CONTACTS 

SUBJECTS
Port Catheter Implanted Surgery Right Chest Day Before Chemotherapy

0803 -
0803 -    ..
0804 - Summary/Objective
0805 -
080501 - Follow up ref SDS 21 0000, ref SDS 20 CO3G.
080502 -
080503 - Operation was an evident success installing a port catheter to
080504 - facilitate intravenous procedures for chemotherapy, including drawing
080505 - blood which both have to occur at least once a week going forward.
080506 - The doctor reported there was a mistake not seeing the patient over
080507 - the past few years after surgery in March in 2002. ref SDS 0 XU75  A
080508 - biopsy was taken to check new redness condition in left breast.  This
080509 - will be discussed with Millie during a meeting with surgeon on 040429.
080510 - ref SDS 0 XU57  An x-ray taken after surgery indicated the operation
080511 - was successful. ref SDS 0 6I5I
080512 -
080513 -
080514 -
080515 -
080517 -  ..
0806 -
0807 -
0808 - 0745
0809 -
080901 - Millie was called into the surgery prep area.
080902 -
080903 - The work today installs a port catheter to avoid needle penetrations
080904 - for blood draws and IVs that cause Millie's arm to swell up severely,
080905 - reported on 040318. ref SDS 17 CO3G  The work was scheduled by Rosalie
080906 - on 040402. ref SDS 18 V750
080908 -  ..
080909 - Talked to the nurse, Chris.  She will ask the surgeon to visit
080910 - with us after surgery.
080912 -  ..
080913 - For surgery administration, Chris asked a number of questions to fill
080914 - out admitting forms that were asked last Friday by Mary, who, also,
080915 - filled out pre-op surgery forms.
080917 -  ..
080918 - It was unclear, why the same questions are asked twice, which invites
080919 - error from confusion when people say and hear things differently, or
080920 - remember partially.  Chris seemed to cite the form Mary submitted was
080921 - among the inventory assembled together on her clip board, so this
080922 - duplicated Mary's work, which increased the time and so doubled the
080923 - cost of the work.
080925 -  ..
080926 - Why then weren't answers from the first form used as a template for
080927 - the staff to fill out the 2nd form, and then ask patients additional
080928 - questions that might be different between the forms?  There was no
080929 - evident reference to the first form during the sign in process today.
080930 - There was no discussion about the effect when a customer remembers
080931 - differently at different times, or if different attendants hear the
080932 - same answer to common questions differently.  If the thought is to
080933 - provide a double check in critical patient data, why not have a single
080934 - form with double columns to check, that requires dual signatures by
080935 - the attendant, and if the answers are different, then the nurse can
080936 - ask the patient, and if the patient does not remember which is
080937 - correct, then the nurse or another clerical person can check Kaiser's
080938 - files to resolve differences, and where differences cannot be
080939 - resolved, then this becomes a fact for consideration in taking action.
080940 - On 990912 report published showing fatal accidents occur 300% more
080941 - often in medical work than in auto and airplain accidents combined.
080942 - ref SDS 4 0001
080943 -
080945 -  ..
0810 -
0811 -
0812 - 0815
0813 -
081301 - Millie waiting to be called for surgery preparation.
081302 -
081303 -
081305 -  ..
0814 -
0815 -
0816 - 0843
0817 -
081701 - Millie taken for surgery preparation.  Store clothing beneath gurney.
081702 -
081703 -
081704 -
081706 -  ..
0818 -
0819 -
0820 - 0905
0821 -
082101 - Millie taken to surgery room for port catheter operation.
082102 -
082103 -
082105 -  ..
0822 -
0823 -
0824 - 0928
0825 -
082501 - Port Catheter Surgery Successful
082502 -
082503 - The surgeon came into the reception area and spoke for about five (5)
082504 - minutes.  She advised that the operation went well, and is expected to
082505 - be successful.
082507 -  ..
082508 - This was a simple, routine procedure that only took about 20 minutes,
082509 - and so there was minimal risk of problems.  An xray performed prior to
082510 - releasing the patient, seems to have confirmed that the operation was
082511 - a success. ref SDS 0 6I5I
082513 -  ..
082514 - The doctor feels the port catheter will accomplish objectives to
082515 - relieve trauma and injury from continuing needle punctures for blood
082516 - draws, IV infusion treatments, and other injections that access veins,
082517 - reported on 031205, ref SDS 16 CO3G, and again on 040318. ref SDS 17
082518 - RX9O
082519 -
082520 -
082521 -
082522 -
0826 -

SUBJECTS
Examinations Post-op Evaluate Progress Recovery Breast Cancer Surger

2103 -
210401 -  ..
