VALLEY MEDICAL HOSPITAL ERRORS = THE DEATH OF MARK TURNAGE (30 YEARS OLD)

If you have come to this blog, you are searching for information on UW Valley Medical Center (VMC) in Renton, Washington, looking for a review of a doctor that works there, or your loved one is hospitalized and you see the errors starting to happen (and your loved ones are vulnerable and have to trust). Many of you have searched for: lawsuits at UW VMC, medical malpractice at VMC, information on doctors Richard Wall, Suzanne Krell, Mary J Vancleave, Michael Hori, Wynne Chen, William Park, Daniel O’Neill, Fatime Goda, Joy Zhao, Duane Carlson, C Gabriel Alperovich, Michael Mena, Oliver Aalami, other UW VMC doctors, particular medical errors, hospital acquired bacteria, whistleblower and deaths at Valley Medical Center. I am also having a lot of folks searching on Medical Quality Assurance Commission (MQAC) complaints.

You have come to the right place.

If you or a loved one has been harmed by Valley Medical Center please contact me at karieturn@comcast.net.

If you have submitted complaints to the Department of Health in Washington State and those complaints have been ignored, again, please send me your story at karieturn@comcast.net; if you have a chance please fill out the survey on state medical boards that is currently being conducted by a local patient advocate, Yanling Yu, of Washington Advocates for Patient Safety. We need to join together in our next steps.

My son, Mark died at UW Valley Medical Center (VMC) due to a horrendous amount of hospital preventable adverse events – ERRORS that could have been prevented and Mark would be alive today. As others that have survived or lost loved ones due to hospital errors at VMC, you know our pain. You have emailed me your stories and the patterns of errors are all similar.

I am horrified for any and all people that have to be hospitalized at VMC or any Public Hospital in the State of Washington. Those of you that are elderly, disabled or over the age of 18 (and single with no dependents) BEWARE YOU ARE AT RISK as these same things I discuss in this blog can happen to you.

Even though the facts and data within your medical records explain what happened, no one at VMC will come to your rescue because they don’t read those (records) and have no adequate tie-in system between the doctors and staff. You will not be allowed to transfer to another hospital, the errors will not be reported (or discussed with you) and you will be blamed for all that occurred during your hospitalization. After all, it’s your fault you went in the hospital, right?

This blog discusses in detail the total system failure at VMC in following basic medical processes established to ensure patient safety, health and recovery. The State of Washington Department of Health (DOH - MQAC, Facilities and Licensing, the Nursing Commission) lack of ensuring compliance (the government auditing a government hospital) and the lack of UW VMC reporting the errors will also be discussed. Does the DOH know about these issues but chooses not to address them? You bet they know.

I will continue on this journey to expose all those that are and continue to be responsible for the occurrence of preventable errors in King County, Washington. MY SON WOULD BE ALIVE TODAY HAD ANY PROCESS OR PLAN BEEN ESTABLISHED AND FOLLOWED CORRECTLY AT VMC BY THEIR DOCTORS AND STAFF.

Ask yourself these questions as you read through this blog about UW VMC:

If this was your child, what would you do?

If you get bacterial infections within days of a procedure being performed – are you safe?

If Dr. C Gabriel Alperovich performs a tracheotomy on you (you have already acquired MRSA, Enterobacter and Bukholderia in your lungs from prior UW VMC procedures) then next Dr. Alperovich places a G-tube in your side and within days you have a new bacteria (Pseudomonas) in your gastrointestinal track/lungs and incision sites (Burkholderia shows up later) – wouldn’t you think that cross-contamination occurred and/or the surgery equipment wasn't sterile? Obviously Dr. Alperovich didn’t re-glove.

If UW VMC neurologist, Dr. Joy Zhao, tells you that your son is brain dead (they can’t do anything else to “help” Mark) and recommends (along with doctors Wall, Krell, Park, Bob Chapman [Rn] and others) ending his life with comfort care – and within hours of this “recommended death” your son wakes up and communicates with you – What would you do?

If you are strapped down to the hospital bed (arms and legs), intubated, heavily sedated, you vomit and a nurse isn’t around…what do you do? At what point does UW VMC Risk Management and the hospital legal staff review what has transpired with Mark (all the errors) and the risks and probabilities of Mark suing after his discharge (IF Mark was to live)?
VERY ALARMING: On Christmas day I have a conversation with Dr. William Park. He is concerned about the pseudomonas in Mark’s lung – pancreatitis is in control (it was not). I tell Dr. Park that Mark will fight the bacteria – the next day (under Dr. William Park’s command) Mark receives a drug called Dexamethasone (December 26 to January 7) which is contraindicated with the bacterial infections VMC gave Mark (MRSA, Enterobacter, Burkholderia and Pseudomonas). Dexamethasone and other meds caused the VMC bacteria to run rampant through Mark’s body (this is what happened to Mark's WBC levels while on this drug). This will haunt me for many years to come.Will you think twice (or even more) the next time you are hospitalized at VMC ~ or when one of your children or parents are? 

In summary of what caused Mark to die - too many hospital errors…
Because of the poor decision making abilities, not following simple processes and total arrogance of the UW VMC Intensive Care Unit (ICU) doctors and staff the following occurred:

UW VMC misdiagnosed Mark having medication withdrawal from abruptly stopping his previous medications and told us he was septic. The VMC doctors did not contact Swedish or Northwest Kidney Centers (NWK) to document the correct drugs and doses Mark was taking prior to hospitalization. If UW VMC had completed this basic NECESSARY STEP medication withdrawal would not have occurred (“Delirium”), Mark would have not been given medications known to cause toxic interactions with MAO inhibitors (“Liver Shock and Failure”), Mark would not have been intubated, Mark would have never received the Hospital Acquired Infections (HAI’s), and Mark would be alive today.

