The Foglight - Six Mistakes in the Making: The Errors I Caught during my Honey Bunny’s Hospital Stay

January 2025

Issue 19: January 2025 

In This Issue: Hospitals can be a dangerous place, as I saw during my husband's recent hospital stay. I caught six issues that could have become a big deal but weren’t because I spotted them. It’s a reminder that mistakes happen even in good hospitals with good doctors. Having someone with you isn’t just helpful—it can make all the difference for someone you love.

Six Mistakes in the Making: The Errors I Caught during my Honey Bunny’s Hospital Stay

 I wasn’t looking for newsletter material—truly, I wasn’t. Rather, I just wanted to take care of my husband. But his recent hospitalization reminded me again how many errors can creep into a course of treatment, even when the doctors are good, even when the patient is educated and alert, and even when, in this case, he is married to a professional patient advocate! The lesson: every hospitalized patient needs a vigilant advocate, whether a professional or just an eagle-eyed friend or partner. 

 Here’s the story. 

 My husband is in his mid-sixties, is a little overweight, and like many others, diabetic with high blood pressure. Over the summer, his diabetes and his blood pressure had been worrying us. His numbers had been going up, and the doctors had been adding medications. But then, in the early fall, they found his creatinine levels were creeping up, which meant his kidneys weren’t functioning properly. The cardiologist and the endocrinologist each cut back some of the medications, the ones known to annoy the kidneys. But it didn’t help. After his creatinine went through the roof, he was sent to see a kidney specialist. The nephrologist ordered a million-dollar set of blood work. Nope. No kidney disease. Then an ultrasound found that, after peeing, my poor Boo had 1,600 cc’s of “residual urine,” still left in his bladder. That’s about ten times the normal amount. So, the doctor sent him to the emergency room, to get a Foley catheter put in to drain his bladder. 

 We went to the emergency room at 5 am the next morning, where my first thought was that he’d get a Foley catheter and go home. But then, while waiting, I read about a condition called post-obstructive diuresis (POD). After you relieve a longstanding urinary blockage, the kidneys, which are used to pushing hard to get urine out, keep pushing hard, and then they over-produce urine. You might be thinking, what’s the big deal about some extra pee? Well, if you pee a crazy amount, you can deplete your fluids and electrolytes. And if you do that to excess, you can die. So, I thought I should inquire.  

 This was the first point at which I intervened. 

 I said to the ER attending, “Hey, what are the chances Hubby might develop a post-obstructive diuresis?” He looked surprised and offered to call a urology consult. The urology physician assistant came by and said he might indeed develop a post-obstructive diuresis. They decided to keep him overnight.  As we sat around and his urinary output climbed, it occurred to me that with all the fluid he was losing, perhaps he should have an IV. When you are putting out a lot of urine, you need to take in a lot of fluid so your body fluids don’t get too low. It’s really hard to drink enough to make up for a very high output.  I made that suggestion, and the doctors concurred. 

 This was the second intervention. 

 So, an IV was started, but only at a slow rate of 50 ccs per hour. I thought maybe that’s okay since my sweetie was also drinking water. The next morning, after seeing his very high overnight and morning output and the IV still at the slow flow rate of 50 ccs per hour, I asked about the IV rate. The attending said, “Yeah, you’re right”—and he turned the IV up to 200 ccs per hour.  

That was my third intervention.  

 Now, on the one hand, it’s bad for a family member, even a doctor like me, to micromanage a patient’s care. But by this point, I was getting a bit paranoid. Later that day, when talking to Cutie Pie on the phone, I said, “Next time the nurse comes in, please double-check what drugs you are on.” Because in the hospital, it’s easy to get the home medications wrong. Hun Bun asked the nurse, then read me a list of his medicines, which were all correct. But he didn’t think to double-check the dosages. When I was there the next day, I asked what the dosages were, and it turned out he was getting twice his dosage of one of his home drugs. So, we had it fixed.  

 That was my fourth intervention.  

 He needed IV fluids at 200 cc per hour for several days. And then, late one afternoon, the IV fluid stopped. Cold. When the IV stopped, Honey Bunny was pleased. He thought the end of the IV fluids meant he was getting better and called me to report the good news. I asked him about his urinary output. It was still crazy high, although a tad improved.  

 I drove over to the hospital and caught the nurse. She said the IV fluids stopped because there were no more orders for IV fluids. She didn’t know if it was done on purpose. (And she was too busy to ask the doctors). I requested a chat with the nocturnist, the evening and overnight hospitalist. He came by and said, “Oops, it was a mistake. I was supposed to check on him this evening and if he was doing well, drop him to 150 cc per hour.” He re-ordered the IV fluids.   

 That was my fifth intervention.  

 Little mistakes and timing errors, simple oversights by smart and well-meaning doctors and nurses happen. Fortunately, he got better, and his output continued to slow down.  

 Then, when they discharged my man, the hospitalist put him back on a drug in a class of drugs that his nephrologist had specifically said were bad for his still irritable kidneys; the hospitalist hadn’t read the nephrologist’s notes. They didn’t catch the mistake, but I did.  

 Sixth intervention by me.  

By the time he was done with his hospitalizations, I had made six recommendations, all of which the doctors agreed with. None of the mistakes were life-threatening, but it was startling to me, even as somebody who works in the field, how much could have gone off the rails.  

 Does this mean every patient needs a professional advocate? Not necessarily. But can it help? Unquestionably.  

What can you do without hiring a private patient advocate? Be present when a loved one is in the hospital. Keep notes about what’s going on and a list of questions. For your own medical appointments, go with someone, ask questions, and—as I will discuss next month—get second opinions.  If you’re asking the questions but need more advice or still feel lost, please don’t hesitate to reach out or leave a comment below.

Email me with your questions, comments, or subscription requests at gerda@mymdadvisor.com. I’d love to hear from you.

Wishing you peace and understanding in your healthcare journey,  

Gerda Maissel, MD, BCPA

Dr. Gerda Maissel, Author

Dr. Maissel is a Board-Certified Physical Medicine and Rehabilitation physician and a Board-Certified Patient Advocate.