CONTACTS 

SUBJECTS
13th Cycle Treatment Taxotere Xeloda Capacitibine Chemotherapy 5th C

0503 -
0503 -    ..
0504 - Summary/Objective
0505 -
050501 - Follow up ref SDS 97 0000. ref SDS 95 0000.
050502 -
050503 - Blood counts very good again today, though ANC continues to drop over
050504 - the past 2 - 3 months. ref SDS 0 P560  Treatment was accomplished
050505 - without incident.  Side effects seem less severe, except Millie was
050506 - diagnosed with pulmonary emboli.  Treatment of this side effect has
050507 - reduced severity of fatigue and shortness of breath. ref SDS 0 QU8K
050508 - Rising CA 15-3 from 51 to 56 reflects slow progress with current
050509 - treatment recovering from IBC relapse. ref SDS 0 2N5J   Ross said the
050510 - Oncology Pharmacy was not aware that the doctor in Oncology prescribed
050511 - Coumadin (warfarin) to treat Millie for pulmonary emboli.  He noted
050512 - that Kaiser's computer system posts prescriptions which is available
050513 - to the Coagulation Treatment Clinic.  However, since he was not aware
050514 - of Millie's treatment for pulmonary emboli, he asked Millie to notify
050515 - the Coagulation Treatment Clinic to adjust her Coumadin prescription
050516 - for concurrent treatment with capecitabine (Xeloda). ref SDS 0 T650
050517 - Ross later called the Coagulation Treatment Clinic and was told that
050518 - the Clinic was not aware Millie is being treated with capecitabine
050519 - (Xeloda) prescribed by Oncology.  The staff entered this in their
050520 - computer and will make the adjustments to Millie's prescription for
050521 - Coumadin. ref SDS 0 VE4K
050522 -
050523 -
050524 -
050525 -
050526 -
050527 -
050529 -  ..
0506 -
0507 -
0508 - Progress
0509 -
050901 - Treatment Regular 3 Week Schedule Steady Level Chemotherapy Agent
050902 -
050903 - Follow up ref SDS 97 407N, ref SDS 95 407N.
050904 -
050905 - Received treatment to begin 13th cycle overall of chemotherapy with
050906 - Taxotere and capecitabine (Xeloda), and the 5th treatment for 3rd
050907 - relapse of IBC.  Scheduling and treatment were reviewed by the primary
050908 - care physician on 060825. ref SDS 94 025H  There was another review on
050909 - 060929.  Treatments were initially irregular, and there has been slow
050910 - response, reported on 060922. ref SDS 96 0D4T  Treatment was on
050911 - schedule for 060929, and again today.  This keeps a steady level of
050912 - chemotherapy agent treating cancer.
050913 -
050917 -  ..
050918 - Debbie had fun with us today.  Her last name was hard to discern sown
050919 - onto her hospital gown.  When asked, she said "Reynolds."  Writing up
050920 - the record and noting coincidence with the actress and entertainer;
050921 - Debbie laughed and said, "Hey, you didn't write that down, I hope!"
050923 -  ..
050924 - Millie had a blood draw yesterday afternoon, Thursday, 061019.
050925 -
050926 -
050927 -
050928 -
050929 -
050930 -
0510 -

