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0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 21 0000, ref SDS 20 0001,
040502 -
040503 -
040504 -
040506 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Background...
040902 -
040903 -    1.  On 081202 Millie submitted a letter to the medical team
040904 -        requesting work to schedule the next CT test in time for review
040905 -        at UCSF to start the 2nd cycle. ref SDS 11 AT7T  Millie asked
040906 -        about doing the test a week before the meeting at UCSF on
040907 -        090108. ref SDS 11 AT9T
040909 -         ..
040910 -    2.  On 081203 Glenna called about scheduling the next CT test as
040911 -        called out in the letter on 081202. ref SDS 12 YZ5I  Glenna
040912 -        submitted a letter notifying the medical team that the next CT
040913 -        test is needed for meeting at UCSF on 090108. ref SDS 12 4P7N
040915 -         ..
040916 -    3.  On 081209 Millie submitted a letter requesting the medical team
040917 -        coordinate scheduling the next CT test on 081230, 081231, or
040918 -        090102 in time for meeting with medical team at UCSF on 090108.
040919 -        ref SDS 13 YL9I
040921 -         ..
040922 -    4.  On 081209 the letter to Kaiser presented the scope for the CT
040923 -        test. ref SDS 13 RL5X
040925 -         ..
040926 -    5.  On 081210 Millie sent another letter asking Kaiser to schedule
040927 -        the CT test, citing the letter on 081209. ref SDS 15 0Y5U  On
040928 -        081210 Doctor Johnson called responding to letters on 081210
040929 -        and 081209. ref SDS 16 LO7J   The doctor scheduled the CT test
040930 -        at Kaiser in Walunt Creek on 081230 1020. ref SDS 16 SX9O  The
040931 -        doctor used the letter on 081209 to make the referral with the
040932 -        scope for the CT test. ref SDS 16 H44N  The doctor asked his
040933 -        assistant, Arlette, to notify Interventional Radiology Services
040934 -        that Millie's CT test on 081230 1020 requires support.
040935 -        ref SDS 16 T15L  Later on 081210, Millie received a letter from
040936 -        the doctor confirming the schedule for the CT test on 081230
040937 -        1020. ref SDS 17 GJ39
040939 -         ..
040940 -    6.  On 081219 Doctor Johnson clarified on the computer the order
040941 -        for the CT test scheduled on 081230 to use Millie's power port
040942 -        for injecting contrast medium, and to include the neck,
040943 -        ref SDS 20 PU4H, and he requested a consolidated report, in
040944 -        order to avoid confusion ref SDS 20 587G, getting two (2)
040945 -        separate reports on different days, which happened for the
040946 -        prior CT test on 081107, as explained during the meeting at
040947 -        Kaiser on 081219. ref SDS 20 PI5M
040949 -  ..
040950 - Today, Millie stopped at Kaiser on the way home from hiking at
040951 - Lafayette reservoir.
040953 -  ..
040954 - Visited with Brenda in Interventional Services.
040956 -  ..
040957 - Asked who is assigned to support Millie's test tomorrow in the CT
040958 - Department to connect pressure injection equipment for Millie's Power
040959 - Port?
040961 -  ..
040962 - Brenda checked the computer for Millie's Kaiser number.
040964 -  ..
040965 - Brenda found that Millie is scheduled for a CT test tomorrow.  She
040966 - could not find an order for Interventional Services to support the CT
040967 - Department.
040969 -  ..
040970 - We reviewed the record of patient history above. ref SDS 0 KH8M
040972 -  ..
040973 - Brenda decided to investigate work requirements.  She walked to the CT
040974 - Department located in the basement about 100 yards from Interventional
040975 - Services through various hallways.
040977 -  ..
040978 - Brenda used a code entered by pressning buttons above the door handle
040979 - to gain access into the CT Department.
040981 -  ..
040982 - After about 30 minutes Brenda and Cassandra came into the hallway for
040983 - a meeting, similar to the meeting with Ike on 080711. ref SDS 4 JR47
040985 -  ..
040986 - Cassandra commended Brenda's patient assistance today taking time from
040987 - her work in Interventional Services to check on arrangements for
040988 - Millie's CT test tomorrow.  Cassandra explained that proactive support
040989 - is critical to optimize team care.  Cassandra recalled today
040990 - discussing patient assistance for Millie's prior CT test on 081107.
040991 - ref SDS 9 MX6K
040993 -  ..
040994 - Cassandra advised that Millie is scheduled for a CT test tomorrow, but
040995 - there is nothing in Kaiser's records showing that the doctor ordered
040996 - the test using Millie's Power Port for pressure injecting contrast
040997 - medium.  We reviewed the record last week on 081219, when the doctor
040998 - checked the computer, ref SDS 20 WP30, and specified doing the test
040999 - with the Power Port. ref SDS 20 PU4H
041001 -  ..
