081112, ref SDS G8 RV49
771728 - ..
771729 - 151. CT test 081107 report on neck fails
771730 - to perform comparisons saying there are
771731 - prior studies to compare; overlooks
771732 - patient history of 11 prior studies
771733 - that included the
771734 - neck.................................. 081113, ref SDS G9 RV49
771736 - ..
771737 - 152. CT test on 081107 resulted in 2 separate
771738 - reports issued days apart, which caused
771739 - confusion in patient care and conveyed
771740 - false impression of error because
771741 - report on neck findings were
771742 - issued separately..................... 081113, ref SDS G9 RU6R
771743 - case study patient history shows 11
771744 - CT and PET studies were performed
771745 - including neck, chest, abdomen, and
771746 - pelvis, and all test findings were
771747 - always consolidated into a single
771748 - report................................ 081113, ref SDS G9 HV4H
771750 - ..
771751 - 153. CT test ordered in Kaiser's computer on
771752 - 081210 to be performed on 081230 included
771753 - the neck, and required using Millie's Power
771754 - Port with support from the Chemotherapy
771755 - Clinic and Interventional Services to
771756 - access the port for injecting contrast
771757 - medium, and further specified a consolidated
771758 - report to avoid mistakes; none of these
771759 - requirements were in the computer referral
771760 - order reviewed on 081219, indicating that
771761 - somone changed the doctor's order in the
771762 - computer without inquiry nor notice;
771763 - the doctor corrected mistakes in
771764 - the computer to conform with
771765 - patient requirements.................. 081219, ref SDS H0 WP30
771767 - ..
771768 - 154. Doctor Johnson at Kaiser disappoited but not
771769 - surprised that UCSF has still failed to submit
771770 - a list lining up therapies for treating Millie's
771771 - cancer as chronic disease essential
771772 - Millie to survive..................... 081219, ref SDS H0 5D6H
771774 - ..
771775 - 155. UCSF reported having lost their list of
771776 - therapies for treating Millie's cancer
771777 - as a chronic disease, requested by Kaiser
771778 - beginning on 080829, and so UCSF asks Millie
771779 - to help the medical develop a comprehensive
771780 - list of follow on treatments targeted
771781 - to Millie's cancer for recovering
771782 - from future future
771783 - relapses.............................. 090121, ref SDS H4 Y67L
771785 - ..
771786 - 156. Communication glitch delayed changing
771787 - Millie's treatment to prevent cancer
771788 - from cascading out of
771789 - control............................... 090130, ref SDS H5 AY8Q
771791 - ..
771792 - 157. CT test report analyst discontinued prior
771793 - practice comparing current findings on
771794 - cancer node sizes with size of
771795 - same nodes on prior
771796 - test.................................. 090107, ref SDS H1 4K5H
771798 - ..
771799 - 158. Kaiser explains policy for issuing multiple
771800 - reports for the same CT test that increase
771801 - time, cost, and medical mistakes was
771802 - implemented in order to increase revenue
771803 - by billing for preparing miltiple
771804 - reports each time the CT
771805 - equipment makes a
771806 - pass.................................. 090109, ref SDS H2 SV8O
771808 - ..
771809 - 159. CT findings for next test on 081230 again
771810 - published in 2 separate reports ignored
771811 - doctor's order for consolidated report
771812 - to maintain a well ordred record that
771813 - helps reduce medical mistakes;
771814 - doctor confused submits
771815 - only 1 of 2
771816 - reports............................... 090109, ref SDS H3 V53J
771818 - ..
771819 - 160. Communication glitch referral coding
771820 - problem at Kaiser delayed starting urgent
771821 - treatment quickly enough to be
771822 - effective at UCSF..................... 090202, ref SDS H6 9Y5I
771824 - ..
771825 - 161. Communication glitch delays initial meeting
771826 - for 3 weeks to start urgent
771827 - treatment............................. 090202, ref SDS H7 XO7G
771829 - ..
