A recent study reports that medical errors are now the 3rd leading cause of death in the US. These statistics can change if the patient, and their family know what to do to help avoid medical injury.
This blog represents my experiences and my opinion only - often at the bedside. All posts are short enough for easy reading - therefore I couldn't possibly share all there is to share. Thank you for visiting.
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World AIDS Day: and What I have Learned by Being with People
Who Have HIV/AIDS
A few years ago, I did a Pulse PACC (Patient Activation through
Community Conversations) with a group of thirteen participants all living with
HIV /AIDS.They chose topics that are
important to them about receiving medical care so they can share their
experience with others, learn what has worked for others, and learn ways to be
an active participant in their own medical care.There is no advice given.Participants are permitted to only share what
has already worked for them so no one hears the words “you should”.
One of the questions that was popular and checked off on
the list was: Do you have a healthcare proxy and how did you choose that
When I read off the question (all questions are anonymous
so no one knows who wants to talk about what) no one spoke.I told them that five people wrote that this
was important.Finally, one young woman
spoke.“How can we choose someone to
make decisions for us if we don’t want anyone to know we have this disease?”
Her question stunned me.Something I never thought about.Others shared their similar thoughts and concerns out loud and the conversation became how
other chose someone as a support person or to be listed on their proxy form. Some even offered to be that person for the one’s
who had no one.The discussion then
became what the healthcare proxy form is. I handed some forms out and learned a
lot that day.
AIDS, in my generation is still a scary topic.I remember when people died from HIV /AIDS,
now they live with it.Still, many
people feel that they wear a sign on them that says that they are promiscuous,
gay or a drug abuser.We know now that
none of that may be true – but even if it is, doesn’t everyone deserve safe care?And, if we want safe care, we must be honest about
our health and habits to the medical team without fear of being judged.
According to the World Health Organization almost 38
million people are living with HIV/AIDS worldwide.In 2018, 770,000 people died from HIV-related
illness which is over 50% fewer who died in 2004.Talking about the disease, as any disease
must be part of treating a patient safely.Being honest and open about your health and healthcare must take
priority.People need to seek medical
attention from clinicians who do not show a bias and have experience with the
care you need.If fear or embarrassment
is an issue, people should bring a support person who could help a them feel in
control and get the care needed.The
support person should know what the patient’s fears and concerns may be so the
support person can be prepared to help address them.And, if you know someone who may be nervous
about seeing a clinician because they have HIV/ AIDS, offer to go with them to
their doctor’s appointments.Having a “team”
with them could help.
For the first time I watched New Amsterdam and was shocked
at the content.
The title of this episode ‘Good Soldiers” was not the part
that I watched that made me a fast fan.It was the interwoven story line of a woman who had a “botched” surgery
a number of years ago by a surgeon who was “protected” by his peers.The surgeon continued working moving from
hospital to hospital leaving a trail of medical injuries. In this case, the woman has spent years in a
wheelchair while the surgeon continued doing surgery often injuring other
patients.When Dr. Max GoodwIn, the
Medical Director played by Ryan Eggold found out about this surgical screw up
that happened years earlier, he started asking questions and found that there
were cover ups.Approaching the Dean of
the medical school, Dr.
Goodwin learned that the dean knew how bad things were
but continued the cover up with his peers to “protect their own”.
Dr. Goodwin suggested the patient may start a lawsuit and
thought it would be a good opportunity to change policy to become transparent and
be honest with the patients.Instead, a
check was written to satisfy the woman.
There are many real-life aspects top this.
The cover ups:It
must be hard for a new person in the medical field to expect to be a
whistleblower early in their career.Who
could they possibly trust to report what could -and maybe should be seen as a
crime?Injure or kill someone and cover
it up is giving people in healthcare a license to kill.I have heard this is not uncommon.I too would have to wonder how do you go to
someone with what may be half the facts and report something so horrible about
someone who probably brings in millions of dollars a year to the hospital?
The check:Should the
hospital have written a check and stopped this whole story from getting
out?Should the woman have accepted a
check to be quiet?In a lawsuit people
often sign what we call “gag orders” discouraging the injured party to not
speak of the incident or the amount of the settlement.When they sign, some people feel that they shouldn’t
and are allowing the behavior to continue.This may be true but why shouldn’t a person who wants to move on take
the money and do that?Some people want
to fight it and will get less money.It
is a personal preference.Unfortunately we
rarely hear the whole story or all sides. Injury = money it’s not that simple.
So what happens when the woman takes the money and the
doors get closed?Is there retraining
for staff?Are all patients who used the
doctor leaving a trail behind him of dead and injured called out on his/ her
behavior?What does a patient or family
do to be sure “This doesn’t happen again” like so many people say they want?