041002 - Cassandra said she just checked the computer with Brenda and saw
041003 - nothing about Millie's power port.  Cassandra apologized saying she
041004 - remembers problems from last month on 081107, ref SDS 9 2E42, and so
041005 - now realizes the CT Department has to make arrangements with IS for
041006 - using Millie's Power Port tomorrow.  Cassandra thanked Brenda again
041007 - for checking today so that work is not delayed tomorrow doing things
041008 - at the last minute, which can cause mistakes from a hectic schedule.
041010 -  ..
041011 - Cassandra advised that she does not have authority to work with Brenda
041012 - (standing in the hallway) today making arrangements for a nurse or
041013 - doctor from Interventional Services (IS) to support Millie's CT test
041014 - tomorrow.  Dennis can make the arrangements with IS, like he did for
041015 - Millie's last test on 081107, ref SDS 9 2E42; however, Dennis is on
041016 - vacation this week.
041018 -  ..
041019 - Cassandra plans to call the manager of the Radiology Department, Al
041020 - Hutchins, who has authority to order support from Interventional
041021 - Services for Millie's test tomorrow.
041022 -
041023 -        [On 081230 coordination effective Al Hutchins ordered support
041024 -        from Interventional Services for Millie's CT test. ref SDS 24
041025 -        DU3F
041027 -  ..
041028 - Cassandra suggested that Millie arrive 10 minutes early tomorrow so
041029 - that the IS nurse or doctor can access the port.  She explained that
041030 - CT technicians are not authorized to access the Power Port for
041031 - injecting contrast medium, because the port connects to a central
041032 - artery.
041034 -  ..
041035 - Cassandra's explanation today aligns with Ike's analysis during the
041036 - meeting at Kaiser on 080711. ref SDS 4 RG9O  On 080905, Paula,
041037 - supervisor of the Oncology Infusion Clinic also understands that
041038 - governement regulations require IS support Millie's CT test using the
041039 - Power Port. ref SDS 5 MK9H  On 081017 Paula reported that Kaiser here
041040 - in Walnut Creek is investigating how Kaiser in Oakland handled laws
041041 - about accessing a central venous artery with CT test equipment using a
041042 - Power Port, ref SDS 6 8Y4N, and seemed to indicate that if legal
041043 - issues are resolved, and the Power Port is accessed by qualified
041044 - nurses in the Infusion Clinic, then support from the Power Port
041045 - manufacturer is not needed. ref SDS 6 035K  Later on 081024, Dennis,
041046 - the supervisor in the CT Department requested background on how
041047 - Millie's Power Port was accessed for Millie's CT test in Oakland on
041048 - 080911, and using the Bard Power Port to inject contrast medium;
041049 - Dennis indicated the manager of the Radiology Department is
041050 - coordinating to find out how Kaiser in Oakland did Millie's CT test
041051 - using the Power Port and attended only by a CT Technician. ref SDS 7
041052 - 2061
041054 -  ..
041055 - We reviewed the record showing that on 081210 Doctor Johnson, Millie's
041056 - primary care phyiscian in the Oncology Department, placed an order for
041057 - the Infusion Clinic to access Millie's Power Port for the test
041058 - tomorrow in the CT Department. ref SDS 16 SX9O  The next day on 081211,
041059 - the doctor's assistant, Arlette, called and advised that Millie is
041060 - scheduled for the Infusion Clinic to access her Power Port for the Ct
041061 - test on 081230 at 1000, which allows 20 minutes to complete the work,
041062 - and for Millie to walk to the CT Department for the test at 1020; and
041063 - that after the test, Millie will return to the Infusion Clinic for
041064 - removal of the Huber needle, and maintenance of the Power Port per
041065 - protocol. ref SDS 18 IG54
041067 -  ..
041068 - Cassandra advised that records she saw in the CT Department reviewing
041069 - requirements with Brenda for Millie's CT test tomorrow do not say
041070 - anything about the Oncology Infusion Clinic accessing the Power Port
041071 - tomorrow.  Brenda commented that records at Interventional Services do
041072 - not indicate that an Oncology Infusion Clinic nurse will access the
041073 - port, so she assumed that the nurse from Interventional Serivces (IS)
041074 - would do this work tomorrow.
041076 -         ..
041077 -        [On 081230 work performed according to planning today for the
041078 -        Infusion Clinic to access Millie's Power Port, and then to
041079 -        remove the Huber needle after the test in the CT Department.
041080 -        ref SDS 24 4S3K
041082 -  ..
