“If you’re being admitted to the hospital, you might want to write ‘Person With Diabetes’ across your forehead with a permanent marker.”
This is Bob Hrodmedka’s recommendation, after staff at West Hills Hospital in West Hills, California, failed to test his blood glucose before an angiogram last year. A type 2, Hrodmedka suffers occasional hypoglycemia and can become combative when his blood glucose dives dangerously low. Prior to his early-morning hospital admission, Hrodmedka fasted as directed. He was then sedated and remained without food while the hours crawled by. His wife, Dawn, became alarmed.
“I kept [telling the hospital staff], ‘He has diabetes, he hasn’t had anything to eat,'” she says. “But they kept dismissing it like it wasn’t important.”
By the time Hrodmedka was wheeled into the cath lab, he had not eaten in 18 hours, and his blood glucose had not been tested since he had tested it himself—six hours earlier.
Hrodmedka remembers waking up while his body flailed convulsively.
“They said he went wild on the table,” Dawn recounts. “I think it was from low blood glucose, but they acted like he was the bad boy.”
Although the angiogram was completed, a sense of terror remained with the couple. How could Hrodmedka trust the hospital staff during his upcoming carotid artery surgery if his diabetes had been so mismanaged during a preliminary procedure?
“They seemed to have zero knowledge of diabetes,” Hrodmedka says.
He tried to discuss the incident with his doctor and the hospital staff. Hrodmedka finally was able to speak with the director of patient relations, who agreed to talk with him only after he threatened to file a lawsuit.
Bad Medicine: How Often Does It Happen?
One would hope that this story is an exception to the rule. But the sad reality is that hospitals and providers frequently bungle or neglect basic steps of diabetes management—sometimes with tragic consequences.
“In some respects, current diabetes care is an accident waiting to happen,” warns Richard Hellman, MD, FACP, FACE, the medical director of the Heart of America Diabetes Research Foundation and a clinical professor of medicine at the University of Missouri-Kansas City School of Medicine.
“The complexity of modern diabetes care calls for more sophistication of care among the current providers than is often available. Often, the most skilled practitioners are not even able to see the patient in times of the greatest need . . . The example given by Mr. Hrodmedka is, sadly, far from rare.”
A 14-year study of 823 patients with diabetes, conducted by Dr. Hellman and colleagues and presented at the 1999 Scientific Sessions at the American Diabetes Association meeting in San Diego, California, found that errors were common. In reviewing the charts of 283 patients who died, the researchers identified a major medical error that caused disability, complications, increased morbidity or, in some instances, death in almost 18 percent of the cases. In addition, 4.2 percent of the charts showed that the immediate cause of death was directly related to an error.
Dr. Hellman is careful to explain that these errors occur not because of hostile intent or ineptitude on the part of one “bad” individual. Rather, errors occur because of a widespread “defective culture of safety” in hospitals and clinics. Although some misdiagnoses and medication errors are probably inevitable, in an organization with poor communication between departments and a lack of back-up checks, small errors remain undetected, and dangerous situations escalate as they are compounded by even more errors.
Surprisingly, some hospitals often fail to utilize the services of the most skilled care providers—including endocrinologists and diabetes educators.
“Diabetes mellitus management is beyond the [scope] of most primary care physicians today due to the changes in treatment options and approaches,” says Allen King, director and co-founder of the Diabetes Care Center in Salinas, California. “I don’t think the caregivers are at fault, however; the field of diabetes is progressing so fast, they can’t keep up.”
Major errors are frequently not obvious to the lay person; determining that an error has occurred requires analysis by medical experts. However, because people with diabetes are so accustomed to being in charge of their own care, a major mistake in medication is less likely to go unnoticed.
“I fear for any time that I would be unable to monitor and take care of myself while in the hospital,” says Bonnie Owen, who managed her own injections throughout her pregnancy and kept her blood glucose “near perfect.”
Owen reports that when she relinquished control of her blood-glucose levels to hospital staff during the final hours of labor, her numbers skyrocketed, causing her otherwise healthy infant to suffer low blood glucose once born. Owen also had trouble convincing labor and delivery nurses that she was capable of testing her own blood glucose and administering insulin.
“Hello?” she exclaims. “What do they think I do all day?”
Marion Volk, RN, MSN, CDE, a nurse educator in Glendale, California, states that her offers to provide education for hospital staff are frequently declined because of budget restrictions.
“A few lawsuits are, unfortunately, what the hospital industry needs. Remaining silent is not going to change the current environment,” Volk asserts.
Mistake or Malpractice?
Medical mistakes are likely to be categorized as just that—mistakes, or “bad results.” “Malpractice” is a much broader term.