SUBJECTS
Side Effects Consultation Pharmacist Tired Fatigue Heavy Chest Short

1603 -
160401 -  ..
160402 - Breathing Difficulty Heavy Chest Pulmonary Emboli Side Effects
160403 - Side Effects Consultation Pharmacist Heavy Chest Difficult Breathing
160404 -
160405 - Follow up ref SDS 97 QU8K, ref SDS 95 QU8K.
160406 -
160407 - On 060724 diary showing history of side effects for 2nd phase taking
160408 - Taxotere and capecitabine (Xeloda). ref SDS 86 QX8K
160410 -  ..
160411 - Millie met with the pharmacist, Ross, briefly in the examination room,
160412 - per below, and notified of reduced side effects. ref SDS 0 819O
160414 -             ..
160415 -            Tired, fatigued - pulmonary emoblims...
160416 -
160417 -               Millie's energy seems improved after Kaiser diagnosed
160418 -               pulmonary emboli and started treatment with Coumadin on
160419 -               061002. ref SDS 99 MI5I  The 3rd week of treatment this
160420 -               cycle was better than last month, reported on 060929,
160421 -               ref SDS 97 FG3N; however, energy remains lower than
160422 -               normal, even for chemotherapy treatments; chronic
160423 -               fatigue prevents routine exercise at the gym.
160425 -             ..
160426 -            Heavy chest - difficult breathing
160427 -
160428 -               This has improved slightly with respect to climbing
160429 -               stairs, walking several blocks, but not sure.
160431 -             ..
160432 -            Dry hands.
160433 -
160434 -               Hands, fingers, cuticals bleeding slightly; patient
160435 -               using commercially available moisturizing lotion.
160437 -             ..
160438 -            Nausea
160439 -
160440 -               Uneasy, queazy feeling in stomache relieved by eating
160441 -               small amounts of food thorughout the day.
160443 -             ..
160444 -            sores in mouth
160445 -
160446 -               None yet, cleaning mouth carefully to avoid problem.
160447 -
160448 -
160449 -
160450 -
160451 -
160452 -
160453 -
1605 -

SUBJECTS
Schedule Treatment Regular 3-week Cycle on Friday 061020 1430 Blood

2003 -
200401 -  ..
200402 - Schedule Next Treatment Continue Fridays
200403 -
200404 - Follow up ref SDS 97 QK6L, ref SDS 95 QK6L.
200406 -  ..
200407 - Today, Millie's next treatment is scheduled for 061110 1430.
200409 -  ..
200410 - Blood draw is schedued forthe day before on 061109 1600.
200412 -  ..
200413 - Meeting with the doctor also scheduled for 061110.  Not sure about
200414 - the time, because we can do it before or during treatment.
200415 -
200416 -
200417 -
200418 -
200419 -
200420 -
200421 -
200422 -
2005 -

SUBJECTS
Blood Tests Chemotherapy WBC White Cell Count Good 13th Cycle Taxote

2303 -
230401 -  ..
230402 - Blood Counts Good Dose Chemotherapy Taxol Normal
230403 -
230404 - Follow up ref SDS 97 Q659, ref SDS 95 Q659.
230406 -  ..
230407 - Debbie submitted the report showing...
230408 -
230409 -    Patient   Provider  Category   View      FR Date   To Date
230415 -     ..
230416 -    Procedure              Results             Reference Range
230417 -
230424 -
230425 -                  ** Marina Way South **
230427 -     ..
230428 -    Test Name            Value Unit     <-------- RANGE-------->
230429 -    @CBC
230430 -    WBC x 10-3               5.3 K/uL           3.5   -     12.5
230431 -    RBC x 10-6              3.79 M/uL           3.60  -      5.70
230432 -    Hemoglobin              12.4 g/dL          11.5   -     15.0
230433 -    Hematocrit              37.3 %             34.0   -     46.0
230434 -    MCV                       98 fL            80.0   -    100.0
230435 -    RDW             H       16.1 %             11.9   -     14.3
230436 -    Plt x10-3              306   K/uL         140     -    400
230437 -     ..
230438 -    Neutrophils              73  %             50     -     70
230439 -    Lymphocytes              24  %             20     -     50
230440 -    Monocyte                  2  %              0     -     11
230441 -    Eosinophils               0  %              1     -      5
230442 -    Basophil                  1  %              0     -      2
230443 -    Bands             No Report  %              0     -      5
230445 -     ..
230446 -    CA 15-3         H         56 U/mL          -<     -     39
230448 -     ..
230449 -    Alkaline Phos     No Report  U/L           38     -    126
230450 -    Bili, Tot Adult          0.5 mg/dL        0.2     -    1.3
230451 -    Creatinine               0.7 mg/dL        0.6     -    1.2
230452 -    ALT (SGPT)      H         37 U/L           14     -     36
230453 -    AST (SGOT)        No Report  U/L           11     -     66
230455 -     ..
230456 -    RBC Morphology    No Report
230457 -    Poikilocytosis  * No Report
230458 -    Anisocytosis    * No Report
230459 -    Schistocytes    * No Report
230460 -    PLT Estimate      No Report
230461 -    PLT Morphology    No Report
230462 -
230463 -
230464 -
230465 -
2305 -