210402 - Examination Schedule Failure Computer Glitch Everybody Busy
210403 -
210404 - The doctor recalled that during the meeting at Kaiser in Walnut Creek
210405 - on 020408, a schedule was set to meet with Millie about every three
210406 - (3) months for post-op review. ref SDS 7 WX4K  This aligned with prior
210407 - planning on 020321. ref SDS 5 029O
210409 -  ..
210410 - The surgeon said that failure to meet with patients according to
210411 - original plans and commitments was a mistake caused by some kind of
210412 - computer glitch.  This was compounded by problems handling a lot of
210413 - details in the Surgery Department.  Health care records for patients
210414 - with a long medical history, like Millie, become large and complex.
210416 -  ..
210417 - Confusion handling complex records causes mistakes.  Managing patient
210418 - history across organizational boundaries takes time for skilled
210419 - practioners using computers to maintain order.  Deviations are endemic
210420 - to high volume activity.  As the number of transactions rises, risk of
210421 - mistakes increases even for highly skilled and motivated people.
210422 - Skill is a function of repetition which grows familiarity with steps
210423 - performing complex tasks.  People highly skilled doing familar tasks,
210424 - like a surgeon doing a heart operation, or an engineer designing a
210425 - computer chip, may be less skilled or unskilled doing tasks that are
210426 - not often needed in their routine work.  When all tasks are done on a
210427 - computer, under the Knowledge Management model, some, perhaps most,
210428 - are often used, but others are used less frequently.  People simply
210429 - forget how to accomplish computer tasks that are not used often enough
210430 - to be familiar the steps.
210432 -  ..
210433 - Andy Grove, CEO at Intel, notes that people like to work on familiar
210434 - things in familiar ways, reviewed on 980307. ref SDS 2 3740  Bill
210435 - Gates, CEO at Microsoft, reported on 021108 that people use only 5% of
210436 - commands for Microsoft programs, because the other 95% are needed only
210437 - rarely, so people cannot remember how to use them. ref SDS 10 455F
210439 -             ..
210440 -            [On 061024 case study health care professionals proficient
210441 -            doing routine tasks with computer, but cannot perform
210442 -            important, infrequently used tasks. ref SDS 35 NU5O
210444 -  ..
210445 - Additionally, circumstances arise that software engineers did not
210446 - expect, causing computers to make a lot of mistakes without anybody
210447 - being aware until days, weeks, even months later.  This takes time to
210448 - fix.
210450 -  ..
210451 - When mistakes using computers to manage patient history keeping
210452 - medical records in order on the job cause people to fall behind making
210453 - corrections.  Often people never catch up, and so examinations that
210454 - should be scheduled are never actually scheduled.
210456 -  ..
210457 - People get very stressed, and sometimes give up trying to keep up with
210458 - daily work, while also correcting records that are out of order, and
210459 - invest time for figuring out what went wrong in order to avoid future
210460 - problems.  People relieve stress by ignoring problems.  When patient
210461 - records get messed up, things fall through the cracks without anybody
210462 - noticing, like scheduling Millie's post-op follow up examinations.
210463 - This past year has been hectic with changes to improve the computer
210464 - system, changes in personnel, changes in policy and procedures, and
210465 - changes in regulations.  A lot of changes make training, planning, and
210466 - performing daily work difficult to implement consistently.
210468 -  ..
210469 - Cited the doctor's explanation in case study of medical mistakes on
210470 - 040416. ref SDS 20 UX3O  Another case study on computer problems in
210471 - health care is reported on 061024. ref SDS 35 QJ4O
210472 -
210473 -            [On 060428 read medical test findings - case study doctors
210474 -            limited time prevents reading findings to correlate
210475 -            clinically for discovering symptomatic trends that enable
210476 -            proactive case management; there is only enough time to
210477 -            read summaries that present the gist of findings.
210478 -            ref SDS 33 VG5L
210480 -  ..
210481 - Today, the surgeon explained that Kaiser's team care practice provides
210482 - redundancy with doctors requesting cross-departmental examinations to
210483 - double check for critical details on diagnosis and treatment plans
210484 - from different perspectives.  Cross-checking increases chances that
210485 - mistakes will surface in time to avoid problems with different people
210486 - and computer systems processing the same data.
210488 -  ..
210489 - In this case, mistakes in the Surgery Department failing to perform
210490 - follow up examinations to assess recovery from surgery, noted above,
210491 - ref SDS 0 XU75, were mitigated by examinations occurring in Oncology.
210492 - Kaiser's team care practice relies on 2nd opinions to sound an alert,
210493 - but somehow that didn't happen this time.
210495 -  ..