The combinations of drugs given to Mark on those first days at UW VMC were deadly and gave Mark the toxic side effects the staff were noting in their Focus Notes (respiratory depression, decreased blood pressure – sepsis; flu like symptoms; confusion, agitated, combative, anxious – delirious; etc.). This toxic combination caused Mark to stop breathing.

UW VMC doctors were given the facts and data to prescribe the correct antibiotics needed to fight the bacteria VMC gave to Mark but the VMC doctors continually ignore recommendations presented to them (from the University of Washington [UW], from their own lab, one doctor (Dr. Michael Hori) is said to be “in charge of prescribing all drugs for Mark.” VMC pharmacy did not perform their job in questioning these medication decisions made by VMC doctors – the administration of antibiotics was literally a “shot gun” approach. There is no check and balance system at VMC.

Note: Dr. Mary J Vancleave mentions in her Focus Note on November 21 that Mark should receive the antibiotic (and so does the UW) Ceftazidime – Mark finally receives his drug on January 12. Dr. Suzanne Krell is on duty and and order to discontinue this is written. On January 13 (per the bill) Mark receives another dose of Ceftazidime – again under Dr. Suzanne Krell’s duty someone discontinues it. Dr. Michael Hori finally prescribes this again on January 14 - the one drug that could have killed the Burkholderia VMC gave Mark and possibly saved him – under Dr. Wynne Chen’s duty someone again discontinues this antibiotic.

UW VMC doctors (Stefanie Nunez, Suzanne Krell, William Park, Richard Wall, Michael Hori, and the Pharmacy) were given the facts and data of Mark’s 2C9 inhibitor study (how your liver metabolizes medications) precautions but continually ignore this critical information and give Mark medications known to cause elevated liver enzymes (and damage/failure). UW VMC pharmacy and Gastrointestinal (GI) staff did not perform their job in questioning these medication decisions made by other VMC doctors - and this is their job.

5 VMC GI doctors were monitoring Mark (Doctors Christopher DiRe, Eric Yap, Daniel O’Neill, William Pearce, Duane Carlson and Frank Thomas). Mark had documented gallstones on November 26 (which none of them read the report). Mark was given medications contraindicated with pancreatitis/gallstones and none of these doctors followed through or verified the records as these are not listed in their Focus Notes. Mark’s condition deteriorated because of their negligence.

Note: Dr. Carlson and Dr. O'Neill are no longer on the UW VMC list of GI’s; Dr. Thomas tries to discontinue a drug contraindicated with pancreatitis/gallstones – his orders are ignored.5 VMC GI doctors never treated the pancreatitis and potential disrupted duct. Dr. O’Neill recommends a transfer and consult with Virginia Mason GI for a stent and his orders are ignored. There was minimal pancreatic tissue noted at Mark’s autopsy.

We tried everything in our power to have Mark transferred to Swedish where all his doctors were located including pay out of pocket for the ambulance transfer. We discussed our concerns with the doctors about the errors and that we lost all confidence in the UW VMC doctors ability to care for Mark (this is dictation from Stefanie Nunez). We were told Swedish rejected the transfer. There is no record of whom Dr. Mary J Vancleave contacted at Swedish (in her Focus Notes); UW VMC say Vancleave was not and is not an employee of UW VMC; Sound Physicians says she is not longer employed there, Swedish has no record of ever being contacted, she is now working for Swedish.

Of note: I personally called Swedish and discussed this with 2 people (the “Cap Rn” in Clinical Administration - Patricia (206-215-6656) and her supervisor Kathy Olsen (206-386-2529, pager 206-405-6653). Swedish is covering up the fact (per UW VMC) that they “didn’t want to get involved.”

To date, UW VMC has no idea which medications were administered to Mark. Based on my letter to UW VMC of an audit of only 3 medications (because the “Medication Administration Records [MAR]” differ from the “Detailed Hospital Bill” which differs from “Physician Orders”), "it may be the nurse did not give it for some reason or that the nurse did not remember to record it on the MAR.

As each of these doctors, that "were in charge," move on to other facilities I will update their links to where they are currently working so others will not be harmed - even if they move to other states.

This is only a few of the errors I discuss in Mark’s blog - please read on as all this can happen to you.

Karie

karieturn@comcast.net

Does the DOH intentionally ignore complaints / deaths that occur at VMC?

The statistics are coming in as I hear from you. The answer – you bet the DOH ignores VMC errors.

I have updated this post with a lot of new information that details how worthless and dangerous these DOH organizations are. They do not want the public to know what is exactly going on in the State healthcare system and do not enforce hospital reporting of preventable adverse events. As far as I can tell, none of the errors that happened to Mark were included on the DOH adverse event log or the DOH hospital acquired infection numbers.

If you have filed any complaints with the DOH Medical Quality Assurance Commission (MQAC), Facilities and Licensing and/or the Nursing Commission I’d like to hear from you. You may also want to read on as I will expose what I located about a Registered Nurse, Jill Stevens, who was also an investigator for the DOH Facilities and Licensing and the mental issues she has faced for years. I will also provided links to the data I obtained from the court system. Even with all the mental issues Jill Stevens has had for years, the DOH let Jill “investigate” patient complaints and even allowed her to renew her Registered Nursing credential in April. UNBELIEVABLE. Jill Stevens, Rn, will have her sentencing on November 5^th. I plan on being there and hope to speak.