SUBJECTS
Anticoagulation Therapy Pulmonary Emboli INR High 3.4 PT Patient Hig

2603 -
260401 -     ..
260402 -    Anticoagulattion Therapy INR High 3.4 PT Patient High 34.2
260403 -
260404 -
260405 -    PT, patient    H        34.2 sec           8.9    -     11.1
260406 -    PT INR                   3.4 sec           2      -      3
260407 -
260408 -
260409 -
260410 -
260411 -
260412 -
2605 -

SUBJECTS
Absolute Neutrophils Count ANC 3869 Well Above 1500 Required for Tre

2903 -
290401 -  ..
290402 - ACN 3869 Well Above 1500 Criteria for Blood Counts Approve Treatment
290403 -
290404 - Follow up ref SDS 97 P560, ref SDS 95 P560.
290405 -
290406 - Millie was surprised that blood counts reported today are very strong,
290407 - per above. ref SDS 97 0N7Q  Experience since 2002 has shown a strong
290408 - correlation between feeling tired, reported today, ref SDS 97 FG3N, and
290409 - having low blood counts.
290411 -  ..
290412 - Formula for ANC, from record on 050128. ref SDS 49 TZ3N
290414 -  ..
290415 - Calculation from 060908 yielded 6390. ref SDS 95 P560
290417 -  ..
290418 - Note that bands are added to neutrophils, but both neutrophils and
290419 - bands have no report today.
290420 -
290421 -                  WBC               =   5.3
290422 -
290423 -                  Neutrophils       =    .73
290424 -                  Bands             =    no report
290426 -             ..
290427 -            ANC = 5.2 x 1000 x .73  = 3869
290429 -  ..
290430 - ANC calculation was submitted by the nurse today.
290431 -
290432 -
290433 -
290434 -
290435 -
290436 -
2905 -

SUBJECTS
CA 15-3 56 Rise from 51 Cancer Marker Current Blood Test Reversing P

3103 -
310401 -  ..
310402 - CA 15-3 56 Rise from 51 Cancer Marker Current Blood Test
310403 -
310404 - Follow up ref SDS 97 2N5J, ref SDS 95 2N5J.
310406 -  ..
310407 - Test today showing CA 15-3 56, ref SDS 0 5K6K, reversed course for the
310408 - first time in several months and increased, compared to the report for
310409 - the test on 060928, received on 060929. ref SDS 97 2N5J
310411 -  ..
310412 - Reflects very slow progress of IBC rash subsiding on the left breast.
310413 -
310414 -
310415 -
310416 -
310417 -
310418 -
310419 -
3105 -

SUBJECTS
Port Connection Prepare for Treatment 1 Try Required Debbie Excellen

3403 -
3404 - 1446
340501 -  ..
340502 - Preparation for Treatment Required One (1) Attempt to Connect Port
340503 -
340504 - Follow up ref SDS 97 EB7J, ref SDS 95 EB7J.
340506 -  ..
340507 - Julie did the administration with Debbie to verify Millie gets the
340508 - correct treatment.
340510 -  ..
340511 - Millie explained having taken Decadron tablets according to the
340512 - prescription to take two tablets twice a day, per instructions on
340513 - 050415. ref SDS 56 8U4O
340515 -  ..
340516 - Decadron was not given by Debbie again before treatment today, because
340517 - Millie took the pills this morning with her meal, as prescribed; and
340518 - Millie will take another treatment of Decadron tomorrow as part of
340519 - chemotherapy treatment with Taxotere today.
340520 -
340521 -        Generic name:  dexamethasone
340522 -
340523 -              http://www.tirgan.com/decadron.htm
340525 -         ..
340526 -        Description and purpose of Decadron is reported in the record
340527 -        on 060721. ref SDS 84 4I4Q
340529 -  ..
340530 - Compazine - Debbie gave Millie a pill prior to treatment.  Millie took
340531 - this with a cup of water; this was after Julie and Debbie did the
340532 - protocol verfication, per above, ref SDS 0 6O5G, which corrected the
340533 - mistake that occurred on 060929. ref SDS 97 NG55
340535 -  ..
340536 - Ativan - was not part of treatment today, previously given on 060721.
340537 - ref SDS 84 FZ5M
340538 -
340539 -        Generic name:  benzodiazepines
340540 -
340541 -        Purpose of Atiman reported on 060721. ref SDS 84 NF6K
340543 -  ..
340544 - Anzemet - was not part of treatment today, previously given on 060908.
340545 - ref SDS 95 O64I  This was reported ineffective on 060929. ref SDS 97
340546 - NR5F
340547 -
340548 -        Generic name:  dolasetron mesylate
340549 -
340550 -               http://www.anzemet.com
340551 -
340552 -
340553 -
340554 -
340556 -  ..
3406 -
3407 -
3408 - 1448
3409 -
340901 - Debbie connected the IV tubes to the port....
340903 -       ..
340904 -      Interlink System Vented Paclitaxel set
340906 -  ..
340907 - This was done without incident, very professional and competent.
340908 -
340909 -
340910 -
3410 -

