Her daughter traced the source to the medicine bottles in Oyler’s home in St. Joseph, Mo. One drug that keeps heart patients like Oyler from retaining fluids was missing. In its place was a toxic drug with a similar name but different purpose, primarily to treat cancer and severe arthritis. The label said to take it daily.
“I gathered all her medicine and as soon as I saw that bottle, I knew she couldn’t come back from this,” said Kristin Sigg, the younger of her two children. “There were many layers and mistakes made after she left the hospital. It should have been caught about five different ways.”
Oyler’s death occurred at one of the most dangerous junctures in medical care: when patients leave the hospital. Bad coordination often plagues patients’ transition to the care of home health agencies, as well as to nursing homes and other professionals charged with helping them recuperate, studies show.
“Poor transitional care is a huge, huge issue for everybody, but especially for older people with complex needs,” said Alicia Arbaje, an assistant professor at the Johns Hopkins School of Medicine in Baltimore. “The most risky transition is from hospital to home with the additional need for home care services, and that’s the one we know the least about.”
Medication mistakes like the one in Oyler’s case — which slipped past both her pharmacist and home health nurses, according to court records — are in fact one of the most common complications for discharged patients. The federal government views them as “a major patient safety and public health issue,” and a Kaiser Health News analysis of government records shows such errors are frequently missed by home health agencies.