 My personal email: karieturn@comcast.net

I never realized how corrupt the disciplinary and investigative process is. I sent in 2 separate binders full of hospital errors backed with the data that happened at Valley Medical (VMC). This was new information that none of the investigators at any of these State offices had seen. Dr. George Heye, MQAC, actually had the balls to write that I didn’t send anything new in. I’ve only just begun on pushing the issue up the flag pole.

The most alarming part is that in reviewing Mark's records I discovered that Dr. Wynne Chen was fully aware that another patient acquired the same bacteria Mark did (Pseudomonas and Burkholderia) during his hospitalization. Dr. Chen received a phone call from the VMC Lab on December 27 and Dr. Chen and the lab discussed further. Even with Dr. Chen knowing this, he never spoke up in any of our family conferences/meetings with the truth that Mark acquired all the bacteria there (and not in another state many, many years ago as Dr. Michael Hori suggested). What ever happened about being ethical? I guess that doesn’t apply to doctors or hospitals.

Thank heavens I set up this blog as many others have come forward, "Whistleblowers" from VMC that should have been protected for telling the truth (and helping other patients) but were harassed into leaving VMC. All regulatory agencies are now fully aware of these facts and I did have a chance to talk to a "Whistleblower's" lawyer. I wish this person the very best of luck as I believe this "hero" is a leader in ethics (something hospitals have a hard time with), an employee a hospital needs to keep for the quality system to function properly, a person that probably saved lives at VMC and a person that needs to be a voice in healthcare reform. I will always protect their name.

In summary of what I sent out were 2 binders full of appeal data - new information that detailed exactly what happened. The first binder contained mainly medication errors: sent to the State of Washington Department of Health (DOH) Medical Quality Assurance Commission (the MQAC), DOH Facilities and Licensing and also to Qualis (the “[non-]hammer” to ensure patient safety of Medicare beneficiaries).

The second binder I sent to everyone was in response/appeal of a 4 paragraph report (discussed below) written by DOH - CMS Investigator, Jill Stevens, Rn. Jill Stevens has severe mental issues and just renewed her nursing license, has no business investigating anything. Jill Stevens wrote a report 4 paragraphs long. It's word for word what Dr. Richard Wall (VMC Medical Director) told us, but the medical records do not back up. In one paragraph in this investigative report Jill Stevens says: “I reviewed audit results for personnel hand washing in all patient care units - last quarter 2010 to first quarter 2011.” Gee, UW VMC employees are washing their hands and an audit actually captured that? Do employees comply when an auditor is standing over them? REALLY?  Jill Stevens has no other idea how infections are transmitted and never performed a compliance review against 42 CFR 482.13 (Patient Rights) and 482.42 (Infection Control). Not only is Jill Stevens a lousy investigator – she probably had no idea where she was or what she was doing due to her “addictive habits” and her feelings of being “above the law.” It’s in the court records.

In both of these cases (with the MQAC and DOH - CMS), no one read the medical records and it is very obvious that Public Hospital #1 (UW VMC) is being protected by the State of Washington DOH. In both cases, it appeared that VMC wrote the report themselves and the VMC Risk Management Officers are very good friends with the DOH investigators (probably because they are being investigated all the time). Can you say "Conflict of Interest?"

What was very alarming is that Qualis actually found several Quality of Care issues in Mark’s hospital stay/death – and our own Department of Health for the State of Washington found nothing? WHY NOT?

Note: The MQAC monitors complaints against doctors; but the Chief Investigator, Jim Smith, at the September 30 commission meeting walked by me and said “our job is to get them [the doctors] out of a malpractice suit” Imagine my horror when I heard this; I immediately wrote a letter to our State representatives and Governor with my concerns about his comment and conflict with the MQAC mission statement. Others have come forward with similar concerns voiced about this Chief Investigator. And to top this off, those that work in the MQAC actually gave this guy an award for Investigator of the Year (or month or day – who cares because it’s wrong).

What should be very alarming to all is the fact the DOH Facilities and Licensing had the data on the whistleblower and the report that another patient acquired the Burkholderia and Pseudomonas after Mark, but they refused to investigate further (to look at any of the records to see who had procedures done prior to Mark that had the bacteria present). My audit findings of this report alone totaled 30 pages of issues Jill Stevens failed to note. And we, the taxpayer in the State of Washington, actually paid for Jill’s salary.

Something else to alarm all of us is a recent phone conversation I had with an Ex-VMC employee in housekeeping. I was told that the housekeeping supervisor (over the operation room cleaning) went out on a leave. Another supervisor took over and had the employees cut the operating room cleaning to a minimum (less than 8 minutes between patients). While the employees complained; the supervisor’s decision stayed in place. This Ex-VMC employee was apologetic - and very informative on the other issues UW VMC currently faces. Apparently, VMC has done some housecleaning of their own and the supervisors have been replaced.

I also received a 4 page investigation report from the MQAC (well, almost 4 pages). Contained in these records I received from the MQAC were all 49 pages printed of this blogspot, the MQAC actually went and did a search for me on “MySpace,” and out of the 281 pages I had to pay for to receive, only 10 pages contained investigation records. 

I want everyone to keep in mind as your read below that current state laws prevent anyone from appealing an MQAC investigation even though it will contain tons of misinformation not backed by any facts and data and is not audited against any Federal process (it’s only their opinions). Can we appeal a traffic ticket? Can we appeal a Medicare financial decision? Can we appeal a charge on our credit cards? You bet we can, but you can’t appeal the MQAC even though they are wrong (all appointment by our Governor)…

When I received the MQAC "investigation reports" the MQAC investigator (this time Connie Pyles) says that a 3^rd party review had occurred and VMC did nothing wrong. There are no records anywhere of this 3rd party’s review and are not included in the records sent to me. The MQAC didn’t bother requesting the review because they knew it never happened.