SUBJECTS
Benadryl Drip Treatment Prepares Patient for Taxotere Chemotherapy A

3703 -
3704 - 1455
370501 -  ..
370502 - Benedryl Reduce Side Effects Taxotere Chemotherapy Treatment
370503 -
370504 - Follow up ref SDS 97 DC7J, ref SDS 95 DC7J.
370505 -
370506 - Benadryl started.
370508 -         ..
370509 -        Purpose reported on 060721. ref SDS 84 DC7J
370510 -
370511 -
370513 -  ..
3706 -
3707 -
3708 - 1502
3709 -
370901 - Benedryl completed.
370902 -
370903 -
370904 -
370905 -
3710 -

SUBJECTS
Taxotere 102 MG Drip Treatment 12th Cycle Taxotere Capecitiabine (Xe

4003 -
4004 - 1503
400501 -  ..
400502 - Taxotere Full Dose Blood Counts on Targets
400503 -
400504 - Follow up ref SDS 97 4N5M, ref SDS 95 4N5M.
400506 -  ..
400507 - Taxotere started - 102 MG.
400509 -  ..
400510 - There was no patient evaulation process today, which fits the
400511 - procedure the first time Millie was treated with Taxotere on 020610,
400512 - ref SDS 6 MR5I; later, on 050415 Kaiser performed patient evaluation
400513 - of side effects for Taxotere treatment. ref SDS 56 4333
400514 -
400515 -
400516 -
400517 -
400519 -  ..
4006 -
4007 -
4008 - 1605
4009 -
400901 - Equipment beeped indicating treatment is over.
400903 -  ..
400904 - Debbie disconnected the IV tubes.
400906 -  ..
400907 - She inserted Herceptin to flush the port.
400909 -  ..
400910 - She then removed the needle from the port, and swabbed the needle
400911 - wound, and placed a temporary bandage.
400912 -
400913 -
400914 -
400915 -
400916 -
4010 -

SUBJECTS
Vitals Blood Pressure Pulse Temperature Taxotere 102 MG Drip Treatme

4303 -
4304 - 1534
430501 -  ..
430502 - Vitals Show Patient Stable
430503 -
430504 - Follow up ref SDS 97 AW4L, ref SDS 95 AW4L.
430505 -
430506 - Debbie took vitals after starting Taxotere drip treatment...
430507 -
430508 -                    Blood
430509 -    Date   Time     Pressure   Pulse  Temprtr  Weight  So2
430511 -     ..
430512 -    061020 1534..... 140  79     67     99.8    151     97
430513 -    060929 1452..... 141  78     66     98.3
430514 -    060908 1335..... 139  79     73     98.1
430515 -    060814 1610..... 139  80     59     98.2
430516 -    060722 1440..... 142  74     67     98.1
430517 -    060711.......... 172  87     54     97.5    147
430518 -    060623.......... 141  87     71     98.0    147
430519 -    060428.......... 129  73     80     99.4    149
430520 -    060217.......... 153  81     61     98.6    150
430521 -    050916.......... 120  80     80     98.5
430522 -
430523 -
430524 -
430525 -
4306 -