Even when medical professionals and hospitals fail to follow accepted standards of practice and breach their duties to the patient, a plaintiff must demonstrate that he or she suffered a significant injury as a direct result of the breach of duty in order to win a malpractice case. If the breach of duty resulted in no harm to the patient, the claimant has no right to recovery.
If major errors in diabetes care run as high as 18 percent, and if vengeful patients are supposedly increasing the cost of medical care as malpractice insurance rates rise and doctors are forced to practice “defensive” medicine, one would expect to find that people with diabetes are filing a correspondingly large number of malpractice suits. But the data—or lack of it—shows otherwise. Although no one agency tracks statistics related specifically to diabetes and malpractice, a review of malpractice cases provided by Jury Verdict Research indicates that lawsuits involving diabetes that result in large awards are scarce.
In the past 20 years, only five cases in the United States engendered verdicts of $900,000 or more for plaintiffs with diabetes. The largest amount returned in a verdict—$10,800,000—was awarded to the mother of a six-month-old baby, who had been brought to a pediatrician and later to a hospital with frequent urination and excessive thirst. Testing that could have prevented ketoacidosis was not performed, and the infant suffered brain damage, deafness and inability to speak. The final settlement amount in this case was $1,900,000.
According to Gary Bagin, director of communications at Jury Verdict Research, so few lawsuits are filed in relation to diabetes that the organization’s database does not contain enough cases to identify a trend. It is possible, however, that diabetes-related suits cannot be accurately tracked because other conditions are identified as the primary injury.
Although medical errors that cause injury are common, patients either do not recognize that they have been the victim of a medical error, do not complain because they are too sick, die because of the error, or quietly and privately settle disputes in arbitration.
How Patients Can Prevent Mistakes in Their Care
Dr. King urges patients to take control when they can, to aggressively pursue diabetes education and self-assessment, and to be part of medical decision making.
Because cases of individual recklessness are few compared to the large flaws in delivery systems for diabetes care, checking on your personal physician’s record or complaining to your state’s medical board about one practitioner may be of little use. But if you need to seek information about a specific physician, there are Web sites where, for a small fee, you can check to see whether your doctor’s license is current and request copies of public documents related to any disciplinary action that may have been taken against him or her.
An example of such a Web site is www.docboard.org. When you click on “DocFinder” and choose a state, you are directed to the home page of that state’s medical board. There you can look up your doctor’s current license status. If you want to request information documenting whether or not disciplinary action has been taken, you must fill out forms manually to receive the information by regular mail.
Certainly lawsuits are warranted in many circumstances, and they can become a vehicle that brings attention to the dangers in today’s healthcare delivery systems. However, the crisis in malpractice is only a microcosm of a much larger crisis: the needs of patients today—whether for basic lifesaving information or for compassion and support on an emotional level—are not being met in today’s healthcare system.
“All [people with diabetes] need to be in control of their diabetes management,” Marion Volk urges. “If they can’t be, they need friends or family members to be there to advocate for them.”
The Doctors’ Perspective
Facing problems that range from overwork to the restrictions of managed-care organizations to soaring malpractice insurance costs, doctors are becoming increasingly vocal.
The American Medical Association states that the nation’s outrageous liability insurance rates are driving physicians from their practices, leaving patients vulnerable and the entire field of medicine in a state of turmoil. Malpractice insurance costs vary according to specialty, but they can reach as high as $200,000 annually for a neurosurgeon.
Many physicians are searching for other ways to eliminate dangers for patients and to deal with liability issues. Patient education and electronic medical records are high on the list of priorities in efforts to eliminate both mistakes and litigation.
Communication with patients as well as respect for their emotional needs seem to be major missing links. Most physicians and hospitals will cut off communication with unhappy patients who file lawsuits.
Surviving Your Hospital Stay
If you are entering the hospital for surgery, childbirth or any other reason, remember that the available medical staff may lack specialized training in diabetes and blood-glucose management.
Last year when I was hospitalized for pneumonia, the nurse on the floor—who believed that I couldn’t be having hypoglycemia, because my glucose had measured 175 two hours earlier—refused to bring orange juice, even when I showed her that my meter now read 62. Be prepared to stay on top of your own insulin, medications and blood-glucose and ketone levels.
If your endocrinologist and/or diabetes care team cannot be directly involved in your hospital care, collaborate with them ahead of time to make a written plan about how your blood glucose will be handled in the hospital. Keep a copy at your bedside, insist that the plan be included in your chart on the floor, and appoint and train a relative or friend who will make sure that the plan is carried out if you are sedated or unconscious.
If you are experienced in managing your own blood glucose, make certain that your hospital chart has a physician’s order stating specifically which aspects of diabetes self-management you will be responsible for during your hospital stay.
Keep plenty of food and snacks at your bedside at all times, along with supplies to test blood glucose and ketones and everything you need to treat low blood glucose yourself.