Since the MQAC was so concerned about searching for me on the internet I felt it prudent to search on the doctor that wrote the report, Dr. George Heye. What did I find? Dr. Heye is a “General Pediatrician” born in 1941 (72 YEARS OLD) that is grandfathered into the American Board of Pediatrics system. He is certified, 1984, and does not meet the requirements of maintenance of certification in “General Pediatrics” - “prior to 1988 certification was granted for life.” “The new process requires 6 core physician competencies that include communication skills, professionalism, medical knowledge, patient care, practice based learning and improvement which includes the ability to measure and improve quality of care and system based practice.” And the DOH feels this doctor is qualified to report out on such a complex case of medical errors? Go and search for this doctor here.

Dr. George Heye, this “General Pediatrician,” (according to others that have come forward) is the MQAC “Gatekeeper.” This doctor not only does not read the complaint, the medical records (must be a requirement for being a doctor in the State of Washington) and makes statements throughout his report that are incorrect. His report contained a lot of “emotions” he is feeling about me (clearly irritated that I made a complaint in the first place and against doctors, the system and VMC), his report is not based on facts and data, and he continually provides statements that have no bearing on my complaint at all. His unprofessional attitude, lack of understanding of modern day public expectations and lack of knowledge in auditing is appalling. Read a couple of Dr. Heye's comments below (and please send me your feedback):

I'm sure the facility lost a lot of money by keeping him there for the entire time-seems like concern for a conspiracy among the doctors

DR. HEYE, This is a CONFLICT OF INTEREST. First, the State Government auditing a State (Public) hospital – then we have a doctor who obviously doesn’t believe in sanctioning doctors (from your comments and my notes at the MQAC Board Meetings) – then we have an old doctor that is trying to save the old system (cover it all up).

Why are you focused on the hospital losing money when that has nothing to do with my son’s death and my complaint? The entire hospital bill was paid in full (over $1.2M) – and it shouldn’t have been because of regulatory guidelines in place on preventable medical errors and harm. OH, Federal Regulations only have to followed by the aviation industry and not health care - right?

DR. HEYE, YES, THAT IS THE CONSPIRACY – why are you not investigating the complaint and looking at the costs and worried about the poor hospital? MY SON LOST HIS LIFE DUE TO THEIR NEGLIGENCE. 

Categories of the mother’s dissatisfaction include...lack of the ability to get a second opinion within the facility

Why on earth would I have wanted a second opinion from any VMC doctors after all the preventable medical errors and harm they did to Mark? OMG, you don’t get it.

I can address the concerns in regard to the medical care but allegations about nursing care, the facility and the circumstances around his transfer/lack of transfer to another facility are not under the purview of MQAC

THEN DR. HEYE ACTUALLY INCLUDES THE BELOW:

but no transfer ever happened, probably for multiple reasons-he was critically ill and the reimbursement system probably gave no incentive to the second hospital to take on his care…

The patient's mother has complained to multiple other organizations/entities including the governor, Medicare/Medicaid, her state legislators, the medical center, the joint commission, Centers for Disease Control, OSHA, the public Health Department, and her insurance company.

The patient's mother is keeping a blog in regard to her son’s hospitalization with multiple postings on various aspects of the patient's care "mistakes."

A major contention by the complainant is that the first two bacteria were introduced because of lack of sterile technique at the time of intubation and the latter two bacteria became prominent because of use of the "wrong" antibiotics”

DR. HEYE, Where did this come from? ALL THE BACTERIA were from the lack of sterile technique at Valley Medical Center (VMC)! Administration of antibiotics was literally a shotgun approach with no acknowledgment of the culture and sensitivity reports.

Despite the complainants assertions that the wrong antibiotics were used multiple times, NO bacteria were ever isolated from any blood cultures-I believe over 40 were obtained throughout the hospitalization one would have to conclude that appropriate antibiotics WERE given because no uncontrolled bacteremia was ever documented!

DR. HEYE, Why can’t you read anything? THIS IS ON MARK’S DEATH CERTIFICATE!

The complainant makes a big deal that the patient was not given a certain antibiotic...She has misread the report

DR. HEYE, There were multiple reports…which “ONE” report made you come to the wrong conclusion (AGAIN)?

She is upset that the patient was given steroids

YOU BET I AM. Check out why (see this link on Dexamethasone and Mark's WBC) – DR. HEYE, did you look at any lab results at all? Moron.

She contends the doctors identified the patient has been diabetic when he wasn't

DID YOU READ THE PHYSICIAN CONSULTATIONS FROM THE FIRST DAYS? NO!!? MARK WAS NOT DIABETIC.

The complainant felt "a second opinion was something that a neutral 3rd-party would perform by coming into the hospital and independently reviewing the case and assessing the patient and was not something that occurred by, having physicians familiar with the case, give details and opinions ahead of time

DR. HEYE, how do you know how I felt? Was this in a medical record that you were supposed to be reading? We didn’t want VMC involved in screwing up anything else and we were going to meet with this doctor over at Swedish – until VMC DR. SUZANNE KRELL shut down our and Mark’s hope of getting a real second opinion…the Swedish doctor wanted nothing to do with VMC and their errors…Even VMC Risk Manager Steve Haton said the same.

