CONTACTS 

SUBJECTS
Neupogen Injection Medical Mistakes Treatment Failed Need Prescripti

1203 -
1203 -    ..
1204 - Summary/Objective
1205 -
120501 - Follow up ref SDS 71 0000. ref SDS 70 0000.
120502 -
120503 -
120504 -
120505 -
120506 -
120508 -  ..
1206 -
1207 -
1208 - Progress
1209 -
120901 - 2 Neupogen Treatments Per Week Prescribed 4th Cycle Begin 080529
120902 -
120903 - Follow up ref SDS 71 JN38.
120904 -
120905 - Millie learned during treatment at UCSF on Thursday 080605 that the
120906 - doctor ordered 2 Neupogen treatments per week in the Chemotherapy
120907 - Order on 080529 (May 29th), ref SDS 71 JN38, guiding treatment for the
120908 - 4th cycle of treatment in the cetuximab and Carboplatin clinical
120909 - study.  A week earlier during the meeting at UCSF on 080529 the
120910 - medical team seemed to prescribe only 1 Neupogen treatment per week
120911 - for the 4th cycle. ref SDS 69 4F42, and this was confirmed during
120912 - treatment that day in the Infusion Clinic. ref SDS 70 TE6N  However, a
120913 - week later on 080605, Diane in the Infusion Clinic submitted the
120914 - Chemotherapy Order for the 4th cycle starting on 080529, and it
120915 - prescribes 2 Neupogen treatments per week. ref SDS 70 PWSY
120916 -
120918 -  ..
120919 - Mistake Issuing Chemotherapy Orders Only 1 Neupogen for 1st Treatment
120920 -
120921 - Chemotherapy Orders were not received from UCSF on 080529 to start the
120922 - 4th cycle of the 2nd arm on the clinical study for cetuximab and
120923 - Carboplatin.  Typically, during meetings with the medical team to
120924 - start a new cycle, the patient receives a Chemotherapy Order, blood
120925 - vials for drug trial evaluations, and any special prescriptions, e.g.,
120926 - Magnesium, Sodium, and these instruments are hand carried by the
120927 - patient to the Infusion Clinic for treatment.  Last week there was a
120928 - mixup on things during the meeting, ref SDS 69 NW3G, including the
120929 - Chemotherapy Orders. ref SDS 69 NW89
120931 -  ..
120932 - Understanding from the meeting on 080529 was for only 1 treatment of
120933 - Neupogen, ref SDS 69 4F38, which was restated by the nurse in the
120934 - Infusion Clinic on 080529, as a result of mixup delivering Cheotherapy
120935 - Orders, and consequent reliance on instructions for the previous cycle
120936 - which specified 1 Neupogen treatment per week, reported on 080501.
120937 - ref SDS 63 M64J  As a result, last week only 1 Neupogen treatment was
120938 - taken for the 1st treatment in the 4th cycle, rather than 2 treatments
120939 - prescribed in Chemotherapy Orders.
120941 -  ..
120942 - This past Thursday on 080605, with just 1 Neupogen treatment for the
120943 - 1st chemotherapy treatment of Carboplatin, blood counts NEUTS 1.55
120944 - were barely high enough to get the 2nd treatment with Carboplatin.
120945 - ref SDS 71 JN3K  So, the error taking only half of prescribed
120946 - treatment with Neupogen last week was not harmful.
120948 -  ..
120949 - At that time on Thursday 080605, the nurse advised that the
120950 - Chemotherapy Order issued the week before on 080529 actually
120951 - prescribes 2 Neupogen treatments per week. ref SDS 71 JN38  At that
120952 - time, on 080605, Millie subitted a letter to UCSF requesting the
120953 - Chemotherapy Order for 080529, ref SDS 72 JO9Q; later that day, after
120954 - treatment on 080605 was completed, Diane submitted the Chemotherapy
120955 - Order for 080529 to Millie. ref SDS 71 YD51
120957 -  ..
120958 - Since Millie still had 2 treatments on hand from the original 6
120959 - treatments prescribed by the doctor at Kaiser on 080502, ref SDS 65
120960 - NL55, she took 1 treatment this morning, and planned to take the
120961 - second treatment tomorrow.
120962 -
120963 -
120965 -  ..
120966 - Neupogen Self-injection Treatment Failed Need Replacement Prescription
120967 -
120968 - There was confusion and error attempting Neupogen self-injection this
120969 - morning, causing treatment to fail.
120971 -  ..
120972 - Millie pinched her skin on the abdomen with her left hand as the
120973 - target for injection.  However, the IV needle in the right hand.
120974 - missed the target due to growing confusion, fatigue, eye sight,
120975 - jitters, anxiety, etc.  The needle was pressed into clothing below the
120976 - target held by the left hand.  Before noticing error occurred,
120977 - medication squirted onto her clothing, causing treatment failure.
