Tuesday, January 8, 2019

Accountable or Responsible: Who is Monitoring the Medication?

Medication Safety and Management

I attended a presentation today by a hospital pharmacist.  Most of the people in the audience of about 50 professionals were representing nursing homes, home care agencies and people who work with older adults.  The presentation was very informative about understanding some of the complications and interactions that older adults experience with their medications.

The audience questions and comments focused primarily on who is responsible for monitoring the medication and reviewing medication.  The “responsibility” seemed to fall on the pharmacist or nurses in the nursing homes, rehabs, assisted living etc. Then the question about the home care agency in the patient’s home – who is checking on the medications?

The Food and DrugAdministration estimates that 1.3 million people are injured by medication errors annually in the U.S. 

With numbers this high, there needs to be some responsibility of the patient and their family in this discussion.  When I brought up that this presentation should be offered to the public, others seemed confused.  When things go wrong, the public has no clue of the complexities in medication management or other areas of medical care.  We only know that if something goes wrong, someone will be held accountable.  These silos have to stop and the public must be more involved in not just their health, but their healthcare and that means opportunities to hear a pharmacist present on medication safety and management.

Saturday, December 1, 2018

A Nurse's Error at Vanderbilt Kills a Patient: My Perspective

Nurses Error Kills a Patient at Vanderbilt

In this article about a nurse who killed a patient because she gave the patient the wrong medication silently explains how such a terrible mistake could happen.  So many people who work in healthcare know how these mistakes happen, and happen, and happen.  No one asked my opinion so here it is:

And now what?  

If we look at the ‘airline industry” as so many people in patient safety do, because in 2001 one person came onto a plane with an explosive devise in his shoe, we, as travelers have been taking our shoes off before boarding a plane – because of ONE incident where NO one died.  How about all the support the patient’s family would receive if the patient died from cancer, heart disease or even a fall. 

What are people saying to the family now?  Probably expecting a lawsuit, a fight, punishment or accountability.  If it were an auto accident there would be insurance so the patient’s family could get compensation and they could move on – no less sad or angry but at least compensated.

In medical care there are so many reasons for these errors to happen and if you are someone who works in the industry you obviously see this.  Yet, as a patient or family member we don’t see how this could happen because no one is explaining this to the public.  So, how can the public possibly be sympathetic to an overworked, underpaid and probably very caring healthcare professional?

My work in patient safety started because of the death of my son but what I learned is that there are so many obstacles to safe care.  If we all, healthcare professionals, patients and the public were all part of the conversation – changes could finally be made.  Writing about this on Facebook – where I found this story - is not enough – there is too much to do and pumping resources into hospitals to keep doing things the same way did not help this patient who died and surely didn’t help this nurse who made the mistake.    

Join us and learn more at https://pulsecenterforpatientsafety.org/

Read the article here

Wednesday, October 17, 2018

Fire Prevention Week

What We Can Learn From Fire Prevention Week

It was Fire Prevention Week.  Did you notice all the school fire drills?  Everyone left the building, moved away and waited for direction. 

I happened to be in a class in NY City teaching high school kids about patient advocacy / safety when the alarm sounded.  First there was an announcement to be prepared for the alarms and everyone must use the stairs to leave the building.  (I was not thrilled to be on the 3rd floor).  The children, teachers and administration all followed in order and walked to the other side of the street.  Everyone was quiet and behaved.  When some of the teachers gave the signal, hundreds of people walked back into the school and to their classes.

It makes me wonder again why everyone is involved in so many safety issues except patient safety.

Imagine if an announcement came over the loudspeakers at noon in the hospital. 

“Patients please make sure all staff are washing their hands.  Patients make sure you know what medications you are being given and that includes the IV bag as well as the pills in the cups with no labels (that are supposed to be labeled). Hospital staff, be sure the patient’s tray tables are within reach and you are not disrupted when getting your patients medication.”

Nah, will never happen – besides patients need to rest……….

Saturday, September 29, 2018

Sexual Assaults and Medical Care

Sexual Assaults Involve Medical Practice Too

If you are being examined by your doctor and something doesn’t seem “right” it may not be. The arrest and conviction of Michigan State University and USA Gymnastics team physician Larry Nassar earlier this year, reminded me why I started talking to young people in high school and middle schools about being an involved and informed patient. In 2006 I was talking to a group of high schoolers about patient safety and speaking to their doctors when two sisters called their doctor “creepy.” That was a surprising term and it set off my antenna. I invited a gynecologist and then a pediatrician to talk to the children and their parents about appropriate exams. Even as adults we rarely have any reason to speak about what our exams are like and don’t know what similarities — or differences — are happening behind that closed door.

