healthy4u: propofol

At my Sept. 24, 2011 post "<a href="http://hcrenewal.blogspot.com/2011/09/sweet-death-that-wasnt-very-sweet-how_24.html">UPMC and the Sweet death that wasn't very sweet: How EMRs can detract from a clear narrative, and facilitate spoliation and obfuscation of evidence</a>" I wrote a detailed summary of a civil medical malpractice Complaint regarding possible electronic chart alteration. As I pointed out, that Complaint made EMR metadata visible to laypeople for the first time that I am aware. A new docket has appeared in that case entitled "Interrogatories to Defendant" from Attorney/physician Deborah Maliver dated Sept. 27, 2011. This document is publicly downloadable from the Pittsburgh Prothonotary Office Civil Docket site <a href="https://dcr.alleghenycounty.us/SelectCaseID.asp?filename=Welcome.htm&NoLoginRequired=yes" target="_blank">at this link</a>, case #GD-09-019407, document #55, or at my cached version <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/lawsuits/Sweet_second_omnibus_discovery_request_vol1025000001C2.pdf">at this link</a> (PDF). It brings up questions of even greater concern to me as a physician, those of mysterious drug orders for powerful sedatives such as propofol, fentanyl and etomidate. Apparently the metadata makes it difficult to account for what could be questioned as "over-generous" dispensing of those drugs. (This is ironic, since the trial of the doctor who administered this drug to deceased singer Michael Jackson has itself <a href="http://www.washingtonpost.com/national/after-jurors-hear-of-michael-jacksons-promise-pain-manslaughter-trial-moves-into-2nd-day/2011/09/28/gIQA037n3K_story.html">just gotten underway</a>.) Here is the first interrogatory request listing numerous drugs: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhz5UUn1fAdqG_C4hgdKbsZVqd8nSvaKZ-Qzu4FIOmkQwUaBnawjjlNLqYhEhlZ4JzBH7dv6EOtqPw01aQI-_eN2D5PNICxR-BX3ZRVqPDx8r37ZrUyUOqTQWsnTTx2od_CB4JegU-H1zu_/s1600/req_drugs.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5657422163070212418" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhz5UUn1fAdqG_C4hgdKbsZVqd8nSvaKZ-Qzu4FIOmkQwUaBnawjjlNLqYhEhlZ4JzBH7dv6EOtqPw01aQI-_eN2D5PNICxR-BX3ZRVqPDx8r37ZrUyUOqTQWsnTTx2od_CB4JegU-H1zu_/s320/req_drugs.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 320px; height: 205px;" /></a>Question 1. Request for full metadata on these drugs (click to enlarge) </div> See Exhibit "A" from the new Interrogatory docket below, as produced in discovery earlier, and download the new Interrogatory in its entirety to see the questions asked about the other metadata: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifbEyA4JmFHLDEi9l7jeLeR49Edosxc81jdxE8L2ehKi0mo1XxAte2xJaH6Q9QY5MPjfgexHoFATqrU53bjf2ofDh3OsrQA00GJ4BRNAfAxpn1AZ6CXLa4QqK4KI0UHnQKWgWnGAnwkkjb/s1600/propofol.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5657414336191328802" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifbEyA4JmFHLDEi9l7jeLeR49Edosxc81jdxE8L2ehKi0mo1XxAte2xJaH6Q9QY5MPjfgexHoFATqrU53bjf2ofDh3OsrQA00GJ4BRNAfAxpn1AZ6CXLa4QqK4KI0UHnQKWgWnGAnwkkjb/s320/propofol.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 381px; height: 221px;" /></a>Exhibit "A". McKesson drug cabinet dispenser audit trail. Five 100-ml vials of <a href="http://en.wikipedia.org/wiki/Propofol">propofol</a> in a row from May 14-May 15? <a href="http://en.wikipedia.org/wiki/Lorazepam">Lorazepam</a> (ativan), propofol and <a href="http://en.wikipedia.org/wiki/Etomidate">etomidate</a> on May 15-16 at a time when a patient had a deteriorating respiratory status? (These drugs suppress the respiratory drive.) Click to enlarge. </div> Question 4 is particularly disturbing: <div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlvErAEhoZ4kZTtYw4FQaahTK0l6pLTMpEiGMrkaERDnxCmpUGzhHHC3yqQ8hOCkcCri22GT_FK9t8Gneg1k4seXSmeUfX3Qvl1o0beyx6fHzz6sc5JX5rKEJNBiUXW_R7seh8HF8Np26H/s1600/do_not_appear.jpg"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5657423242222664578" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlvErAEhoZ4kZTtYw4FQaahTK0l6pLTMpEiGMrkaERDnxCmpUGzhHHC3yqQ8hOCkcCri22GT_FK9t8Gneg1k4seXSmeUfX3Qvl1o0beyx6fHzz6sc5JX5rKEJNBiUXW_R7seh8HF8Np26H/s320/do_not_appear.jpg" style="display: block; margin: 0px auto 10px; text-align: center; cursor: pointer; width: 380px; height: 147px;" /></a>(click to enlarge) <div style="text-align: left;"> Apparently none of these drugs appeared in the eMAR system, the electronic medication administration record. Where did they go? I hope the full audit trails will show a definitive final disposition of these drugs. One would hope a highly computerized medical center could keep track of its inventory of drugs of powerful potential for abuse with 100% certainty, <a href="http://en.wikipedia.org/wiki/Chain_of_custody">chain-of-custody</a> style (that means, 0% guesswork): <blockquote>Chain of custody (CoC) refers to the chronological documentation or paper trail, showing the seizure, custody, control, transfer, analysis, and disposition of evidence, physical or electronic.</blockquote> </div></div>This is of concern to me as a former Occupational Medicine physician (in the transit industry) and a physician in general. I've seen drug abuse result in train wrecks - literally. Drug abuse/failure to be able to track disposition in a hospital would represent a prima facie public health menace. There are also questions about whether users of the EMR signed in or used the accounts of other individuals, which is another weakness of the EMR. No handwriting to evaluate... -- SS 10/24/11 Addendum: Here is a horrible example of what can go wrong when drugs of abuse potential are not tracked with the utmost of rigor: <blockquote>Star Tribune/Minneapolis <a href="http://www.startribune.com/local/minneapolis/132140228.html">Abbott Northwestern patient left 'writhing in pain' sues</a> "Hi, love," Sarah May Casareto greeted Larry V. King as he lay on a gurney before surgery. As they wheeled down the hall, he recalled in court records, she told him that he'd have to "man up" because they couldn't give him a lot of medication. The next 57 minutes of surgery were excruciating, according to a lawsuit filed Tuesday in Hennepin County District Court that accuses the drug-addicted former nurse of skimming his narcotics, which left him "writhing in pain" during a medical procedure for kidney stones last year at a Minneapolis hospital. Casareto, of Forest Lake, entered an Alford plea of guilty Sept. 1 to a fifth-degree controlled substance crime for possessing Fentanyl, a high-powered painkiller, and was sentenced to probation in connection with the Nov. 8 incident at Abbott Northwestern Hospital. The plea enabled Casareto to maintain her innocence while acknowledging ample evidence to convict her. The suit, which seeks at least $50,000 in damages, alleges that she was "negligent and careless" in her care for King, 57, of Bloomington. The suit also names Abbott as a defendant. It contends that Abbott "knew or should have known [before the procedure] that Casareto was exhibiting drug-seeking behavior and that she had become dependent upon narcotic pain medications." It also notes that Abbott officials knew that she had failed "on at least six different occasions" to properly handle patients' pain medication obtained from the hospital pharmacy. King's attorney, Tony Nemo, called the lawsuit reflective of "a growing problem" that should draw closer scrutiny to drug diversion, or the theft of medications intended for patients. "One of the things I know Mr. King is hoping is that this case may cause Twin Cities hospitals to reveal procedures and protocols to, if not prevent, at least minimize this problem in the future," he said.</blockquote> I wonder if information technology problems regarding tracking of drugs with abuse potential existed. Read the whole article at the above link. -- SS

Propofol and Other Drug Questions: Was Michael Jackson a UPMC Patient at the Same Time as Samuel Sweet?

At my Sept. 24, 2011 post "UPMC and the Sweet death that wasn't very sweet: How EMRs can detract from a clear narrative, and facilitate spoliation and obfuscation of evidence" I wrote a detailed su…

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