Published March 19, 2019
According to Consumer Reports magazine, medical mistakes are one of the leading causes of death each year in the U.S., deaths that could have been prevented. In the face of a problem of this magnitude, family members whose loved ones have died this way sometimes feel they have no choice but to take matters into their own hands.
Mary Brennan-Taylor is one of them. Since the death of her mother, Alice, from medical errors in 2009, Brennan-Taylor has told this tragic story to students, health care providers and policymakers locally and nationally in hopes of changing both health care culture and policy.
She has been invited to speak at national meetings of the Centers for Medicare and Medicaid Services, the U.S. Department of Health and Human Services, and the Centers for Disease Control and Prevention. National publications, such as ProPublica and JAMA Internal Medicine, have covered the story of Alice’s death.
Last Thursday, as part of Patient Safety Awareness Week, Brennan-Taylor told Alice’s story to more than 200 pharmacy, medical and physical therapy students from UB, and physician assistant students from D’Youville College. Patient Safety Awareness Week is recognized nationally each year to advance discussions and inspire action to improve the safety of the health care system.
Sponsored by UB’s Office of Interprofessional Education, Thursday’s event is the result of a collaboration between the Department of Family Medicine in the Jacobs School, the School of Pharmacy and Pharmaceutical Sciences, the School of Public Health and Health Professions and UB’s Center for Successful Aging.
“No one should die from sepsis today,” said Brennan-Taylor, a patient advocate, adjunct faculty member in the UB Department of Family Medicine, and Patient Safety Action Network charter member. “My mother trusted the health care system and it failed her. There was an utter breakdown in the system.”
In vivid detail, she discussed Alice’s harrowing and ultimately tragic story. Alice was a vibrant, active, 88-year-old who lived independently, drove her own car, enjoyed a busy social calendar and was known for taking a uniquely humorous approach to life.
She was admitted to a community hospital in early July 2009 for a minor condition, at which time she was only on three prescription drugs. A few weeks later, Brennan-Taylor found that while in the hospital and a rehab facility, her mother had been prescribed and was taking 26 prescription drugs.
An independent physician who Brennan-Taylor asked to review the case called it “the worst case of polypharmacy I’ve ever seen.” At one point, as a result of being prescribed cyclobenzaprine for muscle spasms, Alice was hallucinating that people were trying to kill her and her daughter. Cyclobenzaprine is on the Beer’s criteria, a list of medications inappropriate for the elderly. She had also stopped eating and drinking. By the time the drug was stopped, at Brennan-Taylor’s insistence, the damage was irreversible.
Forty-eight days after admission to the hospital, Alice passed away from multiple health care-associated infections compounded by medication errors, all of which were preventable.
After Brennan-Taylor’s talk, the students broke off into interdisciplinary working groups to analyze what happened in Alice’s case.
“This was a very meaningful part of the afternoon,” said Ranjit Singh, associate professor of family medicine, director of the Primary Care Research Institute at the Jacobs School and a member of Team Alice.
“It really engaged the students to look at a real-life case. This isn’t a made-up case study; it’s a real case that has so many different problems in it. It encouraged them to identify what they think they would have done if they had been on the care team.”
The students were required to identify and research one issue in Alice’s case. One group identified a study reported by Spanish researchers that found that 73 percent of patients older than 65 were taking an inappropriate medication. Another group found that when the pharmacist in an institutional setting visited the patient personally to discuss medications, medication errors were reduced by half.
“The students were challenged to work together to come up with creative, evidence-based solutions so that this tragic outcome is not repeated,” Singh said.
The faculty who facilitated Thursday’s event took the occasion to announce the formal launching of Team Alice, an innovative research and advocacy initiative based in the Center for Successful Aging. Team Alice was inspired by Alice’s story and Brennan-Taylor’s tireless efforts to work for changes to the health care culture that caused her death.
“Alice’s case was initially used as interprofessional instruction for our medical students,” said Robert Wahler, clinical assistant professor of pharmacy practice and a member of Team Alice. “It has now expanded to a research team of more than 15 interprofessional faculty, staff and students from various health disciplines all focused on working to reduce medication harm in the elderly through a variety of approaches.”
Through Team Alice, Brennan-Taylor, Wahler and Singh are developing a partnership in Western New York focused on deprescribing — reducing the prescribing of unnecessary and sometimes harmful medications in the elderly. They hold regular meetings of local stakeholders, including insurance plans, providers in private practice and the area’s Regional Health Information Organization, HEALTHeLINK.
Team Alice also has a research component. “We’ve been examining the problem of potentially inappropriate medications from different perspectives to see what barriers are there and what are the best practices in effectively removing a medication from a patient’s medication list,” said Wahler.
In addition, the group is partnering with Erie County’s Department of Senior Services to convey to patients and caregivers that they should bring a healthy skepticism to prescription medications and that they may benefit from a non-drug alternative, if one exists.