771830 - 162. Doctor orders urgent treatment
771831 - required to start
771832 - quickly............................... 090202, ref SDS H8 Y15J
771833 - UCSF advances initial examination
771834 - 2 weeks............................... 090205, ref SDS H9 0001
771836 - ..
771837 - 163. Treatment with hyperthermia which can be
771838 - given with Doxil to increase effectiveness,
771839 - delayed 2 more weeks in order to create
771840 - essential molds and perform layout
771841 - for complementary low-dose
771842 - radiation treatment................... 090209, ref SDS I0 RF7L
771843 - delaying hyperthermia waiting for
771844 - molds needed only for radiation risks death
771845 - from cancer cascading out of control, because
771846 - neither hyperthermia nor radiation will
771847 - occur in time to be
771848 - effective............................. 090209, ref SDS I0 RF84
771850 - ..
771851 - 164. UCSF providing radiation treatments on referral
771852 - from cancer ignored warnings and requests for
771853 - testing wound in breastbone area for worsening
771854 - cancer, and instead diagnosed reaction
771855 - to radiation allowing cancer
771856 - to spread without treatment
771857 - for 7 months.......................... 090312, ref SDS I1 UL5L
771859 - ..
771860 - 165. Millie submits list of 20 treatments
771861 - to medical team, requested by UCSF and
771862 - Kaiser for treating Millie's cancer as
771863 - chronic disease; Millie requests standard
771864 - of care comparing trade-offs so the
771865 - team is lined up to start treatment
771866 - the next relapse in time to be effective;
771867 - Doctor Johnson plans to discuss at
771868 - next meeting, but nobody every
771869 - has time for proactive
771870 - management............................ 090326, ref SDS I2 T64J
771872 - ..
771873 - 166. UCSF diagnoses wound in breastbone area
771874 - again as reaction to radiation that
771875 - will heal without
771876 - treatment............................. 090330, ref SDS I3 9A66
771878 - ..
771879 - 167. UCSF delays treatment for cancer on Millie's
771880 - arm because wound diagnosed as reaction to
771881 - radiation must heal; however, since the
771882 - wound is cancer, it can only heal by
771883 - starting treatment immediately; so,
771884 - delay allows cancer to
771885 - spread................................ 090401, ref SDS I4 4J4F
771887 - ..
771888 - 168. UCSF Breast Care Clinic fails to collaborate
771889 - with Radiation Oncology on findings from examination
771890 - of wound in Millie's breastbone
771891 - area.................................. 090423, ref SDS I5 CP4J
771892 - UCSF delays treatment again requested
771893 - by Millie in time to recover from cancer
771894 - recurrence on left arm, signaled by 20 point
771895 - rise in cancer marker, when the marker should
771896 - be falling, and on grounds that wound bleeding
771897 - and oozing puss in breastbone area
771898 - must first heal....................... 090423, ref SDS I5 CP4J
771899 - Millie request again to test wound
771900 - in breastbone area for untreated cancer
771901 - was not implemented because the medical
771902 - believed the area had been radiated
771903 - and biopsy would cause severe
771904 - infection............................. 090423, ref SDS I5 456H
771906 - ..
771907 - 169. Millie notifies medical team that breastbone
771908 - area continues to look worse, rather than heal
771909 - as expected for reaction to radiation; she
771910 - requests immediate treatment for cancer
771911 - recurrence on left arm, and asks again
771912 - for testing breastbone area for
771913 - cancer,............................... 090510, ref SDS I6 LJ5T
771915 - ..
771916 - 170. Kaiser orders treatment for Millie with Gemzar
771917 - chemotherapy rather than with MPA prescribed
771918 - by Doctor Rugo at UCSF Cance Center, and
771919 - which is expected to be effective and to
771920 - avoid side effects because MPA is targeted to
771921 - Millie's patient profile for recovering from
771922 - 8th relapse of cancer; Kaiser Oncology Pharmacist
771923 - notifies Millie that Kaiser's order for chemotherapy
771924 - is not expected to be effective, and
771925 - will cause severe side effects,
771926 - even death............................ 090601, ref SDS I7 JH4K
771928 - ..