Complaints about communication among physicians was brought up repeatedly-I think the expectation that every physician managing the patient should sit down with the complainant/patient advocate every day and go over all the developments something that would be impossible as the doctors do their rounds at all different times

Again, DR. HEYE, how do you know what I expected – were you there? I have documented each and every conversation with a doctor and it wasn’t each and every day. Why are you discussing my “emotions” when this has nothing to do with my complaint and the death of my son, Mark?

NO VMC DOCTORS CAME BY EACH DAY AND “SAT DOWN WITH US.”

If your child or grandchild was in the hospital or the Intensive Care Unit (ICU), all family and advocates EXPECT daily tie-ins with the doctors and staff. I am assuming you have no children and most likely no family if YOU really believe what you write. Are you suggesting that parents wait a week until the VMC ICU doctor (who has 26 OTHER PATIENTS) has the “time” to discuss your loved ones status?

DR. HEYE, Health care is a business and it appears you are out of touch with modern day reality. The expectations of patients and families in this new age are something that is covered in continuing medical education. OH, WAIT, I LOOKED YOU UP ON THE AMERICAN BOARD OF PEDIATRICS AND YOU DON’T HAVE TO DO THAT! My opinion is that your lack of knowledge is due to not working in a practice or hospital for what…25+ years? DR. HEYE, you need to put down the pipe. 

The complainant would often ask the same question to multiple different specialists and they would give their opinion, which would sometimes not be entirely consistent with what was said by another physician-this doesn't mean they are wrong or not in agreement, just giving their opinion based on their training.

YOU ARE KIDDING…Right? Why would I ask a Pulmonologist (lungs) a question about Mark’s brain? Why would I ask a nephrologist (kidneys) a question about Mark’s lungs? YOUR COMMENT ISN’T EVEN LOGICAL….

The complainant feels that there was inadequate communication as well based on the fact that every new detail about the case was not discussed with her-some of the issues brought up in her letter don't have any effect on the overall management of the patient.

Again DR. HEYE, all patients and advocates expect to know all “NEW” details when their loved one is hospitalized in an ICU. Get used to it. VMC doctor communication was poor at best so don’t give them that type of credit and it had everything to do with the management of the patient. If you look in the 2 binders of data I sent you my comments are solidified with facts and data and not the “feelings” you continuously write about in your report. Tons of details were never discussed or even reviewed by the VMC doctors.

If the doctor doesn’t have time to review new details with the patients and/or advocate maybe the taxpayer funded hospital needs to: Fire the Leadership? Fire the doctors? Hire more staff? Have 1 project manager that follows patient cases that become complex because of medical errors?

The hospital did not operate as she felt it should much of her opinion on that is lack of understanding of medical practice; some of it is because her expectations were too high in regard to communication, but some of her complaints are potentially legitimate but unanticipated

What does any of this have to do with my complaint about hospital acquired bacteria and all the errors that caused my son’s death? I understand more about medical practice and the business than you do. Did you even read my original complaint and the new information? You are out of touch with investigating.

And we the Taxpayer actually pay for the MQAC (and your salary) to provide biased, unsupported reviews of our complaints so that the hospital errors, deaths and hospital costs continue to escalate out of control? If someone doesn’t take charge and put a cog in the DOH wheels nothing will ever change. Since the State of Washington Legislature gave the medical commissions power to run out of control (with no check and balance system), maybe it’s time the people take control away?

MANY OF US ARE UP FOR THE CHALLENGE.

THE DOH WILL BE EXPOSED….

I keep finding UW VMC errors

Each and every time I review more of Mark’s medical records I uncover even more errors. Not only is this totally unacceptable it breaks my heart. After Mark’s death, when I started reviewing my notes from Mark’s hospitalization and comparing to the medical records I was at 28 pages of errors/issues. Today, I am at 41 pages and I’ve only just begun to uncover all the errors. As a patient at UW Valley Medical Center (VMC) in Renton, Washington, you should be VERY concerned; as I hear from others around the country you should be equally concerned as “these types of errors happen all the time.”

What really happened: Mark did not stand a chance of living after being admitted to UW VMC. As I read through the first 3 days of hospital “Focus Notes (handwritten notes by the doctors and staff)” I now realize the eminent danger Mark was in and I never realized it until today. The doctors involved were “too busy” with other patients, they did not call Swedish or review the hospital computing system for Mark’s medications prior to his hospitalization, they did not adequately tie-in or follow through with their peers, and their serious lack of Project Management skills leaves each ICU patient in danger. This is what I call practicing “Silo Medicine.”

On the first day of Mark’s hospitalization I made the 3rd Floor nurse (Desiree) revise Mark’s medication records on the computer system in his room. While those records were updated in the computer system, 3 days later the doctor’s dictation still has the wrong medications listed in their Focus Notes. What is interesting is that Dr. Daniel O’Neill mentions that Mark has been taking an MAO inhibitor for quite some time; this same MAO inhibitor is not in that list of current medications.

The drug combinations given to Mark on those first days at VMC were deadly and gave Mark the toxic side effects the staff were noting (respiratory depression, decreased blood pressure – sepsis; flu like symptoms; confusion, agitated, combative, anxious – delirious; etc.) and caused Mark to stop breathing. Mark was given a respirator to breathe (intubated) and also given 3 hospital acquired bacteria into his lungs (MRSA, Enterobacter and Burkholderia) at this same time (Pseudomonas shows up later after a tracheotomy and peg tube surgeries). This deadly combination of drugs on those days consisted of (a history of taking an MAO inhibitor), Mark not receiving his Gabapentin and Sensipar (withdrawal), Dilaudid, Fentanyl, Versed and Lorazepam. Come to find out, the Fentanyl should have never been given to Mark because of the MAO inhibitor. Any healthy person would have died with that combination of drugs or worse been intubated by UW VMC staff.