120979 -  ..
120980 - After realizing treatment failed, Millie used the 2nd, and only
120981 - remaining bottle of Neupogen from the original 6 treatments prescribed
120982 - on 080502. ref SDS 65 NL4M  This second injection attempt was
120983 - successful for accomplishing the first of two Neupogen treatments
120984 - prescribed for this week.  However, there is now no Neupogen available
120985 - for the 2nd treatment prescribed for injection tomorrow.
120987 -  ..
120988 - Millie needs another prescription for Neupogen in order to comply with
120989 - the Chemotherapy Order on 080529, ref SDS 70 PWSY, received this past
120990 - Thursday on 080605, ref SDS 71 JN38, which calls for 2 treatments this
120991 - week, and which must be taken tomorrow on Sunday, or at the latest on
120992 - Monday, 080609, based on Doctor Rugo's comments during the meeting at
120993 - UCSF on 080403. ref SDS 53 6Y9K
120995 -  ..
120996 - Millie wants the work done by nurses in the Infusion Clinic at Kaiser
120997 - in order to avoid further problems, similar to the patient at UCSF who
120998 - gets Neupogen treatments by nurses in the Infusion Clinic, reported
120999 - this past Thursday on 080605. ref SDS 71 HL9K  Millie had Neupogen
121000 - treatment in the hospital at Kaiser on 061031 without problems.
121001 - ref SDS 3 9U65  Kaiser notified Millie on 080404 that she would get
121002 - Neupogen treatments in the Infusion Clinic. ref SDS 55 JW6J  The next
121003 - day, on 080405 there was confusion and problems getting Neupogen from
121004 - the pharmacy rather than the Infusion Clinic. ref SDS 56 H65G  Millie
121005 - reported the problem to the doctor in a letter on 080409. ref SDS 57
121006 - W19Q  During the next meeting at Kaiser on 080502, the doctor
121007 - explained difficulties ordering treatments using Kaiser's new computer
121008 - system. ref SDS 65 NM3M
121010 -  ..
121011 - Millie sent a letter, ref DIT 1 0001, to the primary care physician at
121012 - Kaiser with copies to the medical team requesting support for Neupogen
121013 - treatment to comply with Chemotherapy Orders. ref DIT 1 00W3
121015 -  ..
121016 - The letter to the medical team says...
121017 -
121018 -    1.  I made a mistake this morning with self-injection causing
121019 -        failed treatment with Neupogen.  I had another treatment on
121020 -        hand, and so used it, as reported in the record today.
121021 -        ref SDS 0 TZ8I, ref DIT 1 0001
121023 -         ..
121024 -    2.  However, I am supposed to get 2 treatments this week, per Chemo
121025 -        Orders [issued on 080529, but not disclosed by the nurse at
121026 -        UCSF until a week later on 080605, ref SDS 71 JN38, and per
121027 -        above, ref SDS 0 5W50], and I only had 2 on hand [from the
121028 -        prescription issued by Kaiser on 080502, per above, ref SDS 0
121029 -        5W54], so now I am short 1 treatment, which should be given
121030 -        tomorrow or at the latest on Monday. ref SDS 0 H16R,
121031 -        ref DIT 1 XK6G
121033 -         ..
121034 -    3.  Can you please arrange for me to get this treatment at the
121035 -        Infusion Clinic on Monday [implementing Kaiser's prior
121036 -        planning, ref SDS 0 4154].  This will prevent further
121037 -        application errors and support cost containment goals discussed
121038 -        previously. ref DIT 1 XK6M
121039 -
121040 -            [On 080609 Kaiser responded there was confusion again
121041 -            ordering the Neupogen treatment for Millie. ref SDS 73 TZ8I
121043 -             ..
121044 -            [On 080609 Millie went to the Kaiser Pharmacy again to get
121045 -            Neupogen and was charged $2,000 for 6 treatments to get 1
121046 -            treatment that was ordered. ref SDS 73 WM4V
121048 -             ..
121049 -            [On 080609 Kaiser ordered Neupogen treatments for Millie in
121050 -            the Infusion Clinic, ref SDS 73 IL6I; and cancelled the
121051 -            order for treatment in the Pharmacy, which was entered
121052 -            again in the computer system by mistake. ref SDS 73 K195
121054 -             ..
121055 -            [On 080609 Millie returned the Neupogen treatment to the
121056 -            Pharmacy to comply with Kaiser quality care that prevents
121057 -            patients from having double prescriptions. ref SDS 73 856H
121059 -         ..
