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"The Canadian Patient Safety Institute is pleased to endorse Take as Directed. This is a valuable tool to help Canadians navigate the healthcare system safely." —Hugh MacLeod, CEO, Canadian Patient Safety Institute
"An essential primer for all Canadians for navigating the health care system." —Robin Osborn, vice president and director, international health policy, The Commonwealth Fund, New York
"Church and MacKinnon provide useful guidance for navigating the complexities of Canadian healthcare and guarding against unintentional harm. They weave together patient stories, sound advice and useful information, suggesting useful strategies for patients seeking care for themselves and their families." —G. Ross Baker, professor of health policy, management and evaluation, University of Toronto
"An ultimate healthcare guidebook . . . A must read for patients and their caregivers." —Pharmacy Practice
"How to reduce chances of an adverse drug reaction, what to do in the event this happens, how your local pharmacist can be a source of valuable information and how to successfully manage medication side-effects." —Hamilton Spectator
"An invaluable new resource to help Canadians navigate the health care system, especially in relation to medication safety." —Canadian Family Physician Magazine
"I would recommend this book to pharmacists, as it provides a general overview of potential vulnerabilities in the Canadian health care system, along with practical ideas to help patients use the system. It is also a book that can be recommended to patients and other health care providers to increase their understanding of the pitfalls in how the health care system works." —Canadian Pharmacists Journal (March/April 2011)
"While ordinary Canadians will glean some insight into how to more effectively navigate the system, this book would be best read by physicians and other health care professionals. It should also be included in medical and pharmacy school curricula, for it illustrates that the healing of our fractured health care system must come from within." —Canadian Medical Association Journal (CMAJ)
A Cautionary Tale
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Before Paul's wife, Katharine, left to go shopping in the city earlier this morning, she gave him explicit instructions. "Go get an antibiotic for that cold. You don't want it to get any worse and spoil our cruise. And I don't want to catch it." She left their family doctor's phone number on the kitchen table beside his breakfast and his morning pills.
Both former teachers, Paul and Katharine had retired a few months earlier. After perusing an array of glossy brochures, they settled on a cruise of the Greek Islands to celebrate the beginning of this exciting phase in their lives. They were to leave in six days and visit their daughter in London, England, before flying on to Athens.
"Don't let the doctor give you one of those old-fashioned penicillins," Katharine told Paul as she kissed him goodbye. "They never work. Get something strong."
Paul heads to the local emergency department after learning that his family doctor is away until the following week. The waiting room is chockablock with people who are coughing, cuddling runny-nosed babies, limping on twisted ankles, and pressing damp face cloths to skin lacerations in need of repair. A number of ambulances arrive during the almost two hours that Paul waits.
When Paul is finally seen by the harried young physician, he explains that he woke up with a cold yesterday, that he and his wife are soon leaving on a cruise, and that she insisted he get an antibiotic so he isn't sick while they are travelling. He answers the doctor's questions: No, he doesn't have a fever. He's not coughing anything up. He had a sore throat, but it's going away — it's mostly just a head cold.
Paul went over his background health with the triage nurse earlier, but the doctor asks similar questions. Paul has had diabetes for the last six years, he explains. He was admitted to hospital about a year and a half ago with angina. He's on a few medications. He knows one is Aspirin, and he thinks one is for his blood pressure and one for his diabetes. No, he tells the doctor, he doesn't know their names. One is blue and white and one is a peachy colour. There's another one, a little white one, but he's not sure what it is or what it's for. His wife looks after all his medications — he just takes what she leaves out for him.
The doctor examines him. "It looks like a virus," he says. "The best thing is to wait it out. Drink fluids and get lots of rest."
"I've been waiting here for almost two hours. Can't you just give me an antibiotic? It's not like I take them all the time."
The doctor looks at Paul. "Antibiotics only kill bacteria. They don't kill viruses. It's really not going to help you. You'll be feeling much better in about three days, even without an antibiotic."