SUBJECTS
Pharmacist Orders Capecitabine (Xeloda) 13th Cycle Decadron Review S

AI03 -
AI04 - 1447
AI0501 -  ..
AI0502 - Communication Oncology Coagulation Balance Treatments
AI0503 - Xeloda Coumadin Balance Treatments Collaboration Required
AI0504 - Pharmacist Orders Capecitabine Decadron; Coordinate with Coumadin
AI0505 - Pulmonary Emboli Pharmacist Not Aware Communication Medication Fails
AI0506 -
AI0507 - Follow up ref SDS 97 TZ4I, ref SDS 95 TZ4I.
AI0508 -
AI0509 - Ross visited briefly.  He verified that Millie is taking 1.5 pills of
AI0510 - capecitabine (Xeloda) twice a day.  He will have a prescription ready
AI0511 - for Millie to purchase at the 2nd floor Pharmacy after treatment
AI0512 - today.
AI0514 -  ..
AI0515 - This procedure is slightly different from cycle 12 on 060929.  At that
AI0516 - time, the pharmacist asked Millie to explain the protocol for
AI0517 - capecitabine, and advised that asking the patient to state the dose
AI0518 - for treatment satisfies Kaiser's quality control to verify that the
AI0519 - patient is taking the prescribed amount of treatment. ref SDS 97 WK95
AI0521 -  ..
AI0522 - There was discussion of side effects, per above. ref SDS 0 QU8K
AI0524 -  ..
AI0525 - The pharmacist was unaware that Millie had been diagnosed with
AI0526 - pulmonary emboli on 061002 and is being treated again with Coumadin.
AI0527 - ref SDS 99 MI5I
AI0529 -  ..
AI0530 - Ross said that Millie should notify the Coagulation Treatment Clinic
AI0531 - that she is being treated with capecitabine (Xeloda), because the
AI0532 - amount of Coumadin has to be adjusted.  This requirement was
AI0533 - previously discussed on 060711 with Ross' colleague, Zan; however, at
AI0534 - that time Millie had been removed from treatment with Coumadin.
AI0535 - ref SDS 83 S33L
AI0536 -
AI0537 -        [On 061024 Gloria explained that capecitabine impacts effects
AI0538 -        of treatment with Coumadin, which requires frequent blood
AI0539 -        testing. ref SDS A2 TZ4I
AI0541 -         ..
AI0542 -        [On 061024 case study medical practice computer access limited
AI0543 -        even with everything on the computer, people can't find details
AI0544 -        stored in parts of the computer (software modules) that are not
AI0545 -        frequently used. ref SDS A2 JD9L
AI0547 -  ..
AI0548 - There was discussion that requirements for treatment medication should
AI0549 - be coordinated dirctly by the Pharmacy in Oncology under the doctor's
AI0550 - supervision, with the Coagulation Treatment Clinic, rather than depend
AI0551 - on frailties of patient personal memory to convey details critical for
AI0552 - effective care.
AI0554 -         ..
AI0555 -        [On 061214 treatment mistake pulmonary embolism warfarin
AI0556 -        (Coumadin) conflicts with prescription for Diflucan; blood test
AI0557 -        INR rises 6.4 danger zone for hemoraging; blood clot
AI0558 -        coagulation treatment paused for 3 days; INR update test
AI0559 -        advanced. ref SDS A6 HF4O
AI0561 -         ..
AI0562 -        [On 070201 Millie's INR drops to 1.6 after ending treatments
AI0563 -        with capecitabine on 061201, requires adjusting level of
AI0564 -        Coumadin again. ref SDS A8 6U5J
AI0566 -  ..
AI0567 - Ross said that the Coagulation Treatment Clinic has access to patient
AI0568 - treatment prescriptions on Kaiser's computer system, and so will
AI0569 - likely make the correct adjustments in Coumadin to fit Millie's
AI0570 - prescription for capecitabine.
AI0572 -  ..
AI0573 - There was further discussion, that if Kaiser's computers automatically
AI0574 - notify the Coagulation Treatment Clinic about medications prescribed
AI0575 - by the doctor in Oncology, then why was the patient asked to notify
AI0576 - the Coagulation Treatment Clinic about the doctor prescribing
AI0577 - capecitabine, and why didn't Ross know that Millie is being treated
AI0578 - with Coumadin, since the Oncology Clinic Pharmacy here in Walunt