771929 - 171. UCSF discovers medical mistake providing radiation
771930 - services on referral from Kaiser missed treating
771931 - cancer in Millie's breastbone area causing severe
771932 - wound that has spread cancer for 6 months; untreated
771933 - cancer in breastbone may have migrated
771934 - to lungs causing breathing
771935 - problems.............................. 090609, ref SDS I8 W65W,
771936 - UCSF diagnoses Millie's breathing
771937 - problems due to errors possibly over
771938 - radiating skin to treat IBC that is now
771939 - causing progressive radiation
771940 - injury to Millie's
771941 - lungs................................. 090609, ref SDS I8 R24G
771942 - Doctor Hsu orders tests to evaluate
771943 - scope of problems, and prescribes immediate
771944 - treatment with MPA targeted to Millie's
771945 - cancer as necessary and reasonable
771946 - for Millie to recover from UCSF
771947 - medical mistakes...................... 090609, ref SDS I8 1P3K
771949 - ..
771950 - 172. Doctor Rugo advises everybody at Kaiser and
771951 - UCSF is "on board" agreeing in an email to
771952 - treat Millie's cancer as a chronic disease,
771953 - starting first with MPA, and then PARP targeted
771954 - to Millie's patient profile necessary and
771955 - reasonable to recover from UCSF
771956 - medical mistakes...................... 090616, ref SDS I9 D647
771958 - ..
771959 - 173. UCSF failed to treat Millie with PARP
771960 - agreed in letter with Kaiser for Millie
771961 - to recover from medical mistakes getting
771962 - radiation on referral from Kaiser, and which
771963 - is more effective than chemotherapy for Millie's
771964 - patient profile and avoids difficult side effects;
771965 - Kaiser failed to provide standard of care determining
771966 - treatments most effective and least cost, and so
771967 - UCSF asks Kaiser to treat Millie with chemotherapy
771968 - until PARP can start in September, and which
771969 - is not effective and causes horrible
771970 - side effects.......................... 090716, ref SDS J0 EE5W
771972 - ..
771973 - 174. In September; UCSF failed to provide PARP
771974 - treatment targeted to Millie's cancer; Millie's
771975 - cancer much worse with Gemzar chemotherapy
771976 - ordered by UCSF, medical team and reports
771977 - nobody has had time to perform standard of
771978 - care to compare trade-offs on 20 treatments
771979 - targeted to Millie's patient profile, Doctor
771980 - Johnson reports schedule has cleared,
771981 - and so will collaborate with
771982 - Doctor Rugo at UCSF to
771983 - provide standard of
771984 - care.................................. 090909, ref SDS J1 VF60
771986 - ..
771987 - 175. Shingles diagnosed requires immediate care in
771988 - Emergency Room Department to avoid complications;
771989 - medical team failed to advise immediate
771990 - treatment required when notified
771991 - the day before of rising
771992 - symptoms.............................. 100104, ref SDS J3 0P9S
771994 - ..
771995 - 176. Shingles severe infection and hideous painful
771996 - complications caused by months of chemotherapy
771997 - that weakens Millie's immune system, and is not
771998 - effective treating cancer, rather than prescribe
771999 - targeted treatment effective against cancer
772000 - and prevents infection by not
772001 - weakening the immune
772002 - system................................ 100104 ref SDS J2 QB9W
772004 - ..
772005 - 177. Kaiser pauses chemotherapy for 3 weeks risks
772006 - cancer getting worse, but necessary to avoid
772007 - lowering blood counts so that Millie can get
772008 - treatment to recover from shingles, rather
772009 - than prescribe treatment targeted to Millie's
772010 - cancer that does not lower blood counts
772011 - and so can be given concurrently
772012 - to recover from cancer and
772013 - shingles.............................. 100112, ref SDS J4 G68H
772015 - ..