UW VMC gave Mark drugs he shouldn’t have received and didn’t give Mark the ones he needed to fight their bacteria and prevent withdrawal symptoms.

A lot of you have told me that I won’t make a difference; thousands of people and families have already been down this same road. I do agree that organizations like the Joint Commission (formerly the JCAHO) and the Leapfrog Group are only into collecting metrics and not being a beneficial resource for a patient. They protect hospitals so hospitals will give them information; the same is true of the State of Washington Department of Health and collecting error and infection information from hospitals.

A lot of you have also said that my letters to Federal and State agencies will go unheard or I’ll get that “generic” letter that is useless but polite. That has been the case with some but I am still in communications with other agencies. You cannot give up easily.

Look for Mark’s story on Facebook in the near future.

Karie (Mark’s mom)

karieturn@comcast.net

The Numbers Are Staggering

Go out to any major media site today, the number of deaths and costs are all there. Estimates project up to 280,000 people die each year from hospital acquired infections and hospital errors. What does it cost us? About $57.1 BILLION annually; and all of this is preventable. Mark’s hospital bill only (no doctor bills) is currently at $1,119,496.99; of this number $293,076.98 was for medications.

Mark did not stand a chance of living after being admitted to UW Valley Medical Center (VMC). Within days Mark was heavily/over sedated, given a respirator to breathe because of the sedation, given oral contrast during this time (which he vomited and aspirated), given 4 antibiotic resistant bacteria in his lungs, not given the proper antibiotics to fight the bacteria, and after numerous botched procedures and lack of infection controls, the bacteria then spread rampantly throughout his body. All of this was preventable.

We tried everything in our power to have Mark transferred to Swedish Hospital and even agreed to pay the $10,000 ambulance transfer fee. Swedish rejected Mark because they “would not be able to collect any revenue (Medicare was Mark’s primary insurance/Regence Blue Shield secondary); Mark’s allotment of insurance money was spent.” This rejection occurred on day 16. Since this time, I have contacted Medicare and they said these statements by the hospitals are incorrect; all insurance would pay to day 90 then secondary insurance kicks in. Swedish has lost all records of this transfer request and the rejection per Ms. Cox and also Dr. Vassall, Swedish CMO.

I hope you will find my letter to VMC below to be “enlightening” on what really happens in hospitals. My links to the right side detail the horror VMC put Mark through; I know Mark is not the only victim. Hopefully, the visibility I am bringing to VMC and the regulatory agencies will prevent this from occurring to someone else’s loved one. I will keep you informed as this progresses.

My letter to VMC for causing Mark's death

My letter to VMC for causing Mark's death

As we all know, health care costs escalate for a number of reasons. One of those reasons is when hospitals do not follow infectious disease protocols and give their patients diseases they didn’t have when they arrived at the hospital. We all assume that when we go to a hospital we will get better, not die from hospital errors. Last year (per legal discussion) 96,000 people died from hospital errors; the population of Auburn, Washington (according to the 2010 census) is 70,180. This is a staggering amount of taxpayers.

Also of note is if you are over the age of 18, single with no dependents, you are at the mercy of the hospital even though you may still be on your parent’s employer health insurance plan. Hospital legal staff and risk management teams are fully aware that the family will have difficultly suing because of current Washington State Law (with a few exceptions) therefore the patient is at risk for complacency and sub-quality/third world health care. It appears to me that UW Valley Medical Center (VMC) did not want Mark to live (hence not giving Mark the correct drugs identified on 2 susceptibility lab reports) because Mark could have sued VMC for medical negligence/malpractice. What my family, friends, coworkers, internet counterparts and I have observed is that hospitals operate with complete immunity under these and many other conditions.

My son, Mark David Turnage Jr., fell victim to 4 hospital acquired bacterial infections (aka HAIs - MRSA, Enterobacter, Burkholderia and Pseudomonas) that resulted in his death at Valley Medical Center in Renton, Washington on January 16. Mark acquired these bacteria in his lungs (which resulted in pneumonia) and later his gastrointestinal track (through a peg tube then G-tube incision) as a result of VMC not following industry blood borne pathogen standards, VMC internal processes, federal (OSHA/CDC) regulations and VMC doctors not prescribing the recommended antibiotics discovered through susceptibility studies. Ironically, Mark had pneumonia on 9/15/09 and didn’t get these bacteria in his lungs and also had his pneumonia vaccine in September.

Back on November 9, Mark was taken to the VMC emergency room (ER) for classic symptoms of gallbladder distress (acid reflux, pain in upper right abdomen, nausea, couldn’t eat that day). On November 10 around 2:30 am VMC admitted him after identifying pancreatitis through blood work. While I was in the ER with Mark early that morning, UW VMC performed what appeared to be the MRSA nasal swab test. UW VMC later said this test was never performed and/or they lost those records. Dr. Suzanne Krell cancelled this MRSA nasal swab test order (along with other ICU doctors) multiple times.

When the hospital heavily-sedated Mark on November 12 they had to "intubate" him (gave him a respirator to breathe). Within 4 days, per the death certificate signed by VMC Dr. Wynne Chen, VMC found 4 antibiotic resistant bacteria growing in his lungs (initially MRSA and Enterobacter then Burkholderia and Pseudomonas) ~ obviously from the intubation/respirator and no infectious disease controls being followed (hospital acquired). VMC blamed this on Mark being in the Intensive Care Unit (ICU) and said this occurs when patients are in the hospital for a long duration. Being in the hospital for 4 days before these are discovered does not constitute a long hospital stay. I would like to know what strain of MRSA VMC discovered (community versus hospital acquired are different) and if the other bacteria also have strains.