121060 -    4.  By copy to Doctor Rugo and the team at UCSF, I am notifying of
121061 -        possible problems/delays, if we don't get things done on this
121062 -        2nd Neupogen treatment.  If coordination cannot be accomplished
121063 -        with Kaiser, can I come into UCSF on Monday to get the 2nd
121064 -        treatment of Neupogen?  Since NEUTS 1.55 were barely enough for
121065 -        treatment this past Thursday, it seems like the 2nd treatment
121066 -        is needed in order to get the next treatment next Thursday.
121067 -        ref DIT 1 XK7I
121068 -
121069 -            [On 080609 UCSF did not respond; Millie coordinated
121070 -            solution with primary care physician at Kaiser, ref SDS 73
121071 -            4R6L; Kaiser responded later in the day. ref SDS 73 IL6I
121072 -
121073 -
121074 -
1211 -

SUBJECTS
Neupogen 1-Treatment Needed 080609 Notify  Pimary Care Physician Usi

2503 -
2504 - 0057
250501 -  ..
250502 - Neupogen Prescription Required NLT 080609 Notify Kaiser
250503 -
250504 - Note...
250505 -
250506 -    This letter is dated 080608, however, since it is a continuation of
250507 -    the work above the letter is entered here for continuity.
250509 -  ..
250510 - Submitted ref DIT 2 0001 to the primary care physician using Kaiser's
250511 - special Knowledge Management email system, and to confirm notice to
250512 - the medical team at Kaiser and UCSF on problems with Neupogen
250513 - treatment, and need to order work in the Infusion Clinic to recover
250514 - from the mistake.
250515 -
250516 -    1.  I need a Neupogen treatment in the Infusion department at
250517 -        Kaiser either tomorrow on Sunday, or on Monday. ref DIT 2 0001
250519 -         ..
250520 -    2.  UCSF changed my prescription from 1 to 2 Neupogen shots per
250521 -        week due to low blood counts.  This morning I had 2 treatments
250522 -        left from the order you placed on 080502.  I messed up and the
250523 -        first attempt today failed, which lost a treatment.  So, I need
250524 -        another order for the 2nd treatmet, which is prescribed for
250525 -        Sunday, but Monday will be okay, as related in the record for
250526 -        today. ref SDS 0 TZ8I, ref DIT 2 0Y5M
250528 -  ..
250529 - After the letter was submitted, examined the letter using Kaiser's
250530 - special Knowledge Management email system.  Opening the link to this
250531 - record presents essentially a "disaster" for a busy physician.
250533 -  ..
250534 - Kaiser has changed the way links are opened.  Previously, opening a
250535 - link to an SDS record was done by opening a separate window, so people
250536 - can look at both the original source and link.  Now the link opens in
250537 - the same window so context is lost.  Additionally, Kaiser now
250538 - restricts the width of the display within (something, just trying to
250539 - explain this is more complicated than anyone on earth wants to
250540 - consider).  This change presents enormous delay and confusion to the
250541 - doctor.  Reading the rcord requires scrolling to the bottom of the
250542 - Kaiser window.  Sliding the horizontal scroll bar scrolling back to
250543 - the location to read 2 or 3 words, and doing this for every line of
250544 - text in the record.  Nobody on the planet will do that.
250546 -  ..
250547 - There is a work around that only takes a few seconds, but involves
250548 - several steps...
250549 -
250550 -            1.  Place the mouse pointer anywere on the line showing the
250551 -                link, and right click.  This will copy the link
250552 -                address.
250554 -                 ..
250555 -            2.  Use the mouse to open another session of the Internet
250556 -                Explorer (IE) web browser.  If Kaiser has removed
250557 -                access to IE from Kaiser computers, then this solution
250558 -                will fail.
250560 -                 ..
250561 -                If IE is opened, then click on the Address bar to
250562 -                highlight the content.
250564 -                 ..
250565 -            3.  Right click the mouse, and select "Paste"
250566 -
250567 -                This transfers the link address in Kaiser's email
250568 -                system to the web browser.
250570 -                 ..
250571 -                Press "Enter" and the record on patient history will
250572 -                be opend with tools that adjust the window size to
250573 -                read the record normally.
250575 -  ..
250576 - Millie's letter to Kaiser continues...
250577 -
250578 -    3.  I know your schedule can be hectic.  If I don't hear from you I
250579 -        will try taking the UCSF Chemo Order to Oncology Department
250580 -        tomorrow and see if another doctor can arrange for me to get
250581 -        the 2nd Neupogen treatment in the Infusion Department.  I also
250582 -        sent a letter to UCSF asking if they can support Neupogen
250583 -        treatment to get the 3 treatments with Carboplatin, ref SDS 0
250584 -        YQ6U, which so far I have not achieved in the 3 cycles.
250585 -        ref DIT 2 FY6L
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