Anatomy of a ‘Screwup’

Joe and Teresa Graedon give lots of health care advice in their syndicated column, The People’s Pharmacy, and on their National Public Radio show by the same name.

He’s a pharmacologist, and she’s a medical anthropologist.

The Durham, N.C., residents have written more than 14 books on topics from herbal remedies to deadly drug interactions. They should know how to get the best medical care.

But in 1996, Joe’s 92-year-old mother, Helen, died as the result of errors made at Duke Hospital.

Joe Graedon thought he had been a good advocate. He stayed by his mother’s bedside and repeatedly told her caregivers that she couldn’t tolerate morphine and other narcotics.

But in the end, he says, “You have to trust the doctor.”

He felt guilty about not being able to protect her. But soon that guilt turned to action.

He and his wife reconstructed the steps leading to Helen Graedon’s death, and that story opens their new book, “Top Screwups Doctors Make and How to Avoid Them” (Crown, 336 pages, $26).

“A series of medical errors led to the horrific conclusion of a wonderful life,” they write. “We could have sued Duke Hospital for the series of mistakes that were made … (Instead) we began a long campaign to try to reduce medical errors and improve patient safety.”

The couple served on patient-safety committees at Duke and believe it is “a much safer place” today.

“Serious mistakes are made at every hospital in America on a daily basis,” the Graedons write.

“… The death toll from health care screw-ups adds up to at least 500,000 Americans annually. That is the equivalent of more than three jumbo jets crashing every day of the year.

“Because these individuals are dying at home, in hospitals, or in nursing homes, no one is counting the bodies. … The medical profession seems largely immune to the consequences of its errors.”

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The story of Helen Graedon’s death doesn’t take up many pages in the book. But it serves as an example of the mistakes that happen every day.

In December 1996, she was recovering from a successful angioplasty and stent placement to open a blocked artery. When Joe Graedon left the hospital at 9 p.m., his mother was looking forward to going home the next day.

Then at 2 a.m., she called in a panic: “Joe, I’ve been poisoned. Come quick.”

When he arrived, she was thrashing wildly, her muscles in spasm. Nurses had tied her hands and legs to the bed.

Graedon learned that she had been given Demerol, a narcotic pain reliever, even though he had told the staff hours earlier that she couldn’t tolerate narcotics.

His warning was written in her chart, but the chart wasn’t at the bedside when another resident administered Demerol, a standard protocol after angioplasty.

Hours later, Helen Graedon had recovered enough that doctors thought she could go home around noon. Exhausted but relieved, Joe Graedon went home for a quick shower.

Before he returned, he got another call from the hospital. His mother had fallen. She was dead when he got there.

The Graedons believe Demerol interacted with another medicine she was taking to produce “serotonin syndrome,” a condition marked by uncontrollable muscle contractions.

The death certificate said her death was caused by cardiac arrest due to low blood pressure as a consequence of internal bleeding. But it didn’t say what caused the bleeding.

Doctors told the Graedons later that patients who’ve had angioplasty must “lie still” to prevent bleeding at the site where the catheter entered the leg.

“The worst thing that can happen … is for the patient to move around,” Joe Graedon says.

The muscle spasms “almost certainly brought on the hemorrhaging,” the Graedons concluded.

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The Graedons’ subsequent work on patient safety impressed Dr. Karen Frush, a pediatrician and chief patient safety officer for Duke University Health System.

“They have done a tremendous amount to help us here,” she says.

Their suggestions have helped change the way Duke operates. For example, the hospital had developed an online system to allow patients to pay bills and make appointments. The Graedons asked why patients couldn’t also use it to view personal records, such as results of lab tests and X-rays.

“Now that we’ve done that, both physicians and patients realize how good that is,” Frush says.

The Graedons also helped shape Duke’s “rapid response teams” – groups of health care providers called to the bedside if someone perceives a patient is “starting to go downhill,” Frush says.

As initially envisioned, the teams were to be called by medical staff. But the Graedons asked if patients and families could also call a “Condition H” (for Help) to get a team. Today, all three Duke hospitals use that system.

“It really does take constant awareness and commitment to provide the safest possible care because systems are complex,” Frush says. “There are risks all over the place in health care.”

Dr. Nortin Hadler, a University of North Carolina-Chapel Hill rheumatologist and an oft-quoted critic of the U.S. health care system, wrote a blurb for the cover of the Graedons’ book, but his praise is qualified.

“If you’re inclined toward doctor-bashing, this book will give you some fodder,” he says in an interview.

“(The Graedons) do know something about drug adverse events and drug-drug interactions … (but) there’s a real problem with assuming that an understanding of the literature translates perfectly to the bedside. … There is more nuance to informed medical decisions than just the pharmacology of drugs.”

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The Graedons’ book contains more than a dozen lists to help patients and families get the best care.

There are lists of common mistakes made in hospitals or by doctors and pharmacists. Lists of tips to prevent medical errors, dangerous drug interactions and diagnostic disasters. And lists of suggestions to promote good communication and survive old age. (Above all: “Make sure your doctor likes old people.”)

If medical mistakes were a disease, the Graedons write, “there would be a great deal of hand wringing.” There would be an organization, such as the American Cancer Society, to raise awareness.

“Instead, the medical establishment mostly acts as if this problem were invisible. … No other profession could get away with so many screw-ups and still maintain public confidence.”