Why doesn’t the media cover every story so others can feel
safe?When there is a train crash or a
plane crash it makes the news, an investigation, every detail shared.When medical errors kill people or injure the
I went with some friends and colleagues from Pulse Centerfor Patient Safety Education & Advocacy yesterday to meet with a
businessman to talk about our brilliant ideas to improve patient safety.After all, this is a public safety issue. Patient safety and medical errors is not only
focusing inside the hospitals, nursing homes and doctor’s office.Patient safety starts long before a person
becomes a patient.We are people.No matter our color, age, gender, bank account,
career choice, path we have taken in life or education – we are all people.
It was interesting when this businessman
realized we were not there to complain about the system.He was ready for an argument – blame.“No” we told him, “blame, accountability,
anger and punishment all come after the fact.”We are not there to blame or hold anyone accountable.This is not what we do. Our goal is to keep people from getting
injured or worse.Accountability, apology, disclosure all mean someone has been hurt and
we have not done our job.As a community
based organization, we can’t expect to improve if we continue leaving it up to one
side of the aisle to fix this 20 year discussion of medical errors.
The public must be better involved. At Pulse CPSEA we can help make that happen!
We often hear from the owner or the person running a
business how their staff behave.“We
don’t allow that behavior here” someone may say to an irate customer.
It’s not unusual for that statement to be shared to
patients or their families who are not pleased with the care they are
receiving.Years ago, when I worked with
people who were living with various physical disabilities as a patient
advocate, someone in leadership at a hospital said to me, as well as the group he
was presenting to, that nurses and nursing assistants take extra care of people
who have disabilities.They take extra
time and address any special needs they might have at his hospital.
“So”, I asked him, “do you have extra staff to help these
nurses or are they just told to work harder?”His look was the answer I expected.
I was there because of the problems people with
disabilities were having in their medical treatment and he was supposed to have
Another time, a hospital director explained that “we rarely,
if ever see people who are transgender so we don’t need to address that here”. (See
March 2015)After my presentation which was touching on
bias and disparities, I was asked by an employee “how do we address people who
are transgender?”When I asked why that
was important to him, I learned he was in charge of the transport team and they
see many people who they believe are transgender mostly in the emergency
room.Something leadership was not aware
I have heard what a hospital's policy is for handwashing
and then watch how many staff do not wash.By reporting this, at times, I have received thoughtful responses from the
leadership, or the doctor themselves who I challenged. This is how, I believe we, as patients can
Hospital leadership (and I am careful to use the term
leadership because a hospital or healthcare facility is usually made of
brick.The leadership is made up of humans
and decision makers with their own feelings and needs) the human beings who are
in charge of the healthcare system, often do not know what is happening at the
bedside.Many times, I have asked them
to “take off your tie and go sit with a patient to see for yourself the
comments and care your staff – good or bad – use in treating patients.”
I know when I worked at my last customer service job
customers would speak to me about how lousy service was at times. The
management didn’t know because we were addressing the unhappy customers for
them with apologies - so improvements couldn’t be made because they didn’t know
where the problems were.
Then I get a look at this video that has come out and
wonder how long this PA has worked in this hospital.How many complaints were mishandled and how
many people have been injured or hurt?Should they go back to any patient he has ever treated as they would if
it was a disease that could be spread through dirty needles of unclean
equipment?Maybe all his patients who he
ever treated should get a letter that reads “Dear patient, we found a parasite
in our hospital and want to prevent this from spreading further”.
I only ask that though the majority of healthcare workers
are kind, considerate and qualified, the expression “no one wakes up in the
morning wanting to harm their patients” is never used again. There are good and
bad people in every job, every color, every religion, every gender………….
Opportunities for improvement can come when we address them. Please address them!
On August 8, 2019 I was contacted by a person who used your services
because of a swollen pinky.An x-ray was
taken and the patient was told that the next finger over (the ring finger) was fractured
and an infection had developed.This
patient was prescribed antibiotics and it was suggested they see an orthopedist
specializing in hands because of the fracture, which they did.
As it turns out, the patient did not have a fractured finger
(the x-ray was read incorrectly). The patient had gout, which needed
medication, not an antibiotic.
CPSEA is a patient safety organization dedicated to raising awareness about
patient safety through advocacy, education, and support.
The following information may be helpful to
share among your staff.
errors are the third leading cause of death in the United States
to 160,000 people are harmed due to misdiagnosis each year with 40,000 to 80,000 deaths each year caused by misdiagnosis
Additional patient safety
statistics, with references can be found at www.oneisanumber.org.
This letter and information are being sent to you in the hope that they
may be used to improve knowledge and understanding as well as quality of care
and patient safety in your office.I
trust you will take my comments in the positive spirit with which they are
offered. No official report will be filed at this time but I would appreciate a
response indicating how this information was shared, and the steps taken to
correct the concerns raised, so I can inform the person who contacted our
office that it is, in fact, being addressed.
you for your prompt attention to this matter.