THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: April 19, 2004 06:45 AM Monday;
Millie operation for port catheter chemo and drug trial treatments.
2...Port Catheter Surgery Successful
3...Examination Schedule Failure Computer Glitch Everybody Busy
4...Doctor Patient Partnership Supports Effective Case Management
5...Inflammation Expands Left Breast Treatment for Cellulitis Not Effective
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Port Catheter Implanted Surgery Right Chest Day Before Chemotherapy
0803 - ..
0804 - Summary/Objective
080501 - Follow up ref SDS 21 0000, ref SDS 20 CO3G.
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
080517 - ..
0808 - 0745
080901 - Millie was called into the surgery prep area.
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
080945 - ..
0812 - 0815
081301 - Millie waiting to be called for surgery preparation.
081305 - ..
0816 - 0843
081701 - Millie taken for surgery preparation. Store clothing beneath gurney.
081706 - ..
0820 - 0905
082101 - Millie taken to surgery room for port catheter operation.
082105 - ..
0824 - 0928
082501 - Port Catheter Surgery Successful
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
Examinations Post-op Evaluate Progress Recovery Breast Cancer Surger
210401 - ..
210402 - Examination Schedule Failure Computer Glitch Everybody Busy
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
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
210504 - ..
210505 - Doctor Patient Partnership Supports Effective Case Management
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
Default Null Subject Account for Blank Record
240401 - ..
240402 - Inflammation Expands Left Breast Treatment for Cellulitis Not Effective
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
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?
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.
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
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