AI0579 - Creek, has access to the same list of treatments as the Coagulation
AI0580 - Treatment Clinic in Martinez, and further the Oncology Pharmacy staff
AI0581 - is working directly with doctors who prescribe treatments?
AI0582 -
AI0583 -        [...in another record today primary care physician developed
AI0584 -        Kaiser computer system for automatic notification of patient
AI0585 -        medications, ref SDS A1 YQ8J; frustrated because Oncology
AI0586 -        pharmacy and Coagulation Treatment Clinic not aware Millie
AI0587 -        being treated with capecitabine and coumadin. ref SDS A1 M69H
AI0589 -         ..
AI0590 -        [On 061024 Coagulation Treatment Clinic uses software that
AI0591 -        requires accessing another part of Kaiser's computer system to
AI0592 -        coordinate patient treatments; such access requires training,
AI0593 -        and time for performance; therefore direct notice from the
AI0594 -        doctor and support staff in Oncology Pharmacy, as occurred
AI0595 -        today, per below, ref SDS 0 VE57, and also by the patient, as
AI0596 -        encouraged by the pharmacist, per above, ref SDS 0 S69H,
AI0597 -        assists the Coagulation Treatment Clinic in making an accurate
AI0598 -        and effective balance of treatments for pulmonary embolism with
AI0599 -        chemotherapy treatments for cancer using capecitabine (Xeloda)
AI0600 -        in this case. ref SDS A2 TZ4I
AI0602 -  ..
AI0603 - Ross was not comfortable relying on Kaiser's computer for notifying
AI0604 - the Coaguluation Treatment staff to prescribe Coumadin for pulmonary
AI0605 - embolism, and in amounts compatible with concurrent capecitabine
AI0606 - treatments ordered by the Oncology department to treat Millie's
AI0607 - cancer.
AI0608 -
AI0609 -        [On 061020 primary care physician cannot access Kaiser's
AI0610 -        computer for details in the medical chart. ref SDS A1 ET5J
AI0612 -         ..
AI0613 -        [On 061110 doctor's list of current medications incorrect not
AI0614 -        listing Coumadin, and also does not list antibiotics for
AI0615 -        cellulitus, Lovenox, also, for PE, Procrit is not listed for
AI0616 -        anemia (low energy) to redress low blood counts for hemoglobin,
AI0617 -        Tums is not listed for GERD. ref SDS A4 SE86
AI0619 -         ..
AI0620 -        [On 061112 Doctor Seier found patient history on 061027
AI0621 -        prepared by lead ER physician, and this assisted diagnosis and
AI0622 -        treatment for cellulitus relapse on 061112 ref SDS A5 XS5J;
AI0623 -        patient history of other doctors treating Millie for cellulitus
AI0624 -        beginning on 061027 under Kaiser's team care practice was not
AI0625 -        available. ref SDS A5 5L6H
AI0627 -  ..
AI0628 - Ross indicated that complexity of constantly expanding medications
AI0629 - prescribed in varying multi-agent combinations increase mistakes
AI0630 - entering details in the computer system.  Tired, busy people with a
AI0631 - hectic schedule hurry to catch up enter data incorrectly or get
AI0632 - distracted and forget to enter critical details.  Sometimes people
AI0633 - don't have time to check the computer.  These human factors that cause
AI0634 - errors and omissions require checks and balances with feedback for an
AI0635 - audit trail to verify accuracy in treatment prescriptions.  (see
AI0636 - below, Ross corrected errors ordering Milli's Coumadin treatment for
AI0637 - pulmonary embolism. ref SDS 0 VE57)  An example are continuing
AI0638 - failures of analysts to compare imaging tests with prior related work
AI0639 - to demonstrate accurate understanding of trends on emerging problems,
AI0640 - reported on 061012. ref SDS A0 2935  Sometimes small, innocuous
AI0641 - details compound into major problems, reported on 921127. ref SDS 1
AI0642 - 0674  He therefore asked Millie to get feedback from the Coagulation
AI0643 - Treatment Clinic, since balancing Coumadin treatment with capecitabine