041083 - Cassandra thanked Brenda for clarifying the scope of work for Millie's
041084 - CT test.  Cassandra will explain to Al, the manager for the CT
041085 - Department, that the order for Interventional Services (IS) to support
041086 - Millie's CT test tomorrow does not include accessing the port, nor
041087 - removing the Huber Needle.  Brenda was listening, and so is alerted
041088 - today that the only task the IS staff person will perform is
041089 - connecting the infusion equipment to the injection needle, and then
041090 - disconnecting the needle, which is the same scope normally performed
041091 - by the CT Technician, noted by Ike during the meeting at the CT
041092 - Department on 080711. ref SDS 4 JQ92
041093 -
041094 -        [On 081230 Pat in the CT Department disconnected the CT
041095 -        pressure injection equipment from the Huber needle, after first
041096 -        observing Helen from IS make the initial connection; this
041097 -        procedure was timely and effective. ref SDS 24 FF81
041099 -  ..
041100 - Cassandra advised that Millie's last blood test at Kaiser on 081210
041101 - shows Creatinine 0.66. ref SDS 14 8U4N  She indicated this lab result
041102 - meets CT Department protocols for a safe test.  The more recent test
041103 - at UCSF on 081218 shows Creatinine 0.73. ref SDS 19 8U4N  The test at
041104 - Kaiser on 081226 did not include Creatinine. ref SDS 22 M85G
041106 -  ..
041107 - Cassandra feels this record meets Kaiser's requirements for Millie to
041108 - get the CT test tomorrow.
041110 -  ..
041111 - Cassandra advised that tomorrow the CT Department will be performing
041112 - biopsies, so Millie's CT test will be performed in a trailer outside
041113 - the hospital, and next to the parking lot.  This is the trailer where
041114 - Dennis was working on 081107, when Cassandra called to get
041115 - instructions for Millie's prior CT test. ref SDS 9 E640  Cassandra
041116 - explained the trailer is located next to the PET scan test trailer.
041117 - She asked if Millie knows how to find the trailer.
041118 -
041119 -        [On 081230 Millie initially CT test assigned to outside
041120 -        auxillary trailer because CT Department busy performing
041121 -        biopsies, ref SDS 24 DU3O; test was ultimately perfomred in the
041122 -        CT Department because emergency in Interventional Services
041123 -        delayed support, so onsite nurse from Interventional Services
041124 -        performing biopsies took a few minutes to support Millie's CT
041125 -        test. ref SDS 24 FE6H
041127 -  ..
041128 - Patient history on 081112 shows Millie has had numerous PET scan tests
041129 - in the trailer next to the parking lot, ref SDS 10 GM3N, most recently
041130 - on 061227, and reported 070102. ref SDS 3 FV5J  The trailer is visible
041131 - walking from the parking lot, and so the location for the test
041132 - tomorrow is well known.
041134 -  ..
041135 - Cassandra advised that after the Infusion Clinic access the Power Port
041136 - tomorrow at 1000, Millie should come first to the CT Department here
041137 - in the hospital to register and pay for the test.  Then she will walk
041138 - out to the trailer for the test.  After the test, Millie will return
041139 - to the Infusion Clinic to remove the Huber needle, and maintain the
041140 - port.
041142 -  ..
041143 - Thanked Cassandra and Brenda for proactive planning today.
041145 -  ..
041146 - Cassandra thanked Brenda for taking time from her work in IS coming to
041147 - the CT Department and assisting in setting things up today so that
041148 - everything will go smoothly during the test tomorrow.
041150 -  ..
041151 - There was no discussion today about why the CT Department was not
041152 - aware of the Doctor's order for Millie's test to use a Power Port for
041153 - injecting contrast medium, and that this was scheduled with the
041154 - Infusion Clinic, and that coordination with IS was required, per
041155 - Cassandra's report today above. ref SDS 0 5F6L
041157 -  ..
041158 - This is the second time in a row, including the test on 081107, when
041159 - the CT Department staff did not get the doctor's instructions for the
041160 - test.
041162 -  ..
041163 - One explanation is that doctor's rarely enter comments to clarify the
041164 - scope of CT tests.  The department does so many tests routinely, that
041165 - there is no cultural tradition to examine the entire referral from the
041166 - doctor.
041168 -  ..
041169 - Another explanation is Kaiser's Knowledge Management system that
041170 - requires learning to press some buttons to see the entire referral.
041171 - This occurred previously on 081106, when Robin called to schedule
041172 - Millie for a core biopsy to test for status change. ref SDS 8 IP7L  At
041173 - that time the problem was that people did not know how to press "Page
041174 - Down" to get the full scope of the work. ref SDS 8 PQ9Y  Gloria in the
041175 - Coagulation Control Clinic previously explained how busy medical staff
041176 - do not have time to use all of the information in the computer to
041177 - guide patient care, reported on 061024. ref SDS 2 TZ4I  Same problem
041178 - occurred for 2 years in Oncology, reported on 060711. ref SDS 1 5Y5J
041180 -  ..
041181 - Problems using computers for health care case management are shown in
041182 - a case study on 061024. ref SDS 2 NU5O
041183 -
041184 -
041185 -
041186 -
041187 -
041188 -
041189 -
041190 -
041191 -
0412 -