We (the family) personally witnessed and documented the lack of infectious disease controls and processes on many occasions (no gloves, putting on gloves but not washing hands first, gloves not being changed after cleaning the tracheotomy, gowns not being used, bathing techniques, etc.). I have outlined these in a separate report (cross-contamination). Just a few examples of further incompetency are described below (my full report will be sent to the compliance organizations on the distribution list):

On November 26 VMC performed an ultrasound and detected 1 or 2 gallstones, however, the VMC doctors didn’t review the report because this information was never mentioned in daily rounds or family conference meetings. I discovered this information after reviewing some of Mark’s medical records I received on January 13 (which I pointed out to the Gastrointestinal [GI] Dr. Christopher DiRe the next day). Dr. Christopher DiRe had no clue and was surprised to hear this (I pointed him to the November ultrasound report so he could look it up on the computer in Mark’s room).

November 27 Dictation from Dr. Mary J Vancleave states “The patient was initially started on broad-spectrum antibiotics. Numerous respiratory and blood cultures have been done, and all have been negative except for tracheal aspirate on November 14, which grew out Enterobacter cloacae and MRSA, and was maintained on the appropriate antibiotics…Tracheal aspirate on November 21 grew out the MRSA and Burkholderia cepacia, which is sensitive to ceftazidime.” Mark was not given ceftazidime until January 12; I discovered this information after Mark’s death while reviewing his medical records. Of note is the fact that I am not told about the Burkholderia until December 4 by Dr. Lindy Klaff (the intensivist), not Dr. VanCleave (the hospitalist).

What happened over the 68 days in the VMC ICU was horrific and an experience no one, patient or patient advocate, should ever have to go through. We saw everything from medication errors, arrogance to 2nd opinions and family knowledge, denied patient advocate 2nd opinion requests, a lack of tie-in of the staff (mainly VMC doctors), limited and conflicting communication with the doctors, infection disease controls not being followed, medical errors/procedures that had to be repeated (not done correctly the first time, and I was not notified, I discovered during medical record review), and the list goes on. All of these issues have been extensively documented in my own separate audit report.

On January 4 the VMC doctors removed a peg tube and replaced that with a G-tube. By January 7 massive amounts of bile were oozing/bubbling out of my son’s G-tube incision. Three days later (on January 10) Pseudomonas was identified in the incision from a swab test (traveled from his tracheotomy ~ again infectious disease processes, controls and regulations were not followed) and Pseudomonas was now growing in his abdomen. Mark went through massive pain, belching, foaming of the mouth, rectal tube collection bag was totally inflated with gas (not feces), and the feces that escaped the rectal tube and was on the bed between his legs was gurgling like a geyser from all the gas. What I was never told (and I found on March 10 while doing a medical record review) was that VMC knew on December 14 that Mark had Pseudomonas growing in his feces. This information should have been discussed with me, Mark’s patient’s advocate (Dr. Wynne Chen was on call ~ Mark’s fever went to 105 on this day). How dare the doctors for keeping this type of information from us, obviously a medical error the VMC doctors didn’t want to disclose to me. On January 14 we were told by Dr. Duane Carlson (GI) that those symptoms (described above) explain that a bacteria population could have caused this (as the bacteria eat through Mark’s GI tract they produce gas). This was a horrendous amount of pain for Mark.

We requested a 2nd opinion on January 11 (definition below for VMC doctors and staff), however, Dr. Suzanne Krell’s presentation to Dr. Robert Driscoll (Swedish GI) was about Pancreatitis and not the horrific GI issues Mark was facing (belching massively, foaming at the mouth, massive leakage oozing/bubbling out of G-tube incision, the gurgling sound from the G-tube incision…all these listed in my previous paragraph). We are later told Dr. Suzanne Krell presented Mark’s case to Dr. Driscoll as Pancreatitis with uncontrollable Pseudomonas (we assumed the Pseudomonas was in his lungs). Of course, Dr. Driscoll had no “advice or consult” to add. I have discussed this matter further with Dr. Driscoll on my March 11 appointment with him.

A second opinion is a third party unbiased opinion of the facts and data presented to them. The second opinion is an independent review of the patient, symptoms and drugs given. A second opinion request is not a conversation between doctors about the patient.

A consult is a doctor calling another doctor and asking for advice.

My son eventually died from the bacteria causing pneumonia and the hospital not giving him the VMC and University of Washington (UW) recommended antibiotics (from the sensitivity studies [November 21 and January 1 respectively] which are attached) to treat the bacteria. The Valley sensitivity report from November 21 identified Ceftazidime (which Mark wasn’t given until January 12) and the UW sensitivity report from January 1 identified Ticarcillin/Clavulanic Acid as the best antibiotics to give Mark. The UW study said Ticarcillin was susceptible in 64 Pseudomonas and 64 intermediate Burkholderia. Mark was given Zyvox (Linezolid) which wasn’t even listed as being an antibiotic to be considered; Mark never received Ticarcillin. According to Dr. Wynne Chen’s “Discharge Summary” Dr. Michael Hori was the doctor dictating the antibiotics given to Mark. Dr. Michael Hori actually stopped all antibiotics on December 10 when Pseudomonas was found; when I questioned Dr. Fong about this he called Dr. Michael Hori and had the antibiotics started again. 