210496 - This aligns with planning by the Oncologist on 020726 to get backup
210497 - analysis from the radiologist on progress treating Millie, ref SDS 9
210498 - YO6K, which never actually occurred; and, further fits the model of
210499 - medical management in Kaiser's Healthwise Handbook calling for second
210500 - opinions from different disciplines, reported on 990625. ref SDS 3
210501 - T47O
210502 -
210504 -  ..
210505 - Doctor Patient Partnership Supports Effective Case Management
210506 -
210507 - The doctor further noted today that patients should be persistant
210508 - supporting the doctor/patient partnership by requesting examinations
210509 - across departments, so that planned redundancy actually occurs,
210510 - essential for a high quality of care.  Kaiser's Healthwise Handbook
210511 - presents doctor-patient partnership and team care model for optimizing
210512 - medical practice, also, reviewed on 990625. ref SDS 3 4185
210514 -  ..
210515 - Difficulty following published requirements due to limited time aligns
210516 - with case study on 020504. ref SDS 8 NS6F
210518 -      ..
210519 -     [On 040429 surgeon to rely on notice from Oncology Deparmtment for
210520 -     notice on when to perform examinations that apply team care
210521 -     practice for quality care. ref SDS 22 QS9K
210523 -      ..
210524 -     [On 050824 Advice Nurse being persistant reminding the surgeon to
210525 -     implement requirements in Kaiser's Healthwise Handbook on
210526 -     following up patient calls to collaborate and coordinate via email
210527 -     for accurate communications and patient medical history.
210528 -     ref SDS 30 4M7N
210530 -  ..
210531 - On 990912, reporting cited medical mistakes as a major cause of
210532 - concern, exceeding the impact of auto and airpline accidents combined.
210533 - ref SDS 4 NL51  Earlier on 921021 JPL reported that handling
210534 - documentation is a "sore subject" at NASA, ref SDS 1 A252, which led
210535 - to the loss of the Challenger in 1986, ref SDS 1 4499, and later to
210536 - loss of the Columbia in 2003, ref SDS 12 0001, for reasons reported by
210537 - NASA Chief Sean O'Keefe on 030826. ref SDS 15 8K4G
210538 -
210539 -
210540 -
2106 -

SUBJECTS
Default Null Subject Account for Blank Record

2403 -
240401 -  ..
240402 - Inflammation Expands Left Breast Treatment for Cellulitis Not Effective
240403 -
240404 - We discussed Doctor Johnson's findings in Oncology on 040318 that
240405 - redness has returned to the left breast, and was treated for
240406 - cellulitis. ref SDS 17 IM6J  On 040402 treatment was not effective, so
240407 - diagnosis was changed to reaction to radiation treatments in 2002, and
240408 - was treated with steriods. ref SDS 19 IM6J  On 040416 treatment was
240409 - ended for inflammation from reaction to radiation, but redness
240410 - persists in the left breast. ref SDS 20 IM6J
240411 -
240412 -     [On 070202 similar quandry distinguishing IBC from spreading rash
240413 -     and changing inetnsity, which could be Cellulitis. ref SDS 36 U24F
240415 -  ..
240416 - The surgeon said that the left breast, treated previously on 020312,
240417 - and again on 020327, ref SDS 6 0001, was not examined during the
240418 - procedure this morning, because this occurred above the right breast.
240419 - As a result, the redness problem was not noticed when the port was
240420 - surgically implanted for chemotherapy treatments.
240422 -  ..
240423 - We went into the surgery recovery area, and the doctor examined
240424 - Millie.  The surgeon asked how long redness has occured?
240425 -
240426 -     [On 050928 strong feelings about commitment to recovery, surgeon
240427 -     praised. ref SDS 31 MQ7N
240429 -  ..
240430 - The primary care physician in oncology first reported redness in the
240431 - left breast on 030109, and prescribed treatment for cellulitus.
240432 - ref SDS 11 KW5F  Millie recalled this seemed to get better and then
240433 - got progressively worse.  In May an emergency meeting was requested to
240434 - have an examination.  When the doctor examined the left breast a week
240435 - or so later on 030606 he indicated redness had receded, ref SDS 13
240436 - 7C6W, but noted that Millie is high risk for recurrance of cancer.
240437 - ref SDS 13 NE4G  Another examination was performed on 030710.  At that
240438 - time, a CT test reported skin thickening on the left breast could be
240439 - reaction to radiation treatment a year earlier, or could be invasion
240440 - of dermal lymphatics by cancer, which required clinical evaluation.
