Recalling the series of medical errors that contributed to death

Mar 15, 2019

Over six weeks in the summer of 2009, Alice Brennan went from an 88-year-old woman planning her 70th high school reunion to being dead. Her daughter spoke Thursday to a mixed student group of medical, pharmacy, physician assistant and physical therapy students at the University at Buffalo about what happened.

"I am the daughter of a woman who died from profound medical error in a very dysfunctional medical system. It can happen anywhere and it does."

Mary Brennan-Taylor holds a photo of her late mother.
Credit University at Buffalo

Almost from the time Brennan died, daughter Mary Brennan-Taylor has been spreading the word of what can go wrong. UB's medical school has had her in to speak for years and Thursday's group included an array of UB and D'Youville students for her sad story.

Then, the students broke into groups to talk about what they had heard and what they learned from a story of serial bad decisions. The speaker didn't identify the hospital or the nursing home where her mother was a patient, saying it is too common a problem. Brennan-Taylor said it is important for the students to learn about the needs of our elderly.

"Being able to understand the dangers of medication, especially in an elderly population, and the damage that can be done by inappropriate medication and really being on guard to make sure that ageism is not something that enters into their realm of practice," she said.

As she unfolded the story in a Jacobs Medical School auditorium, Brennan-Taylor made clear all branches of health care were involved in what happened to her mom, infected with some of the worst ailments like MRSA and being given 26 different medications.

UB pharmacy student Matthew Poremba said that is not supposed to happen.

"Pretty much more than anybody I know or have ever met in real life should be on, and I see it happen a lot where people just keep getting treated for adverse events from things they were placed on," Poremba said. "I know they talked about the Flexeril early on, which can cause a lot of anticholinergic side effects and that alone can wind up putting you on three or four more meds which have side effects that cause you to be on more meds, right?"

As Brennan-Taylor explained, there was a time when the situation might have been turned around, but wasn't. Dr. Ranjit Singh, co-director of the university's Patient Safety Research Center and a specialist in geriatrics, said it is harder for med students to grapple with the issues in cases like this.

"They're told that you're the captain of the ship. You're supposed to know everything. You're supposed to take charge of everything," said Singh. "So we try to catch them at an early age and we try to help them understand they are part of a team, and that if there is a captain of the ship it should be the patient, and that as medical students or physicians they bring a certain set of skills, and that pharmacists bring a specific and different set of skills and nurses bring a specific and different set of skills."

Third-year med student Alex Alfiero said it is a lesson to the students in their careers.

"Realize that people make mistakes and that's why it's important," he said. "One of the things that we're looking at is alerts on EMRs and flagging things, like certain medications that shouldn't be given to certain age groups or populations, especially that to help with physicians who maybe had to work an overnight shift or haven't had a vacation or a day off."

"It's a good way to apply what we're learning in school because we came with other professionals," said  D'Youville PA student Madeline Robinson. "We talk about all the time our role in preventing polypharmacy and preventing transfer of care problems and infectious disease problems, and getting everybody else to give insights on their role and then seeing where the loopholes were that it didn't get carried out the way it should be."