772016 - 178. Shingles relapse -- doctor worried sudden drop
772017 - in blood counts with chemotherapy presents dilemma
772018 - solved by treatment "targeted" to Millie's cancer
772019 - that enables concurrent treatment for shingles
772020 - and cancer; yet, Kaiser orders Abraxane
772021 - chemotherapy that risks cancer getting
772022 - worse, shingles recurrence, and
772023 - prevents concurrent treatment of
772024 - cancer and shingles................... 100302, ref SDS J5 FC68
772026 - ..
772027 - 179. Kaiser notified IBC progressing visibly on
772028 - right chest, and cancer marker CA 15-3 424
772029 - at all time high, indicating chemotherapy
772030 - not effective, and causing severely painful
772031 - side effects; Millie requests switching
772032 - treatment in time to be effective and
772033 - targeted to Millie's patient profile,
772034 - so onerous side effects are
772035 - avoided .............................. 100501, ref SDS J6 U44V
772036 - medical team fails to switch treatment;
772037 - instead continues ineffective chemotherapy
772038 - for 2 weeks, causing continuing severe side
772039 - effects; and pauses treatment for 2 more
772040 - weeks, proposing to delay discussion
772041 - for a month to plan recovery from
772042 - Millie's most severe cancer in
772043 - 9 years............................... 100503, ref SDS J7 HH4I
772044 - cancer marker rises rapidly to CA 15-3
772045 - 520, highest in patient
772046 - history............................... 100513, ref SDS J8 IZ7N
772048 - ..
772049 - 180. Kaiser caused Millie to get Phlebitis painful
772050 - often fatal disease by ordering treatment
772051 - with chemotherapy, which Kaiser had
772052 - previously disclosed would not be
772053 - effective treating Millie's cancer
772054 - and increased exposure to fatal
772055 - disease............................... 100601, ref SDS J9 OP4G
772057 - ..
772058 - 181. Kaiser failed to order prescribed treatment
772059 - for Millie to recover from 11th relapse of
772060 - cancer caused by UCSF medical mistakes because
772061 - Kaiser could not communicate with UCSF
772062 - by telephone nor email for over
772063 - a month............................... 100601, ref SDS J9 4F6I
772065 - ..
772066 - 182. Kaiser caused Millie's wrongful death by
772067 - delaying response 40 days to claim demanding
772068 - life saving treatment which violated Medicare
772069 - rules requiring response within
772070 - 10 days............................... 100713, ref SDS K0 J94Y
772072 - ..
772073 - 183. Kaiser caused Millie's wrongful death by
772074 - withholding prescribed treatment and ordering
772075 - consultation with primary care provider who
772076 - previously withheld care on grounds Kaiser
772077 - could not communicate with email nor
772078 - telephone to order treatment
772079 - for a month........................... 100713, ref SDS K0 J64Q
772080 -
772081 -
772082 -
7721 -
SUBJECTS
CT Test 040410 Shows Cancer Lymph Nodes No Increase Size Growing No
7803 -
780401 - ..
780402 - CT Test report continues...
780403 -
780404 - The heart is normal in size.
780405 -
780406 - ** A D D E N D U M E X I S T S B U T N O T F I N A L I Z E D**
780407 -
780408 - The liver cyst and splenic granulomata are stable. The pancreas
780409 - and adrenal glands are normal. The kidnesy are unremarkable aside
780410 - from a tiny cyst. The aorta is normal in caliber. There is no
780411 - adenopathy and no evidence of free fluid. The pelvis is
780412 - unremarkable.
780414 - ..
780415 - There are degenerative skeletal changes.
780416 -
780417 - ** A D D E N D U M E X I S T S B U T N O T F I N A L I Z E D**
780419 - ..
780420 - Impression
780422 - ..