I found out later (after reviewing the VMC detailed hospital bill) that they also gave Mark an immunosuppressive (Dexamethasone from December 26 to January 7) while his body was trying to fight all these bacteria. At this same time I am being told by Dr. Richard Wall, VMC ICU Medical Director, that Mark’s immune system isn’t responding; imagine that. Dexamethasone is a steroid 4 to 5 times stronger than Prednizone and also causes elevated liver enzymes. With the amount of drugs they gave Mark during his hospital stay at VMC, I am surprised that liver failure was not also mentioned on the death certificate. There was no reasoning and systems thinking for the prescriptions ordered and given to Mark. The amount of drugs administered would have caused any healthy persons liver to fail. At Swedish, where all of Mark’s doctors were, we hired a psychiatrist to manage Mark’s medications to ensure there were no interactions and that his liver could metabolize those. I showed this same genetic drug metabolism study to Dr. Wall, Dr. Park, Dr. Nunez, Dr. Krell and Dr. Hori ~ they either didn’t comment (Krell/Nunez), told me the study had to do with psychiatric drugs (Hori), showed no interest in reading it (Park), or told me it had to do with Mark being immunocompromised (Wall). I know what a CYP2C9 inhibitor study is, why didn’t they? The VMC doctors ended up prescribing a drug Mark’s liver couldn’t metabolize; and as soon as I thought about it I called the nurse, had her stop the iv and call the doctor. It appears that I am the one that should be a VMC doctor.

The inability and rejection (Medicare DRG codes) to have Mark transferred to Swedish, which I aggressively tried to work, and I even agreed to pay all the transportation costs, is yet another issue and letter that will be addressed and follow this letter.

Because of all the hospital errors; conflicting information and lack of communication between doctors, staff and family; the lack of daily tie-ins (many doctors were “missing in action”); and literally no one “driving the bus” for Mark’s coordinated care plan we requested formal family meetings to discuss Mark’s health care plan, we wrote our expectations of the doctors and staff on Mark’s ICU room whiteboard, and discussed VMC processes, methodologies and failures of the VMC healthcare quality system. Communication between the doctors – the staff – and the family should be seamless. Communication at VMC became a “pull” from the family versus a “push” from the doctors.

Through the course of Mark’s hospital stay at VMC I have extensively documented daily notes (80+ pages) of our interactions between doctors and staff. I also have documented my “audit” findings from the above (28+ pages and growing) and will forward to the appropriate oversight organizations. I can count the number of times we were told that “Mark is not the only person here” ~ “I don’t have time for this” ~ “I have 26 patients and don’t have 30 minutes to spend with each of them” ~ “I don’t know...go ask (insert other doctors name here)” ~ all from doctors in an ICU. Isn’t an ICU supposed to have the most cutting edge, educated leaders for doctors? I can also count the number of times we had to track down doctors. I will make it a personal life mission to get the word out on how important it is for all families to assign a patients advocate and to be at VMC at all times when your loved one is hospitalized. I will encourage the advocate/family to get actively involved in reviewing the medical records up front, asking a ton of questions and not to believe anything a VMC doctor tells you.

As final solidification of all of my comments, please read Dr. Wynne Chen’s “Discharge Summary” ~ a true example of the lack of commitment, tie-in, or even reading what was really going on with Mark (his patient or any other patient at VMC for that matter). While I liked Dr. Wynne Chen’s forthcoming attitude, he clearly wasn’t “on the boat with the team.” Mark did not grow Pseudomonas in a pseudocyst (as Dr. Chen states was in the paracentesis fluid). Did Dr. Wynne Chen even read the lab work? I did. Also is of note is that we never requested a second opinion from the University of Washington. Where did Dr. Wynne Chen read this because this wasn’t what happened or what was requested. Obviously Dr. Wynne Chen (like all your other ICU doctors) didn’t read Mark’s medical chart or tie-in with the other doctors. Dr. Wynne Chen also mentions that no gallstones were seen; again Dr. Wynne Chen didn’t read the ultrasound report from November; a private autopsy revealed that Mark did have gallstones. This is a classic example of how out of touch VMC doctors are.

VMC failure to follow industry standard protocols and regulations for preventing hospital acquired infections (HAIs) is totally unacceptable. Because of this, I have also started the process of filing a formal complaint with the CMS Quality Improvement Organization for their doctors to review all of Mark’s medical records and VMC processes. I have also contacted CMS to begin the formal process for all medical bills to be rejected since the hospital was at fault for the massive amount of bills (the hospital bill only is over $1.2M) mainly due to these bacteria. I am also performing a separate audit of the detailed/itemized VMC hospital bill; those questions will be arriving at VMC Patient Accounts within a couple of weeks. I have also contacted the Office of Quality Monitoring (formerly JCAHO) to file a formal complaint. I am in the process of petitioning the State of Washington to have the death certificate changed to reflect what actually happened based on documentation, medical records and my discussion with Dr. Suzanne Krell on January 12 “that GI issues would not kill Mark, the pneumonia and sepsis from the pneumonia would,” all caused by VMC incompetence and complacency.

Finally, for all the VMC ICU “doctors,” Mark’s sepsis was from the bacteria in his lungs and GI track (all caused by VMC). There was no mystery infection (or infection in his pancreas) as you all kept looking for and telling me about; hence, 42 blood cultures and every one of them came back negative. I’ve only begun my review of Mark’s medical records and found enough to horrify any mother in the small amount I have reviewed. My son Mark did not deserve to die like this; Mark’s death was not “natural.”

I am anticipating your reply,


Karie Turnage (Mark’s mom)
Renton, WA