"Can't you give me a prescription in case I don't feel better in a few days? I don't want to have to come back again — or to have to find a doctor in Greece."
The doctor hesitates but finally agrees. "Just promise me you'll wait a few days before you start taking it. If you're feeling better, just toss the prescription out."
"One more thing," Paul tells the doctor. "My wife wants me to get something stronger than penicillin."
The doctor shrugs and scribbles out a prescription. He passes it to Paul as the sound of an ambulance siren beckons him away.
On the drive home, Paul stops at the pharmacy half a block from the hospital. He isn't sure which pharmacy Katharine uses; it doesn't cross his mind that it should matter. He tells the pharmacist the same things he told the doctor about his other medications. Paul buys a bottle of water at the front of the store and takes the first pill in the car on the way home.
Four days later Paul awakens feeling terrible. He has had a backache and sore shoulder muscles for a few days, but he's been blaming it on the yard work he's been doing in preparation for their time away. This morning, though, even before he gets out of bed, he feels much worse. "It's like I'm getting the flu all over again," he tells Katharine.
"It sounds like the antibiotic isn't working," Katharine says. "The doctor didn't give you penicillin, did he?"
"I asked him not to."
Paul gets out of bed with considerable difficulty. His muscles are weak and painful, which makes it difficult to stand, much less walk down the hall to the bathroom.
"I'm taking you back to the hospital. I think you need a stronger antibiotic," Katharine says.
With her help, Paul eventually manages to reach the toilet. He notices that his urine has an odd tea-coloured hue.
Katharine carries a list of their prescription medications in her wallet and she passes it to the triage nurse when they arrive at the hospital. The doctor who saw Paul four days ago is again working in the emergency department. Paul admits, somewhat sheepishly, that he began taking the antibiotic immediately after his last visit.
After an examination and a series of investigations, the doctor diagnoses rhabdomyolysis — a condition that is causing disintegration of muscle tissue throughout Paul's body. He tells Paul and Katharine the condition is very rare but is most likely due to an interaction between the antibiotic Paul is taking and one of the medications he takes at home. Unfortunately the doctor did not have access to Paul's list of medications when he saw him four days ago. He tells Paul and Katharine that rhabdomyolysis is a potentially life-threatening condition and that up to two-thirds of all individuals with this condition develop kidney failure that may require dialysis.
Paul is admitted to hospital. He develops kidney failure, but it resolves without dialysis. Nonetheless, he spends almost two weeks in hospital. After he is discharged from hospital it is many months before Paul is strong enough to return to his usual activities. The planned Greek cruise, of course, is cancelled.
Recently, much attention has been paid to the issue of errors occurring within the health-care system. A 2004landmark study by Baker and Norton, for example, showed that one out of every thirteen (7.5%) adult patients in Canadian hospitals experienced at least one adverse event; many of these were errors related to the prescribing or administration of medication.
When an individual experiences an adverse event, a number of factors come into play and ultimately culminate in the outcome. Health-care providers often use the "Swiss cheese model" to explain how poor outcomes occur. At each stage of a health-care encounter, there is a risk that something could go wrong, much like a small hole in a block of Swiss cheese. Paul, for example, was at increased risk for an adverse outcome because he was unable to convey to his caregivers the names of the medications he was taking. Normally, a series of checks and balances are inherent in the delivery of health care; think of them as the substance of the cheese itself, preventing one small error, or Swiss cheese hole, from aligning with other small holes and resulting in a large hole, or a significant problem for the patient. Paul, for example, had a number of "holes" that aligned to create his unfortunate illness. Besides his lack of information about his medications, he requested a prescription for a medication that he probably did not need. He was seen by a physician who was extremely busy, unfamiliar with him, and did not have access to a list of his regular medications. Similarly, Paul's prescription was filled by a pharmacist who was unfamiliar with him and with the other medications he was taking. These all seem like minor matters, but when they align for one patient during a single health-care encounter, the outcome can be catastrophic.
