Saturday, November 9, 2019
NEW AMSTERDAM Television Drama
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 unsuspecting……………………….
Saturday, October 19, 2019
It's Not About Blame
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!
Saturday, August 17, 2019
From Boardroom to Bedside
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 the answers.
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 of.
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 make change.
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………….
In all fairness, the comments by the hospital are on their Facebook Page https://www.facebook.com/MemorialHermann/photos/a.161161947712/10157102790052713/?type=3&theater
Friday, August 16, 2019
Letter Sent to Another Doctor's Office
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.
Pulse 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.
- Medical errors are the third leading cause of death in the United States
- 80,000 to 160,000 people are harmed due to misdiagnosis each year with 40,000 to 80,000 deaths each year caused by misdiagnosis
Thank you for your prompt attention to this matter.
Sunday, August 4, 2019
The Meaning of Consent
I was recently at the hospital with a patient who was getting a complex surgery. The patient didn't seem to understand what was going to happen during or after surgery. Just before the surgery we saw the surgeon who was going to explain the procedure. The surgeon had the consent form on a clipboard ready for signing.
I offered to read the consent with or for the patient after the doctor explained the procedure. The doctor did the explanation, handed the patient the forms and the patient signed without reading.
The AMA says:
The process of informed consent occurs when communication between a patient and physician results in the patient’s authorization or agreement to undergo a specific medical intervention.
To enable patients to participate meaningfully in decisions about health care, physicians have a responsibility to provide information and help patients understand their medical condition and options for treatment.
No where does it say that the patient who signs, actually understands the procedure or surgery only that they are authorizing the procedure /surgery.
So, does the consent mean that the patient understands the procedure and risks? Maybe it means that to the clinician, To the patient it may mean only that they are giving permission.