Making Changes to Reduce the Number Medical Errors and Avoid Loss of Life [Interview][Transcript]

Dr_Carol_Gunn_Medical_Errors_Patient_SafetyGuest: Dr. Carol Gunn
Presenter: Neal Howard
Guest Bio: Dr Carol Gunn is a physician practicing in Portland, Oregon, whose professional mission changed after the loss of her sister. She is now an outspoken advocate for patient safety and is beginning to collect other patient safety stories. Dr Gunn believes that with strong healthcare leadership, transparency and accountability, the tide will turn on medical errors. She can be contacted at www.CarolGunnMD.com.

Segment overview: In this segment Dr. Carol Gunn talks about her work in the patient safety field.

Transcription

Health Professional Radio

Neal Howard: Hello and welcome to Health Professional Radio. I’m your host Neal Howard, so glad that you could join us today. Many of us deal with medical errors, preventable medical errors. We say that everyone makes mistakes but when it comes to healthcare professionals, those that we count on to keep us healthy and those that we go to when we’re well for lack of a better term a “broken” – we set the bar kind of high I’ll say. Our guest in studio today is Dr. Carol Gunn, practicing physician in Portland Oregon, whose life and professional mission was changed drastically after the loss of her sister due to preventable medical errors. She since then become an outspoken advocate for patient safety and has begun collecting other patients’ stories as well. She believes with strong healthcare transparency and accountability, the tide will turn on medical errors. How are you today Dr. Gunn?

Dr. Carol Gunn: I’m well. Thank you for having me.

N: Thank you so much. When you say that your life and your professional mission changed after the loss of your sister, how did that come about? How did your sister’s death come about?

G: So Anna was a 59 year old woman and she had a bone marrow transplant in 2013. And after the transplant about 7 or 8 months after the transplant, she started having odd neurologic symptoms, and 5 months after that she started to have chest pain.

N: Uh huh.

G: And unfortunately her doctors didn’t investigate why she might be having these chest pains and treated it at first with antacids and then narcotic. And then she was even admitted to the hospital, they were still dealing with her neurologic symptoms. Though having chest pain, and no one evaluated it and then 12 days in she had a heart attack and a few days after that. And her medical record actually clearly state that she died from having ongoing waves of heart attacks. So because no one had been looking at her earlier complaints of chest pain, they missed the huge, huge easy piece of information where she likely could still be alive today if someone had treated her correctly.

N: So you’re saying that this is absolutely preventable?

G: Absolutely.

N: There are a lot of checks and balances in place when it comes to someone with you say a bone marrow transplant. With someone with a bone marrow transplant, has an extensive medical history and background – are you saying that no one looks into her history to say well maybe…?

G: Well prior to the transplant day, she had a full cardiac workup and she was great. And she’d been followed previously, just her preventive care and had done well. So when she had this new symptom, it wasn’t recognized as a new symptom or a new important syndrome symptom. And so she didn’t have the basic care given when someone generally says “I’ve got chest pain” which includes a $50 EKG, a kind of an evaluation of what might be causing the chest pain. So she started complaining about it to her doctors in February, it was until mid-May were she actually had a full evaluation, and by then she’d already lost 50% of her heart’s pumping power. She was just not able to make her gain after she received a stent, it’s just too much for her.

N: Every time you go to see a different doctor, you have to tell them your entire story over and over and over again unless you take your medical records with you and your x-rays in all these little disks. If you’ve got to do that, how is it that you’ve got 1 person that’s telling the same doctors – not new doctors – doctors that have been seeing her, and is there no communication whatsoever?

G: Well I think there were some tunnel vision, so I think initially she was particularly when she got to the hospital, she told them she had a 2-month history of chest pain. It’s very clearly written the note, and then the physician that was admitting her said “Okay we’ll restart narcotics.” And then the next team that saw her pretty much the rest of her, they and the hospital said “okay we’ll continue the narcotic,” without anyone saying “Why would she be having chest pains like this?” There is a lack curiosity, if you ask. And there was no…

(crosstalk)

N: Was she by herself?

G: Yeah, we had friends and family coming and going with her down there. And I know she was admitted early evening on a Sunday and her son was with her, her collegiate son. But I’m not sure why, I mean I think they just thought because they looked at the old records and said “Oh, treated it with narcotics in the past. We’re just gonna keep treating with narcotic.” And so there was just a big colossal myth.

N: Before your sister’s passing, did you ever say or did something ever ring any type of bell, any type of red flag that someone else who feels that some type of mistake has been made? I mean you don’t want to see one pill in a cup and then go all out and say “Oh you guys are incompetent.” You don’t want to do that. But what are the some of the things that a person should look for and how do they start the conversation? Do you pull the doctor aside and say “Hey this is what I think. Based on the fact that I’m not even a doctor.”

