My husband, Roger, was admitted to a South Carolina hospital with pneumonia and an embolism. He began to improve and after a week in the hospital we were told he was ready for discharge.

Then the hospitalist shared with us that Roger had gotten too much blood thinner and said he was stopping his Lovenox shots immediately. But before he entered this important change into the medical record, a nurse came into the room with an injection.  We told her the doctor had stopped injections and instead of checking with him, she proceeded to give another overdose, stating, “This will be the last one.”  She was correct. It was the last one and it nearly cost my husband’s life.

Later that evening, Roger complained of side pain. The nurse did not come to the room but told her aide by phone that it was gas. When he complained later that the pain had gone to the other side, I heard her tell the aide on the phone to say the gas had moved to the other side. To make a diagnosis with second-hand information over the phone to an aide is not acceptable.

When we finally did see the nurse, we asked about pain medication.  She said he could have either Tylenol or morphine.  We both said out loud, “No morphine!” A few hours later she came into the room and gave him a shot.  When I asked what it was she said, “Morphine,” and added, “That’s how we do things around here.” If the nurse had checked, she would have seen that Roger had severe bruising across his entire stomach and sides, a telltale sign of internal bleeding, especially with pain present. She did not check with or report his condition to the attending physician.

Roger was in a stupor for about 15 hours bleeding to death with no rescue in sight.  The physical therapy team tried to get him on his feet the next afternoon and both times he collapsed backward onto the bed with eyes rolling. They also did not call the attending physician. As I watched his blood pressure plummet downward to a critically dangerous level, I finally screamed to get a doctor.  The doctor came in and immediately rushed him to the critical care unit.

In critical care, they found every organ in his body had failed. The physicians were lined up outside his room with specialties in liver, kidney, heart, lung, etc. They worked extremely hard to save his life. While there he bloated up and had to have his wedding ring cut from his finger. He endured so much pain and suffering among other things with veins collapsing and had to have surgery to put an IV in his neck.

My question is: How does a patient go from pending discharge to every organ in his body shutting down? There is a clear explanation. Roger was the victim of one of the most common causes of death/near death experiences in hospitals across the nation, namely blood thinner overdose and “failure to rescue.” This could have been prevented if the people assigned to care for him had paid attention to their patient.

My husband left the hospital a broken man. He had been an active, robust man working 50-70 hours a week at a power plant and walking around the plant and staircases on a regular basis. When he entered critical care they could no longer hold his job for him. He was our breadwinner and it broke his heart and spirit that he could no longer provide for us.

Roger only lived another year. The assault on his body ultimately proved to be too much. The world has lost a fine man.  We missed our 50^th wedding anniversary last June and he will not be here for the birth of his grandson. Roger deserved better. He should still be with us.