Over the years women have mentioned that they thought they might be getting what they felt were inappropriate exams. Often unsure whether they were imagining it or what to do about it, they never shared this secret until Pulse came along. I visited a police station and asked what the procedure would be if a woman claims to be assaulted or inappropriately touched by her doctor. The policeman behind the desk said that if it were a licensed physician, the accuser would need to go to the state department of health and licensing board to file a complaint.

Now fast forward ten years and there is the #Metoo Movement, the Olympic gymnasts’ case, the sex abuse and assaults by movie and television celebrities such as Bill Cosby and Harvey Weinstein. Politicians and high-ranking officials are making the news and priests are being accused and convicted of sex abuse from years ago to the present.

With all this happening around us, why couldn’t clinicians — for whom we are expected to undress and expose our bodies — also be part of this abuse and scandal? When we see a clinician, we are already feeling vulnerable because we may be hurting or injured, not feeling well, wanting to get better, and trusting that whatever is happening is appropriate. Especially because we willingly removed our clothing and subjected ourselves to an exam, how could a woman now “complain” about being touched inappropriately?

I am no stranger to the feeling of an “assault” by a doctor. I knew on two different occasions by two different doctors that what they were doing was not appropriate. When I left the exam room I knew I would never go back and that was the end of it. Or was it?

I have been impacted by this behavior and it helped me form my work today as a patient advocate. I understand why people come forward many years later. Although I don’t personally feel compelled to share the names of those who took advantage of me, I understand the rights of others to do so.

Although I would not share those doctors’ names, I would be devastated to see them put in a leadership position anywhere. I am confident that there are more “victims” out there who would rather just forget about their experiences as I did and as so many women do. We need to talk about what an exam is like and what to expect. We need to be unashamed to share an uncomfortable experience. We need to be able to encourage and support filing a complaint and getting or sending someone for support or counseling. Even if the people I have heard from don’t go back in time and relive what happened many years ago, we can use this as a platform to move forward and make it safer for other girls and women. By talking about this and forming a coalition of groups in support of those who have been assaulted by clinicians 30 or 40 years ago, we can make it safe for women today to say, “It happened to me last week” . . . . because we believe you.
Learn more here: http://doctors.ajc.com/

Tuesday, July 31, 2018

Dependency Based on Better Communication

Opioid Dependency and Addiction Could End with Better Communication

Would you be surprised if someone you know didn’t know what LGBT stood for?  Lesbian, Gay, Bisexual, Transgender may be common terms used – when you are speaking about someone’s sexual orientation and / or gender.  But what if that subject never came up for someone?  I was surprised too recently to find out someone wasn’t sure what the term meant.

The word “mortality” rate also means the death rate.  A cardiologist is a doctor who specializes in the heart and pulmonology is a specialty of the lungs.

New York Mayor Rudy Giuliani thought he was free from cancer when his doctor told him his tests came out positive – mixing up the word positive to mean a good thing.

When we label this information as health literacy we are putting the responsibility completely on the patient to understand what is being said to them.  If they don’t know – that they don’t know – than how can someone possibly know what to ask?

Patients who are being discharged from the 
hospital or ambulatory setting are given pain
medication and told to take it as needed every XXX hours, up to XXX times a day (you can fill in the blanks). They leave with a medication that if they know they could become addicted or dependent, might choose not to take it at all and may decide on some other medication.

Now, think of all the ads and news about the opioid epidemic and I wonder how many people think that might not include them?

A commercial shows a man who tries his mother’s medication called Vicodin and becomes addicted.  He uses the name of the medication in the commercial and now that he is addicted, he is shown slamming his arm in a door to break it so he can get more.  The announcer uses the word opioid.  “Opioid dependence can happen after just five days”.  Why aren’t they using the name of the medication?  “Opioid dependence such as Vicodin and other pain medications can happen after just five days”.  Maybe we need to start putting these words together at discharge, at the pharmacy and in commercials to be sure that all people know that opioids is the type of medication – not the name of a medication.