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Francine Hardaway Headshot

System Failure: Health Care

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A friend of mine, far from indigent, had her teeth cleaned three weeks ago. She was the picture of health when she went in to the dentist, and today she is dead, a victim of everything that is wrong with our system, although not of any malpractice. She is the second person in my life to die from the most serious problem in our health care system: lack of continuity of care.

The first died of misdiagnosed malaria in an emergency room in Arizona. They sent him home telling him he had the flu, even though he told them he had just returned from Africa.

The most recent died Wednesday night only hours after being discharged from the hospital with a pic line and a supply of intravenous antibiotics and no understanding of how sick she was. No one had educated her on the seriousness of septicemia, which is what she had when she entered the hospital, or of endocarditis, which she had already developed between the first series of tests in the hospital and the second.

Why did they discharge her? Because she asked to go home. And did anyone ask if she lived alone?

Septicemia is a condition in which bacteria are in the blood. But once that bacteria lands in the heart, havoc can occur very quickly. It's easy to Monday-morning quarterback these things, but I feel they should have kept her in the hospital one more night after they found the endocarditis, just to make sure the second antibiotic was working.

And so did her eldest child, who sensed something might be going wrong and flew in that evening to stay with her mom "just in case." A former pharmaceutical rep, she was more aware of the seriousness of her mother's condition. She made what now looks like a heroic effort, upending her life to fly home.

So it was that the daughter, who tried her best to intervene, found her mother the next morning; she had passed in her sleep.

Of course there is a religious explanation for this: it was "her time."

But I don't believe that about a totally healthy person who subjects herself to a dental procedure and dies. All day I've been trying to deconstruct the incident, which -- I repeat -- was nobody's "fault."

I've concluded the health care system itself has septicemia: system-wide infection. Let's start with the fact that almost nobody lives in the town in which they grew up anymore. Aging parents to do not live with their children in America, or indeed in any developed nation. No one is really observing many single people closely, the way they observe children. A child would not have been permitted by his/her parents to walk around for three weeks with a fever and no treatment. A divorced woman? Who would know?

Add to that, the flawed studies we take as gospel: the American Heart Association recently revised its guidelines about whether people with certain heart abnormalities like mitral valve prolapse need to be on prophylactic antibiotics before dental treatment. It's now considered unnecessary, although it was necessary for the past 30 years. Perhaps it is still necessary in people above a certain age.

And what about asking people if they live alone before they are sent home from the hospital with a potentially life-threatening condition before they are stable? What about waiting to see if that second antibiotic, prescribed after the results of the last tests, has taken hold before discharging the patient?

To me, the saddest thing about the loss of my friend is that no one is to blame, and yet this should not have happened.

We don't take a systems view of health care, making sure all the pieces of the supply chain are functioning before deciding the patient will survive. Wal-Mart does a better job of keeping track of light bulbs than we do of people. Cars on an assembly line are now quality-controlled more than patients. It's time for some TQM, Six Sigma, or continuous process improvement in health care, as we have in manufacturing. Many hospitals will say they already have this, but it seems not to include the patient.

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