780423 - Adenopathy as described. The brain is normal. There is no change
780424 - in the chest and abdomen.
780426 - ..
780427 - A Fisch MD
780429 - ..
780430 - DD: 040415 DTL 040415 AYF
780431 -
780432 - ** A D D E N D U M E X I S T S B U T N O T F I N A L I Z E D**
780433 -
780434 - ** A D D E N D U M E X I S T S B U T N O T F I N A L I Z E D**
780435 -
780436 - ** ADDENDUM ** ADDED ON 040416 BY WCRHYY **
780437 - ** ADDENDUM ** ADDED ON 040415 BY WCRDXN **
780439 - ..
780440 - CT OF HEAD, NECK, CHEST AND ABDOMEN 040410
780442 - ..
780443 - TECHNIQUE: Intravenous as well as oral contrast was used.
780444 -
780445 - ** A D D E N D U M E X I S T S B U T N O T F I N A L I Z E D**
780447 - ..
780448 - Comparison Previous study on 040307
780449 -
780450 - Prior tests....
780451 -
780452 - 040307 reported on 040318.............. ref SDS 65 LK5L
780453 - 031031 reported on 031205.............. ref SDS 60 IG9K
780454 - 030626 reported on 030710.............. ref SDS 57 AL6N
780455 - 030428 reported on 030508.............. ref SDS 53 LK5L
780457 - ..
780458 - Evaluation of the head shows normal configuration of the
780459 - ventricels and sulci. No abnormal collection of intra or extra
780460 - axial fluid is seen. No focal parenchymal abnormality is
780461 - detected. No abnormal enhancing lesion is seen. The visualized
780462 - orbits and paranasal sinuses are unremarkable. No osseous
780463 - abnormalities were detected. Evlauation of the mandibular region
780464 - is limited by extensive streak artifact from the patient's dental
780465 - apparatus. Nevertheless, the parotid glands appear unremarkable.
780466 - Submandibular glands are also unremarkable. There is a 13 x 7 mm
780467 - lymph node seen within the left posterior triangle, best seen on
780468 - image #26. There are also multiple subcentimeter adjacent lymph
780469 - nodes also detected. Again also noted is an 11 x 10 mm node in
780470 - the high left supraclavicular region seen on image #31. This has
780471 - not significantly changed.
780473 - ..
780474 - The report received on 040318 has a specific category for "Neck,"
780475 - which is missing from the report received today. ref SDS 65 WB8Q The
780476 - report today says the "neck" was tested along with many other major
780477 - components. ref SDS 0 799I The report today of a...
780478 -
780479 - 13 x 7 mm lymph node seen within the left posterior
780480 - triangle, best seen on image #26. ref SDS 0 7U4O
780481 -
780482 - ...appears to support the report received on 040318 that says...
780483 -
780484 - 11 x 7 mm node in the left posterior cervical triangle
780485 - (image #28). ref SDS 65 WB8Q
780486 -
780487 - ...suggesting expansion of the condition during the 4 weeks that
780488 - separate the test dates.
780490 - ..
780491 - The report today...
780492 -
780493 - 11 x 10 mm node in the high left supraclavicular region seen
780494 - on image #31. ref SDS 0 7U4O
780495 -
780496 - ...appears to support the report received o 040318 that says...
780497 -
780498 - 11 x 9 mm node in the high left supraclavicular region
780499 - (image #32). ref SDS 65 WB8Q
780500 -
780501 - ...suggesting expansion of the condition during the 4 weeks that
780502 - separate the test dates.
780504 - ..
780505 - In order to optimize review by the physician caring for a patient,
780506 - this section of the report, needs rework to maintain a consistent
780507 - format and descriptions that associate the problem of cancer with
780508 - common diagnosis and treatment patterns, e.g., brain, neck, breast,
780509 - lung, etc., per above, ref SDS 0 PTSX, so that understanding is
780510 - express rather than implied, because implications are tenuous, when
780511 - people are pressed for time, per study above. ref SDS 0 PTSX
780513 - ..