Usually, of course, taking an unnecessary antibiotic does not result in a near-fatal illness. (It does, however, contribute to growing resistance to antibiotics, which will be discussed in Chapter 4.) Had Paul seen his regular family physician, she would have been aware of the other medications he was taking. Probably, she would not have prescribed the antibiotic that resulted in rhabdomyolysis when it was taken in combination with another of Paul's medications. We know that the busier a physician is, the greater the chance he or she will prescribe an unnecessary antibiotic for a common cold. Had the physician seeing Paul been less busy, he might not have agreed to issue the prescription. That day, though, chances are it was faster to write the prescription than to continue to argue with Paul that he didn't need it. If the pharmacist had been familiar with Paul, she would also have had records indicating what medications Paul was taking and would have, in all likelihood, contacted Paul's physician to discuss the potential drug interaction prior to dispensing the antibiotic that made Paul ill.
Health-care providers and policy makers, as well as independent organizations such as the Canadian Patient Safety Institute, look for the root causes of adverse events and how health-care practices can be changed to make delivery of health care safer. However, each of us has a critical role to play in ensuring that we have the best possible outcome from our encounters with the Canadian health-care system, including using medications in a safe, responsible, and appropriate fashion.
In this book we will empower you to obtain the best and safest possible health-care outcome from your encounters with the Canadian health-care system and have your medication work safely and effectively for you. After a behind-the-scenes look at how our health-care system works, or doesn't work, we will draw on our experience as a family physician and a pharmacist and researcher and walk you through a visit to your doctor or to a hospital. We will tell you how to prepare for a visit to your regular physician and how to deal with an unexpected illness or injury when you are cared for by an unfamiliar provider. We will talk about situations in which the best remedy is no medication at all. In the event that medication is prescribed, we will tell you what information you shouldn't leave the doctor's clinic or the hospital without.
We will also review your encounter with the pharmacist, who dispenses your medication, and offer tips on how you can make the very best use of your pharmacist's expertise. We'll tell you how to safely use your medications at home, what to do if you believe your medication isn't working, and where you should turn if you think you're experiencing a side effect. We'll also offer tips on accessing medications if you are having difficulty affording them, where to find credible drug information on the internet, and how to decide if a nontraditional medication such as an herbal remedy is right for you.
In writing this book, we have created a number of vignettes, such as the one of Paul and Katharine, based on people we have cared for and worked with. However, in order to protect their privacy, it was necessary to mask and alter details that could identify them. In some cases, the stories we tell are based on composite patients.
First up — let's examine just how safe our health-care system is, or isn't, and look at what factors contribute to an optimum health-care outcome for you.CHAPTER 2
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In Take as Directed, we will walk you through the various steps of the health-care system to help you get the most out of your health-care experience. Throughout the book, we will have a special focus on medications but much of the advice and perspective we bring will be applicable beyond just your use of prescription and over-the-counter drugs. Before we begin this journey through the various professions, settings, and locations of our health-care system, however, we will address in the next two chapters some of the "big picture" issues of our health-care system. The first of these issues is the safety, or lack thereof, of our health-care system and medication use.
What's in a Name?
Many words and phrases describe adverse consequences of health care and, more specifically, of medications. A few of the more commonly used terms include adverse drug events, adverse drug reactions, drug-related morbidity, medication errors, medication incidents, medication misadventures, and side effects. These terms are often used interchangeably, even though they can mean quite different things. Phrases such as medical error and medication error also can convey a sense of blame. Unfortunately, even experts in the field misuse terms on occasion and sometimes cannot agree on which terms should be used. Some experts in Canada tried to bring some clarity to this issue a few years ago by creating a publication called the Canadian Patient Safety Dictionary. So, what is one to do to survive these potentially confusing terms?
