Cocaine and Sentinel Events are Bad for You

F-15E crash site in Libya

F-15E crash site in Libya

This is based on a paper I wrote during my neurology block a couple of weeks ago. I struggled to compare this topic to flying because of the terrifying magnitude of the problem in healthcare. For a rough comparison, we have destroyed a total of 124 F-15 jets from 1972 – 2014.1 That is less than 3 a year despite over six million flight hours, many with people shooting at us.

Clinical Summary:

A CT scan of the brain. The dark spot shows a large stroke in the MCA region. You don't want this.

A CT scan of the brain. The dark spot shows a large stroke in the MCA region. You don’t want this.

Mr. R was in his 60s, used cocaine and had already had a stroke on the left side of his brain. He was brought to an Emergency Department paralyzed on the left, confused and unable to speak. CT scan showed a massive new stroke on the right side of his brain (Medial Cerebral Artery or MCA region). The patient was to be treated by my team. His transfer to us was delayed by two days though when he fell forward out of bed and hit his head. Fortunately, additional testing did not show extra damage from the fall.

I was stunned by the recovery the patient was able to make. The morning we met he couldn’t understand us and didn’t know the left side of his body existed. The next week he was able to move and talk to us! Two weeks later we had the patient on 24hr supervision orders because he was still intermittently confused but improving. We were about to send him to a rehabilitation facility. The patient again tried to get out of bed, and again fell on his face. This time he damaged his spine and possibly his spinal cord. His discharge has been postponed.

cocaineDiagnosis Review:

  1. Cocaine can be bad for the brain, increasing the risk of ischemic stroke by 7-fold. Without too many big words, using cocaine can cause both subtle and not so subtle brain damage.2
  2. A person can recover a great deal of functionality following a left MCA stroke, in part by shifting tasks to the mirror brain on the right side. The healing won’t work as well, however, if the other side has already been damaged by an earlier stroke.

Topic Review:

The Institute of Medicine published the famous “To Err Is Human” report in 1999. The report caused an uproar when it reporting that “up to 98,000 people a year die because of mistakes in hospitals.”3 The Office of Inspector General for the Department of Health and Human Services reported in 2010 that bad hospital care contributed to the deaths of 180,000 patients per year in Medicare alone. A recent study published in the Journal of Patient Safety says the numbers may actually be “between 210,000 and 440,000 patients each year who go to the hospital but suffer some preventable harm that contributes to their death.”4

To ErrFalls are always in the top ten sentinel events reported to The Joint Commission (JC). The JC estimates that “hundreds of thousands” of patients fall every year in hospitals. Of the 465 that were actually reported, 63% resulted in death. One study estimated that each fall adds an average of 6.3 days of hospitalizations and another study estimated the cost at $14,000 per fall.5

Contributing factors described in a Sentinel Event Alert from the JC included:

  1. Inadequate assessment
  2. Communication failures
  3. Lack of adherence to protocols and safety practices
  4. Inadequate staff orientation, supervision, staffing levels or skill mix
  5. Deficiencies in the physical environment
  6. Lack of leadership

Reflection:

Medical errors are the third leading cause of death in the US behind heart disease and cancer.

That seems hard to believe until seeing a patient face plant in a hospital. Twice. This patient was improving rapidly but I knew he was obviously still a fall risk. I said so each time our team met with him but I clearly wasn’t loud enough. I was truly amazed by the neurological progress this patient made after such a devastating stroke. Yet he was repeatedly set back by his falls. A better prevention program in this case would have been more beneficial than any of our treatments. Looking at the contributing factors above I suspect that many, if not all, were again factors in both of this patient’s falls. These falls added cost to the patient, his family, to our care team and to our taxpayers.

I sincerely hope that no other patient falls and wrecks himself due to a failure in my leadership.

References:

  1. F-15 Flight Mishap History. Attack/Fighters 2015; http://www.afsec.af.mil/shared/media/document/AFD-150116-037.pdf. Accessed October 26, 2015.
  2. Morgan J. Evaluation and management of the cardiovascular complications of cocaine abuse. UptoDate 2015; http://www.uptodate.com.hsl-ezproxy.ucdenver.edu/contents/evaluation-and-management-of-the-cardiovascular-complications-of-cocaine-abuse?source=preview&language=en-US&anchor=H10&selectedTitle=1~150 – H10. Accessed October 13, 2015.
  3. William Richardson ea. To Err is Human. In: Medicine Io, ed. The National Academy of Sciences: Institute of Medicine; 1999:8.
  4. ALLEN M. How Many Die From Medical Mistakes In U.S. Hospitals? 2013; http://www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals. Accessed September 10, 2015.
  5. James Bagian ea. Preventing falls and fall-related injuries in health care facilities. Sentinel Event Alert 2015; Issue 55:http://www.jointcommission.org/assets/1/18/SEA_55.pdf. Accessed October 13, 2015, 2015.
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