780514 - CT Test report continues...
780515 -
780516 - Again seen is what appears to be a nonspecific 5 mm low density
780517 - focus within the right thyroid lobe. This is without interval
780518 - change.
780520 - ..
780521 - The report received on 040318 describes...
780522 -
780523 - nonspecific 5 mm low density lesion in the right lobe of the
780524 - thyroid.
780525 -
780526 - "Lesion" somehow sounds more ominous than "focus," however in medical
780527 - practice they mean the same thing?
780529 - ..
780530 - CT Test report continues...
780531 -
780532 - Evaluation of the chest reveals multiple axillary lymph nodes, the
780533 - largest on the right measuring 15 x 9 mm and the largest on the
780534 - left measuring 14 x 10 mm. Post operative changes are again noted
780535 - within the left axillary region and the breast. No significant
780536 - mediastinal or hilar lymphadenopathy is appreciated. The lung
780537 - windows again show left apical scarring with fibrotic changes.
780538 - Also again noted are simple, very small subpleural nodules in the
780539 - right midlung zone. There is no evidence for mass and there is no
780540 - infiltrate or effusion.
780542 - ..
780543 - The report received on 040318 does not describe lymph nodes measuring
780544 - 15 x 9 mm and 14 x 10 mm; but that report found lymph nodes in the
780545 - neck that are much smaller than those in the chest reported today, yet
780546 - have cancer. ref SDS 65 VM7I
780548 - ..
780549 - CT Test report continues...
780550 -
780551 - Evaluation of the abdomen again shows a stable appearing 13 mm
780552 - cyst within the dome of the liver. Also again noted are multiple
780553 - splenic granulomas. The gallbladder, pancreas and adrenal glands
780554 - are unremarkable. There are again multiple subcentimeter what
780555 - appear to be cysts within the kidneys, unchanged. There is no
780556 - retroperitoneal lymphadenopathy appreciated. No free fluid is
780557 - noted. There is moderate ectasia of the iliac vessels. There is
780558 - diverticulosis of the sigmoid colon. No mass is seen in the
780559 - pelvis.
780561 - ..
780562 - Impression
780564 - ..
780565 - Multiple prominent cervical and supraclavicular lymph nodes.
780566 - Stable fibrotic at left apex. Stable right liver cysts.
780567 -
780568 -
780570 - ..
780571 - Distant Metastasis Cancer Neck Only Evidence of CT Scan Shows
780572 -
780573 - Follow up ref SDS 67 ZE5O, ref SDS 65 ZE5O.
780574 -
780575 - The doctor indicated the report shows that cancer is limited to the
780576 - neck area. ref SDS 0 IG9K While this is not expressly stated in the
780577 - report, the findings appear to show there has been some expansion of
780578 - lymph nodes in the neck, since the prior report received on 040318,
780579 - per above. ref SDS 0 7U6O
780581 - ..
780582 - What are implications from rate of growth for lymph nodes in the neck
780583 - -- normal, below or above average?
780585 - ..
780586 - What are implications of nodes in the chest that seem to be larger
780587 - than the nodes in the neck that have been diagnosed as cancer?
780588 - ref SDS 0 7V3R
780590 - ..
780591 - What is the disposition of lymph nodes under the arm, discussed on
780592 - 040318, ref SDS 65 HC7F, and that seem to be missing from the CT
780593 - tests? ref SDS 0 7V3R
780594 -
780595 - [On 040419 biopsy taken to evaluate redness. ref SDS 73 789F
780597 - ..
780598 - [On 040429 pathology on biopsy found cancer that may require
780599 - surgery for masectomy. ref SDS 75 F66N
780601 - ..
780602 - [On 040517 pathology report on biopsy submitted to patient, shows
780603 - diagnosis of inflammatory breast cancer (IBC). ref SDS 77 7D6F
780605 - ..
