MISHANDLED PATIENT INFORMATION BEHIND MAY MEDICAL MISTAKES –
HOW SAFE ARE L.A.’S HOSPITALS?

Health Care Special Report  Brief

By David Greenberg
Los Angeles Business Journal
September 9, 2002

UNTIL this year, Steve Le spent much of his free time playing in city softball leagues. He also enjoyed hiking, sometimes in places as far away as Australia.

But these days, the 28-year-old Los Angeles pharmaceutical salesman is spending hours in physical therapy each week, the result of medical problems he claims he suffered due to a hospital error that kept him nearly incapacitated for months.

According to a lawsuit he filed in Los Angeles County Superior Court against Santa Monica-UCLA Medical Center and the doctors who treated him, mismanagement of his medical information left a bacterial infection in his spinal cord undetected--threatening to confine him to a wheelchair, if not kill him.

John Lundberg, deputy general counsel for the University of California system, which recently received the Le suit and is investigating it on behalf of the UCLA hospital, said that if the allegations prove true, they represent an isolated incident.

“This is obviously an aberrant circumstance,” he said. “I don’t think it’s simply because things got chaotic or there’s understaffing.”

Although botched surgeries and misdiagnosed ailments get most of the publicity, studies show that mishandling of information is another industry-wide problem that can result in patient injury and death.

Dorel Harms, vice president of professional service for the California Healthcare Association, the hospital industry trade group, declined to comment on the Le case, but said mishandling information is an ongoing dilemma. “Hospitals have been attacking this for years, but there are so many areas where a step can be missed,” she said.

Transmitting records is particularly tricky when it involves a patient who was never admitted to a hospital but only seen in the emergency room, she said.

Two surgeries

According to Le’s suit, evidence of the infection was detected through a blood culture at Santa Monica-UCLA Medical Center but the information was never reported by lab officials and wasn’t detected by a spine specialist for another month. “The lab didn’t report it to anybody--not me, not my primary care physician, not the orthopedic surgeon,” Le said in an interview.

After the diagnosis, Le was rushed to St. John’s Health Center in Santa Monica for the first of two spinal surgeries that hospitalized him for 18 days (14 in the intensive care unit) and caused him to miss four months of work, the suit said.

Le began feeling symptoms of the infection on Feb. 25 when he said he felt a sharp pain in his right leg. He went to the Santa Monica-UCLA emergency room the next day.

When an MRI showed no infection, he said doctors told him he had a herniated disc in his back that required attention from an orthopedic surgeon.

Le said he was discharged with a prescription for the anti-inflammatory drug prednisone, a steroid-based drug.

According to Le’s attorney Marcus Petoyan, results of the blood work at UCLA that were never relayed to doctors showed Le was suffering from an epidural abscess that was causing a deterioration of the spinal cord and infection throughout his body.

“All of the symptoms were the result of an epidural infection,” said Petoyan, a partner in Sherman Salkow Petoyan & Weber. “  But worse than getting no treatment, he was given treatment in the form of the steroid that suppressed his immune system, resulting in a more aggressive course of this infection.”

The bacterial infection was finally discovered 20 days later when the spine specialist looked up Le’s medical records on Santa Monica-UCLA’s patient records system.

“They told me I should rush to the ER,” Le said.

This time, Le’s brother drove him to St. John’s, where doctors that evening performed a laminectomy, intended to clear out the abscess on the back side of Le’s spine. On April 2, doctors performed the same procedure for the front portion of his spinal column.

Months of recuperation followed, during which time Le said he was confined to a full-body brace, and later a walker.

With the case pending, Le said his feelings toward his ordeal range from feeling lucky he barely escaped a far worse outcome and the concern that others could suffer that plight.

Lundberg would not comment on the specifics of the Le case, but he noted that in general all UC hospitals should have their quality assurance committees examine their operations to determine if there is a potential for mistakes--and even suspend staff, if necessary, when errors crop up.