240441 - The doctor explained that severe redness of the breast would indicate
240442 - cancer has recurred. ref SDS 14 GI4H  About a month ago, Millie
240443 - noticed redness returned to the left breast, and so requested a
240444 - meeting for review.  On 040318 the doctor made an examination and
240445 - observed inflammation, ref SDS 17 IM6J, which was then treated for
240446 - Cellulitus with antiobotics. ref SDS 17 PY4N  Redness seems to have
240447 - gotten progressively worse the past few months, so there is concern if
240448 - the left breast is okay?
240450 -  ..
240451 - After hearing background on the breast redness problem, the doctor
240452 - used Kaiser's computer for 10 minutes or so, located about 15 feet
240453 - across the room in the common administration area.
240455 -  ..
240456 - After looking at the computer, the surgeon came into Millie's
240457 - post-surgery recovery cubical and said that she decided to take a
240458 - punch biopsy of the left breast for review by pathology.
240459 -
240460 -     [On 060428 read medical test findings - case study doctors
240461 -     limited time prevents reading findings to correlate
240462 -     clinically for discovering symptomatic trends that enable
240463 -     proactive case management; there is only enough time to
240464 -     read summaries that present the gist of findings.
240465 -     ref SDS 33 VG5L
240467 -  ..
240468 - Findings from pathology will be discussed during the meeting with
240469 - Millie on 040429 at 1445 that was set previously scheduled with
240470 - Jessica following the meeting, where Mary did the prep for the surgery
240471 - today, at Kaiser in Walnut Creek on 040416. ref SDS 21 LW6J
240472 -
240473 -     [On 040429 pathology report on biopsy shows cancer requiring
240474 -     further surgery. ref SDS 22 C155
240476 -      ..
240477 -     [On 040504 primary care physician in oncology department advises
240478 -     that biopsy is normally performed on breast redness; pathology
240479 -     invaribly find no cancer, so in this case, a biopsy was not
240480 -     ordered through the history of this problem beginning on 030109.
240481 -     ref SDS 23 WI8F
240483 -      ..
240484 -     [On 040517 the pathology report on the biopsy diagnoses metastatic
240485 -     Carcinoma involving dermal lymphmatics consistent with
240486 -     inflammatory carcinoma of the breast. ref SDS 24 7D6F
240488 -      ..
240489 -     [On 041130 wound from punch biopsy worsens, after nearly being
240490 -     healed prior to stopping cancer treatments on 041104; antibiotics
240491 -     prescribed. ref SDS 25 6T5G
240493 -      ..
240494 -     [On 050107 examination by the surgeon showed biopsy wound not
240495 -     healing, treatment plan to continue chemotherapy with AC toward
240496 -     evaluation of surgery. ref SDS 27 IS5N
240498 -      ..
240499 -     [On 050324 surgeon observes slow healing of biopsy wound after 3
240500 -     treatments with AC. ref SDS 28 906K
240502 -      ..
240503 -     [On 050727 follow up examination by surgeon shows biopsy wound
240504 -     fully healed after 4 treatments with Taxotere and capecitabine.
240505 -     ref SDS 29 WI6K
240507 -      ..
240508 -     [On 050928 strong feelings about commitment to recovery, surgeon
240509 -     praised during meeting to review surgical treatment options.
240510 -     ref SDS 31 MQ7N
240512 -      ..
240513 -     [On 051021 after 18 months of treatment biopsy on 051012 negative
240514 -     for inflammatory carcinoma. ref SDS 32 544N
240516 -      ..
240517 -     [On 060711 status change was reported negative for biopsy on
240518 -     0409419. ref SDS 34 SW7O
240520 -  ..
240521 - After the surgeon completed the biopsy and prepared documents for
240522 - processing by the pathology lab, a technician wheeled in a portable
240523 - machine.  An x-ray was taken, and in about 5 or 10 minutes, the
240524 - technician reported that the x-ray showed a successful surgery.  As a
240525 - result, Millie was processed for release from the hospital.
240527 -  ..
240528 - Checking Millie out of the surgery department showed a rush to fill
240529 - out a number of forms, including the biopsy, which was not actually
240530 - scheduled, and so necessarily compresses the normally alotted time for
240531 - documentation.  The impression from watching these tasks performed is
240532 - that information is prepared hastily, using hurried handwritting.  On
240533 - 990912, communication errors from hurried, tired doctors and nurses
240534 - were identified as a major source of errors in medicine, ref SDS 4
240535 - 0285, and illegible handwriting was one of the issues cited in the
240536 - reporting. ref SDS 4 NL7I
240538 -  ..
240539 - Overall, everyone did a terrific job, including the new nurse who was
240540 - being trained, and did the final checkout ops, removing the IV and
240541 -
240542 -
240543 -
240544 -
240545 -
240546 -
240547 -
240548 -
2406 -