I knew that my patients were once without mental illness, just like my little sister Doris had been before her diagnosis 10 years before, and I always tried to picture them like that, each their own best version of themselves.

A sister’s preventable death.

In this month’s Reflections column, “No Room for Error: Reflections on My Sister,” family nurse practitioner Kelly Vaez shares the story of the unexpected death of her sister, who had been diagnosed with schizophrenia ten years earlier. It’s particularly heart-wrenching to be able to see clearly, in retrospect, the ways in which our rushed, fragmented, and mental-health-unfriendly health care system contributed to what was probably an easily preventable death.

A dentist prescribed an unusually long course of antibiotics after a routine tooth extraction. The primary care team seemed unaware of the antibiotic therapy. No one made the connection between Doris’ diarrhea and this antibiotic, a frequent cause of C.diff infection.

And finally, loperamide—a drug that should never, ever be given for diarrhea that might be caused by C. diff—was prescribed with what seems to have been minimal assessment for the cause of the diarrhea. Was this last because the patient was a young adult with schizophrenia, and […]