G: Yeah, I think you do start the conversation with the doctor and say “That doesn’t make sense to me. Can you tell me more about that?” I mean we did do that, I mean I raised the question “Why she’s so short of breath? Why is this happening?” “We got it under control.” And so I probably could have been more persistent too. I still can’t explain, it’s almost inexplicable to me why someone didn’t fully evaluate that. Particularly when I looked at her medical records and how they described why she was having – so with chest pains and heart issues often times you have shortness of breath, which she also had. And they would describe this shortness of breath to all these other issues which didn’t make much sense. So I think part of the problem was they were focused on her neurologic issues.

N: Uh huh.

G: And then didn’t realize the importance of the chest pain. And she knew it and I will say after they recognized that was after she had have a heart attack in the hospital and needed a stent. She and I were together the next morning in the room and she was mad because she knew how many times she had said it and she actually thought they were … when you were in the hospital you don’t always know what medications you’re being given and why. And she thought they knew, then she realized then after the heart attack that they had not known and she was mad, she was livid.

N: Oh absolutely.

G: She asked me to go after it. She asked me “Are you gonna go after it?” And I said “Do you want me to?” And she’s like “Absolutely. No one should ever go through what I’ve been through.”

N: Now as an advocate for strong healthcare leadership including transparency, you speak on a lot of different subjects when you were recently at the Oregon Patient Safety Commission speaking with those leaders. When it comes to this electronic medical records, I mean we’re talking about when doctors are actually putting their own notes as opposed to someone else putting in their notes…

(Crosstalk)

G: Yeah doctors, acceptably yes.

N: Yes. When it comes to doctors spending so much time inputting records as opposed to actually sitting down and talking with a patient, maybe as you said before “tunnel vision.” They hear the same thing from the same patient, and they just want to get their notes done and turn that box off.

G: Yes, you’re absolutely right. And I also presented at a local hospital here in their medical ground rounds and that was one of the comments from one of my own mentors. He said “Carol we don’t have time to sit down with the doctor or with the family anymore because we’re spending so much time on the computer.” It’s like, but that’s where we need to be. I mean I don’t know how to solve that that without giving more time back to the providers, whether they’re physicians, nurses or whatever. That is where we learn a lot of things, and as well as sitting with the family member, because sometimes the family members have some pieces of information that the patient isn’t able to describe themselves and so without that kind of personal touch we’re gonna loss this battle.

N: Other than your sister’s story and your own personal loss, how do you get others interested in preventing medical errors? Say, those who don’t encounter medical errors or maybe a stitch path and that’s all that they know about. How do you get people on fire to prevent this medical errors that aren’t the small stuff?

G: Well I think it’s just like any other advocacy. It starts as a slow war and then it has to get louder and louder. And with the numbers of errors that are being been made, we know the estimate between 200 and 400,000 deaths per year – that’s a huge number. We know that lots of people touched by that, that’s our third leading cause of death and so if we can just start talking about this…

N: Medical errors are our third leading cause of death?

G: Yes. Heart disease is one, and number 2 is cancer, and medical errors would be the third.

N: So you’re saying that simple the mistakes, the preventable mistakes made by physicians nationwide are killing us as fast or faster in some cases than cancer. That’s…

(crosstalk)

G: Certain types of cancer, right. So number one is cardiac reasons, number 2 is cancer and number 3 yes. And it’s not just one study that shown this, I mean there had been multiple studies that have shown that the number is huge, just like this. So I know there’s been studies by the Office of the Inspector General, the Department Health and Human Services that shows that 15,000 Medicare patients die each month with a contribution from a medical error. So the numbers kind evolved draw it back to the 200 to 400,000 a year. It’s so outrageous.

N: Outrageous absolutely. Now as we wrap up the segment, you do say that upon opening your sister’s case and looking deeper into her situation you came in contact with other people that were going thru the same thing or had been through the same thing and you’ve asked them to give you their personal stories and submit them via your website at www.carolgunnmd.com, that’s Gunn G U N N carolgunnmd.com. In addition to submitting their stories, what else will someone find when they go to your website?

G: They’ll find Anna’s story again, they’ll also find how to contact me. I’m just early on this journey, Anna only passed in May of 2014 and it’s taken a while for me to get back on my feet even. And so early in the journey and I don’t know where it’s gonna lead me but I’m just gonna keep waving to this flag that we must do something differently.

N: You’ve been listening to Health Professional Radio, I’m your host Neal Howard. We’ve been in studio today talking with Dr. Carol Gunn, Advocate for strong healthcare leadership transparency and accountability in the hopes of turning the tide on medical errors. Her website www.carolgunnmd.com Visit there, submit your story of a medical error or how you’ve identified and prevented a medical error before it turned into a significant loss or possibly loss of life. It’s been great having you here with us again Dr. Gunn.

G: Thank you for having me. I certainly appreciate it.

N: Thank you so much. Transcript and audio of this program are available at healthprofessionalradio.com.au and also at hpr.fm and you can subscribe to our podcast on iTunes.