AI0644 - (Xeloda) is important for treating cancer and pulmonary, since both
AI0645 - are life threatening.
AI0646 -
AI0647 -        [On 070106 similar problem treating heart attack patient.
AI0648 -        ref SDS A7 RS62
AI0650 -  ..
AI0651 - Ordinarily, treatment prescriptions to relieve life threatening
AI0652 - maladies, reported on 060722, ref SDS 85 BI5J, should be conveyed with
AI0653 - urgency, and feedback loops for the attending physician to verify that
AI0654 - treatments are properly balanced.  Ross explained Kaiser policy that
AI0655 - accuracy balancing medications to prevent harm to the patient is a
AI0656 - responsiblity of the prescribing doctor and pharmacy.
AI0658 -  ..
AI0659 - Challenges applying requirements for feedback and traceability to
AI0660 - original sources for strengthening accuracy are studied in records
AI0661 - on...
AI0662 -
AI0663 -             Pulmonary emboli risks........... 060722, ref SDS 85 6G6O
AI0664 -             Medical practice................. 040416, ref SDS 13 GN7J
AI0665 -             Management standards............. 020504, ref SDS 5 NS6F
AI0667 -         ..
AI0668 -        [On 061024 background on difficulties accessing computers that
AI0669 -        reduce productivity. ref SDS A2 TF45
AI0671 -  ..
AI0672 - Earlier today, Debbie commented that even though nurses now have fewer
AI0673 - patients to treat in the Oncology Infusion Clinic, the work is more
AI0674 - confusing, because nurses spend more time with the computer.  Kaiser
AI0675 - has three (3) different software programs that are overlapping in some
AI0676 - respects.  Nurses have to learn and use all three, including continual
AI0677 - revisions.  Full or optimal use of software program functions to care
AI0678 - for patients is therefore hard to achieve.  Previously, on 020110
AI0679 - statistics presented show that difficulty learning to keep up with
AI0680 - changes to software is a common problem.  For example, most people
AI0681 - only use about 5% of Microsoft features. ref SDS 4 CK4K  An example
AI0682 - occurred on 060711 when the primary care physician explained that a
AI0683 - key part of patient history on status change took over 2 years to find
AI0684 - in Kaiser's software , because Kaiser had failed to provide training
AI0685 - and support. ref SDS 83 RK4L
AI0686 -
AI0687 -        [On 061020 primary care physician cannot access Kaiser's
AI0688 -        computer for details in the medical chart. ref SDS A1 ET5J
AI0690 -  ..
AI0691 - As related above in discussion with Ross, ref SDS 0 TR47, a recent
AI0692 - example of computer access problems is the study on 061012 showing
AI0693 - continuing failure of anlaysts to make correct comparisons with prior
AI0694 - tests for trend analysis to discover emerging problems in time for
AI0695 - effective treatment. ref SDS A0 2935
AI0697 -  ..
AI0698 - Debbie gave an example of delays and fatigue from extra time and
AI0699 - effort because staff are required to cut and paste to transfer data
AI0700 - from one program to another.  It takes a lot of concentration to avoid
AI0701 - mistakes when a nurse must attend to a patient, answer a telephone, or
AI0702 - talk to a nurse or a doctor, then remember the context to resume a
AI0703 - specific sequence of steps to perform after being interruped, 2
AI0704 - minutes, 5 minutes, 20 minutes earlier.  Debbie said this means that
AI0705 - work never settles into a professional practice that allows increasing
AI0706 - skill through experience, because experience is in constant flux.  The
AI0707 - technology people continually make improvements and add new programs,
AI0708 - so nurses spend more time learning to use new computer steps that
AI0709 - reduce time for treating patients.  She feels that is why nurses are
AI0710 - now treating fewer patients than a few years ago.  She prefers working
AI0711 - with the old paper system, and treating more patients.
AI0713 -         ..
AI0714 -        [On 061024 case study medical practice computer access limited
