Despite his pharmacology training and advocating on her behalf, Joe Graedon’s mother, Helen, died when the hospital gave the wrong medication. He told caregivers repeatedly that she could not tolerate narcotics or morphine while she was recovering from a successful angioplasty. According to Commercial Appeal, Joe and his wife, Teresa, a medical anthropologist, have written a book on how to avoid top medical errors, using Helen Graedon’s story as fuel.
Helen Graedon had recovered to the point where the hospital would release her the next day, so Joe went home to sleep. She called at 2 in the morning in a panic as her muscles spasmed uncontrollably. When Joe arrived, the nurses had tied her to the bed. Helen was given Demerol, a narcotic pain reliever, despite the warnings that she could not tolerate the narcotics. Later that day, doctors had cleared Helen to go home around noon. Joe headed home, but got a phone call before he arrived. By the time he got back to the hospital, his mother was dead.
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The Graedons argue there was a bad drug interaction between the Demerol and another medicine Helen was taking, causing the spasms. While the death certificate lists cardiac arrest due to low blood pressure as a consequence of internal bleeding as the cause of death, it does not explain what caused the bleeding. However, it is important for angioplasty patients to lie still to prevent bleeding. The Graedons believe the muscle spasms caused the internal bleeding and, ultimately, Helen’s death.
Following Helen’s death, Joe and Teresa have worked on improving patient safety. Some experts like Dr. Karen Frush, chief patient safety officer for Duke University Health System, have praised the Graedons’ work. Their suggestions have helped shape the way Duke hospital is run.
Other experts, like Dr. Nortin Hadler, believe the book will simply fuel doctor bashing. He admits, “they do know something about drug adverse events and drug-drug interactions… (but) there is more nuance to informed medical decisions that just the pharmacology of drugs.” While this may well be true, it does not excuse hospital medication errors.
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The Graedon’s new book, Top Screwups Doctors Make and How to Avoid Them, gives suggestions for ways to prevent medical errors and lists common mistakes made in hospitals, by doctors or by pharmacies.
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