In Take as Directed, we will primarily be using the terms adverse events (AEs) and adverse drug events (ADEs). These are well-recognized terms that were used in the largest study of adverse health-care consequences in Canada to date. As defined by the Canadian Patient Safety Dictionary, an adverse event is "an unexpected and undesired incident directly associated with care or services provided to a patient; an incident that occurs during the process of providing health care and that results in patient injury or death; an adverse outcome for a patient, including injury or complication."
There will be some exceptions to our use of these two terms. Most of these exceptions involve reporting the results of studies where a different term, medical error, was used. While we personally would not have chosen to use that term, we need to use it within the context discussing the results of those studies to avoid distorting the meaning of the study results.
Oprah Winfrey and Health-Care System Adverse Events
Due to Oprah Winfrey's popularity and cultural influence, when she pays attention to a new book, movie, or issue, there is often a ripple effect throughout the United States, Canada, and beyond as others start to pay attention to that same issue. For an author, having your book endorsed by Oprah is almost a guarantee that you will be on a bestseller list. At times, Oprah has appeared on lists of the most influential celebrities and women around the world.
So, when Oprah devoted an entire episode of her TV program, The Oprah Winfrey Show, on March 10, 2009, to adverse events, a lot of people started to think seriously about this issue. She interviewed Hollywood actor Dennis Quaid and his wife, Kimberly, about a serious adverse drug event that almost claimed the lives of their newborn twins (see "Dennis Quaid and Deadly Heparin"). She included many other real-life tales of adverse events, including a mother who discovered that she didn't have breast cancer after she already had a mastectomy.
Dennis Quaid and Deadly Heparin
It was a time of joy. Hollywood actor Dennis Quaid and his wife, Kimberly, had welcomed their newborn twins, Thomas Boone and Zoe Grace, just two weeks earlier. The twins were doing well but had remained in hospital.
Then everything changed as the Quaids were told that their twins had been two of three infants at Cedars-Sinai Medical Center in Los Angeles who had experienced an adverse drug event. All three infants had been given an injection of a drug called heparin, which is used to thin blood and prevent clots. Instead of receiving the typical dose for infants of 10 units, the babies each received a dose of 10,000 units. As a result of receiving 1,000 times the typical dose of heparin, the newborns started to bleed internally. Although the twins ultimately survived after spending several days in the neonatal intensive care unit, the Quaids reached a settlement of U.S.$750,000 with the hospital and the hospital was fined by the California Department of Public Health.
Unfortunately, this was not the first such error involving an overdose of heparin. Moreover, other similar events have happened since the episode involving the Quaids' newborn twins. As a result of their experience and other similar errors, the Quaids have become public advocates for improving health-care safety and preventing adverse drug events. In addition to TV appearances on shows such as 60 Minutes and The Oprah Winfrey Show, Dennis Quaid often speaks to front-line health professionals. For example, he gave the keynote address at the American Society of Health-System Pharmacists Midyear Clinical Meeting in Las Vegas in December 2009.
In our country, the Institute for Safe Medication Practices Canada has been actively educating health-care professionals about how to prevent these events, such as developing a heparin tool kit. Accreditation Canada, which accredits our hospitals, has introduced new recommendations about using heparin in patient care areas of hospitals. Even the World Health Organization has recognized the seriousness of this issue, creating a new initiative called Action on Patient Safety: High 5s, which includes strategies for dealing with high-concentration IV drugs. We hope these efforts will help prevent other parents from experiencing the type of agonizing situation experienced by the Quaids.
Was Oprah onto something, or were these stories of adverse events simply a way to boost TV ratings? Are there real, trustworthy statistics to support the attention given to this issue? How does the safety of the health-care system in Canada compare to other similar countries? What are the factors that place an individual at risk for experiencing an adverse event? How common are adverse drug events? These are some of the questions we will answer in this chapter.
Excerpted from Take as Directed by Rhonda Church, Neil MacKinnon. Copyright © 2010 Rhonda Church and Neil MacKinnon. Excerpted by permission of ECW PRESS.
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Posted December 30, 2010
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