780606 - [On 040517 research on IBC shows that swollen lymph nodes under
780607 - the arm are a symptom of IBC. ref SDS 77 6M9H
780609 - ..
780610 - We need to see the final version of the CT test, because the report
780611 - received today has a notice that there is another addendum.
780612 - ref SDS 0 EG57
780613 -
780614 - [On 040517 the doctor advised that the version submitted today
780615 - is the final version, and that the notice in the report that an
780616 - addendum exists, and so the report is not finalized, is a mistake.
780617 - ref SDS 77 NL6J
780619 - ..
780620 - The doctor noted the current version of the report found no cancer
780621 - in the brain. (see "Impression" - ref SDS 0 7M63)
780622 -
780623 -
780624 -
7807 -
SUBJECTS
Redness Returns to Left Breast Diagnosed as Cellulitus Treated with
Breast Softer Change May Indicate Recovery from Trauma of Surgery
Diagnosis Changed from Cellulitus to Radiation Reaction Treated with
Cancer Treatment Delayed Cellulitus Diagnosed Treated with Antibioti
Breast Redness Returns to Left Breast Diagnosed as Cellulitus Treate
Breast Redness Diagnosis Changed from Cellulitus to Radiation Reacti
8708 -
870901 - ..
870902 - Chemotherapy Cleared to Start Avastin Trials
870903 - Treatment Proceeds Diagnosis Cellulitus Changed to Radiation Reaction
870904 - Redness Breast Diagnosis Changed from Cellulitus to Radiation Reaction
870905 - Radiation Reaction Redness Breast Diagnosis Changed from Cellulitus
870906 -
870907 - Follow up ref SDS 67 IM6J, ref SDS 65 IM6J.
870908 -
870909 - The doctor examined the breasts and commented that redness on the left
870910 - side seems to have reduced slightly from examination on 040402.
870912 - ..
870913 - The doctor noted there is nothing in the CT test today that suggests
870914 - cancer in the left breast, see above. ref SDS 0 WE7N
870916 - ..
870917 - Treatment for reaction to radiation with steriods was ended today, and
870918 - so chemotherapy treatment with Taxol and Avastin, which was previously
870919 - delayed on 040318 to treat cellulitus, ref SDS 65 PY4N, can commence
870920 - on 040420, as reported in the call from Rosalie on 040407. ref SDS 68
870921 - 3S6L
870922 -
870923 - [On 040419 biopsy taken to evaluate redness. ref SDS 73 789F
870925 - ..
870926 - [On 040429 pathology on biopsy found inflammatory breast cancer
870927 - (IBC), may require surgery for masectomy. ref SDS 75 F66N
870929 - ..
870930 - [On 051021 mastectomy surgery performed left breast based on
870931 - biopsy tests performed on 051012, which found no evidence of IBC,
870932 - and inflammation consistant with minimal to mild radiation effect.
870933 - ref SDS A1 7B4O
870934 -
870935 -
870936 -
870937 -
870938 -
8710 -
SUBJECTS
Blood Tests Painful Conditions Requires Higher Skilled Technician to
Port for New Treatments Administered Intravenously Avoids Pain and D
Port Will Provide Partial Releif from Excessive Needle Insertions in
9405 -
940601 - ..
940602 - Blood Tests Causing Painful Condition on Right Arm
940603 - Port to Support New Treatments Administered Intravenously
940604 -
940605 - Follow up ref SDS 67 CO3G, ref SDS 65 CO3G.
940606 -
940607 - On 040409 Millie asked about a "dual port" system. ref SDS 69 7J96
940609 - ..
940610 - Surgery scheduled for 040419, per report on 040414. ref SDS 70 YP8I
940611 -
940612 - On 040407 Rosalie called and explained that Kaiser does not use a
940613 - "dual" port procedure. ref SDS 68 3S6L
940614 -
940615 -
940616 -
940617 -
940618 -
940619 -
940620 -
940621 -
940622 -
940623 -
9407 -