Joyce Oyler (left) died because of medication mistakes by a Missouri pharmacy and home health agency. Her daughter, holding the photo of her mother and aunt, says the error "should have been caught about five different ways." (Travis Young/Austin Walsh Studio for KHN)

Within two weeks of Joyce Oyler’s discharge from the hospital, sores developed in her mouth and throat, and blood began seeping from her nose and bowels.

Her daughter traced the source of these problems to the medicine bottles in Oyler’s home in St. Joseph, Mo. One drug that keeps heart patients such as Oyler from retaining fluids was missing. In its place was a toxic drug with a similar name but a 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.

Between January 2010 and July 2015, the analysis found, inspectors identified 3,016 home health agencies — nearly a quarter of all those examined by Medicare — that had inadequately reviewed or tracked medications for new patients. In some cases, nurses failed to realize that patients were taking potentially dangerous combinations of drugs, risking abnormal heart rhythms, bleeding, kidney damage and seizures.

The variety of providers that patients may use after a hospitalization creates fertile ground for error, said Don Goldmann, chief medical and science officer at the nonprofit Institute for Healthcare Improvement. “This episodic care at different places at different times is not designed to keep the overall safety of the patient in mind,” Goldmann said.

One factor is the lack of organization and communication among these other parts of the medical system. Of the $30 billion that Congress appropriated to help shift the system to electronic medical records — to ensure better coordination of care and reduce errors across the board — none went to nursing homes, rehabilitation facilities or providers working with individuals in their homes.

“The systems are not adequately connected,” said Robert Wachter, a professor at the University of California at San Francisco who studies patient safety.

At any point, problems can occur.

At hospitals, federal data show that fewer than half of patients say they’re confident that they understand the instructions of how to care for themselves after discharge.

In nursing homes, case management frequently comes up short. A 2013 government report found more than a third of facilities did not properly assess patients’ needs, devise a plan for their care and then follow through on that.

And at home health agencies, failures to create and execute a care plan are the most common issues government inspectors identify, followed by deficient medication review, according to KHN’s analysis. Over the first half of this decade, 1,591 agencies — 1 in 8 — had a defect inspectors considered so substantial that it warranted the agencies’ removal from the Medicare program unless the lapses were remedied.

‘Devastating’ cancer drug

Oyler’s death in October 2013 shows how a fatal mistake can slip past multiple checkpoints. The 66-year-old retired safety manager left Heartland Regional Medical Center in St. Joseph after being treated for congestive heart failure, in which the heart fails to pump effectively, causing fluid buildup in the lungs, shortness of breath and swelling in the feet. She returned home as a hospital nurse telephoned the local Hy-Vee Pharmacy with eight new prescriptions. One was for the diuretic metolazone.

But the medications a pharmacy technician wrote down did not include metolazone. Instead, it listed methotrexate, which can damage blood cell counts, organs and the lining of the mouth, stomach and intestines. The drug is so potent that the Institute for Safe Medication Practices includes it among eight “high-alert” medications with consequences so “devastating” that they warrant special safeguards against incorrect dispensing.

Oyler’s prescription included daily-dosage instructions for the diuretic. Methotrexate is never supposed to be taken more than once or twice a week for patients not being treated for cancer, and almost always at a much lower dose.


Kristin Sigg discovered her mother had been given a highly toxic cancer drug, not a heart medicine, after her hospitalization. Joyce Oyler died less than three weeks later. (Travis Young/Austin Walsh Studio for KHN)

In a court deposition taken as part of the lawsuit the family brought, Hy-Vee’s pharmacist blamed himself for not catching the error. “For whatever reason, on that certain day, that didn’t trigger with me,” he testified. Hy-Vee argued that its safeguards were as strong as those at other pharmacies, although the pharmacy manager admitted in a deposition that “quite honestly, there was a breakdown in the system.”

The family’s attorney, Leland Dempsey, said court evidence suggested the drug mix-up was made by the pharmacy technician who took the prescription orders. “The pharmacy tech made numerous spelling errors on the drugs,” he said. “She had a dosage off on another drug.”

In February, a jury awarded Oyler’s family $2 million in damages from the pharmacy. The judge lowered the award to $125,000 because of Missouri’s cap for noneconomic damages in medical malpractice cases. Hy-Vee declined to comment.

Nurses overlook prescription mistake

Yet the error could have been snagged right as Oyler began getting care from Heartland’s home health care agency. Medicare requires home health agencies to examine details of a patient’s medications to ensure all the drugs match the prescriptions ordered, are being taken in the right dose and frequency, and don’t have negative interactions.

Still, neither of two Heartland nurses who visited Oyler at home stopped her from taking the wrong drug. Less than a year before, Missouri state inspectors had cited the agency for inadequately reviewing medications for three patients. State records show it had pledged to make improvements.

“Why they didn’t catch it was beyond me,” Oyler’s husband, Carl, said recently. “They had a printout from the hospital” with every medication correctly listed. “It was all there,” he said.

After 18 days, her family took her to North Kansas City Hospital, where doctors determined that the methotrexate had irreparably damaged her bone marrow’s ability to create blood cells. She died three days later of multiple organ failure.

“By the time we got her into the emergency room, essentially she had no blood cell count,” her husband recounted. “It was irreversible. It was a gruesome, slow, painful way to die.”

Heartland Regional Medical Center paid Oyler’s family $225,000 in a settlement last year, court records show. Mosaic Life Care, the name by which Heartland now operates, said in a statement that it is “consistently improving processes and adopting new technologies to further reduce risks of errors and to improve communication.”

“Most people don’t know this is a problem,” Sigg said. “They assume doctors are talking to each other, until they experience it, and it’s not the case.”

— Kaiser Health News

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.