AI0715 -        even with everything on the computer, people can't find details
AI0716 -        stored in parts of the computer (software modules) that are not
AI0717 -        frequently used. ref SDS A2 JD9L
AI0719 -         ..
AI0720 -        [On 061214 treatment mistake pulmonary embolism warfarin
AI0721 -        (Coumadin) conflicts with prescription for Diflucan; blood test
AI0722 -        INR rises 6.4 danger zone for hemoraging; blood clot
AI0723 -        coagulation treatment paused for 3 days; INR update test
AI0724 -        advanced. ref SDS A6 HF4O
AI0726 -  ..
AI0727 - The problem of stable technology for people to learn and also learn to
AI0728 - deploy productively into a highly skilled professional practice was
AI0729 - discussed with Doug Engelbart at SRI on 000327. ref SDS 3 4420
AI0731 -  ..
AI0732 - Debbie also said that Kaiser is getting 200 new Oncology patients a
AI0733 - month in the Walnut Creek hospital.
AI0734 -
AI0735 -     [On 061110 Contra Costa county has the highest cancer rate in the
AI0736 -     country. ref SDS A3 KE93
AI0737 -
AI0738 -
AI0739 -
AI0740 -
AI0741 -
AI0743 -  ..
AI08 -
AI09 -
AI10 - 1543
AI11 -
AI1101 - Stopped and visited with Ross breifly in his office near the entrance
AI1102 - to the Infusion Clinic.
AI1104 -  ..
AI1105 - Mentioned that Millie appreciates Ross's work, and that questions do
AI1106 - not reflect lack of confidence, but support the work with feedback, as
AI1107 - called out in Kaiser's Healthwise Handbook, reviewed on 990625.
AI1108 - ref SDS 2 3960
AI1110 -  ..
AI1111 - Ross said that collaboration with the patient was helpful feedback,
AI1112 - called out in Kaiser's Healthwise handbook.
AI1114 -  ..
AI1115 - After talking to Millie in the Infusion Clinic, per above, ref SDS 0
AI1116 - T650, he called the Coagulation Treatment Clinic in Martinez, and
AI1117 - reported that Millie is being treated with capecitabine (Xeloda).  He
AI1118 - was told that capecitabine (Xeloda) would be added to Kaiser's
AI1119 - computer program for the Coagulation Treatment Clinic, and that
AI1120 - Millie's Coumadin treatments would be adjusted accordingly.
AI1121 -
AI1122 -     [On 061020 meeting with primary care physician discussed roles and
AI1123 -     responsibilities to verify that treatment prescribed by the
AI1124 -     primary care physician is implemented; doctor frustrated that
AI1125 -     computer system implemented 10 years ago to automtically notify
AI1126 -     everyone in a common data base of patient medications requires
AI1127 -     oversight and feedback loops for verification. ref SDS A1 M69H
AI1129 -      ..
AI1130 -     [On 061024 called Coagulation Treatment Clinic, and Gloria
AI1131 -     confirmed that Millie's chart has been posted to show she is being
AI1132 -     treated with capecitabine (Xeloda). ref SDS A2 TE60
AI1134 -      ..
AI1135 -     [On 061024 case study medical practice computer access limited
AI1136 -     even with everything on the computer, people can't find details
AI1137 -     stored in parts of the computer (software modules) that are not
AI1138 -     frequently used. ref SDS A2 JD9L
AI1140 -  ..
AI1141 - Previously, on 050415 Zan, who also works in the pharmacy, avoided a
AI1142 - treatment mistake by collaboration with the patient and the doctor to
AI1143 - change the prescription and order the correct treatment. ref SDS 56
AI1144 - KX49
AI1145 -
AI1146 -
AI1147 -
AI1148 -
AI1149 -
AI1150 -
AI1151 -
AI1152 -
AI12 -

SUBJECTS
Energy Normal Stable Alert Drive Home After Treatment IBC 3rd Relaps

AM03 -
AM04 - 1733
AM0501 -  ..
AM0502 - Energy Normal Stable After Treatment Taxotere Support Drugs
AM0503 -
AM0504 - Follow up ref SDS 97 F54N, ref SDS 95 F54N.
AM0505 -
AM0506 - Millie was alert after treatment today, and not wobbly nor
AM0507 - disoriented.
AM0509 -  ..
AM0510 - On 060724 diary side effects for 2nd phase taking Taxotere and
AM0511 - capecitabine (Xeloda). ref SDS 86 QX8K
AM0512 -
AM0513 -
AM0514 -
AM0515 -
AM0516 -
AM0517 -
AM0518 -
AM06 -