Thursday, August 24, 2017

System Errors or Human Errors

When Errors Happen is it The System?

When I am hired by a hospital or medical facility to speak to the staff about patient safety, my first thought is that this is a facility that cares about safety and patients.  Since my work is primarily about patients and their safety, it must mean they are serious.  Why else would I be there?

Still, there is never a guarantee.  I spoke a few years ago and a hospital.  Once for senior leadership and then for the “hands-on” patient staff.  A double presentation because they are “that serious” I thought to myself.  Unfortunately there is no guarantee no matter how hard they try, that patients will be safe.  I just read an article about that hospital and a patient who died because of the care he received.  Although there may be many others, this one made the news.  I truly believed that this hospital, in another state, was serious about patient safety and though I believe the people I was involved with there were serious, there are so many opportunities for errors to happen.

Most people in healthcare call the errors or unplanned deaths “system errors” not enough staff, distraction by a nurse or pharmacist or any number of reasons a mistake can happen.  In this case, as in many cases, this hospital’s system, in my opinion was working.  Instead someone may have cut corners or not went to leadership about the problems that ultimately caused this patient’s death.

When a family members calls to talk about a bad outcome at a local hospital, I suggest they speak to the hospital leadership.  The people who are running the facility may not even know that an injury occurred or why.  They need to know where the system, or people are failing.  I also looked carefully at this article – without all the facts and saw where a trained family member may have been able to save this patient’s life.  A trained family member may have been in a position to speak up and alert someone that something doesn’t seem right.   They didn’t and the patient died.  If they did, how would that be measured?


Saturday, August 19, 2017

Listening Skills Learned


Is the Country's State a Practice in Listening?

As a patient advocate, it is my job to be objective and nonjudgmental.  I listen to the patient and their family and listen to the doctor or nurse explain to the family  whatever it is they need to explain.  It is not up to me to make decisions for the family.  It is not up to me to agree or disagree with the care plan.  It is up to me to be sure that information is given in a way that the patient and family understand and that if they don't, they can ask questions.

In my work, I often listen to patients who have special and unique needs to learn what their obstacles are for safe, quality medical care.  People with severe illnesses, families of people with dementia / Alzheimer's, young single mothers to name a few.  I learn from them what it's like to be them, though I don’t pretend to always understand it.   I also get to spend time at the bedside with families and to be with them during this often, difficult time of pain, sorrow and vulnerability.  Advocates who take our training learn the importance of these
skills.

So, what’s my point?  I also listen to conservative radio and liberal news, speak to people who have opposite views from my own and want to learn what makes them think the way they do.  I want to hear what makes people so different in their thoughts and ideas. There is a lot to learn about different viewpoints.   People are angry and frustrated with the way things are in today’s political setting.   

What is concerning is when people use words with no appropriate relationship to what they really mean.  Name calling, making fun of someone’s appearance, or using words not related to the problems being addressed.


As soon as people use, as part of their dislike for someone the way they look, walk, dress, their facial expression or hairstyle it takes away from the important facts that we need to concentrate on.  How boring this world would be if we all agreed.  For those of you who want to moderate, mediate and / or advocate for others, there is plenty of practice opportunities in today's daily conversation.

Friday, July 28, 2017

Helping at the Hospital

When a Patient Needs Support

The surgery went well.  There was no infection.  The medication was correct and the patient didn’t fall.  So why was this 24-hour hospital stay so awful that the patient talked about it for almost an hour as one of the worst experiences this patient ever had?

The humane and respectful behaviors we all expect from those caring for us were missing.  A cup of coffee when the patient requested it, the phone and remote within reach, retrieve a  fallen pillow on the floor, some crackers, a response to the call bell are just some of the things that can make a patients experience better in the hospital.  We all recognize that hospital staff are often overworked or short staffed yet a friendly response to a patients request can mean the world.

Families often need to work or go to school and can’t sit by the patient’s bedside.  But having someone available to meet these needs can really change the patient’s perspective of how their care was. And yes, it can mean a better outcome.  If the patient got out of bed to reach what fell on the floor and fell, that could cause serious injury and a substantial cost to the hospital and patient’s insurance.  Eating inappropriate food brought in by loved ones because the patient didn’t  have anything else to eat, might cause a problem with healing causing a longer hospital stay.


So, even though a patient may be sharing that there was the lack of comfort care, there are some concerns of patient safety that can be addressed.  If you know someone going to the hospital,  even if you have no patient safety training, consider bringing a book and sitting in the waiting room and check on the patient every 15 minutes.  You won’t be a burden and you can be sure the patient is getting what they need.

Wednesday, July 19, 2017

Let the Little Boy Cry

You Don't Know What I'm Thinking

A little boy about 10 years old fell off his bike and ran to the grownups to be patched up.  His mother and the other adults told him “don’t worry, you will be fine” without ever asking him what’s on his mind.

The next day his bandages had blood on them and it seemed his cuts may have opened up.  He brought his concerns about a bloody bandage to the grownups.  Again he was told don’t worry and this time was told no one ever died from blood on the bandage.  This was a second time the grownups decided he could not speak about his concerns.  Did they or he, even know what they were?

A wet, bloody bandage should not be OK on a hospitalized patient.  It should not be OK on a boy riding his bike.   Blood seeping through a bandage should be questioned.  Telling a child he /she won’t die because they have a cut or worse, is not addressing what they are concerned about.  Are we raising children to not question the care they receive because when they want to cry, they are told things like “you won’t die from that”?

Play this same scene out when a 60 year old woman has indigestion that seems ”weird” and the doctor says no one ever died from indigestion so she stops in her tracks from questioning the care she received. An adult questions that maybe she is getting the wrong medication - and a nurse says “stop worrying so much”.

When people are frustrated, scared or inconvenienced by sickness or an injury, healthcare providers as well as friends or family members often respond to what they, themselves think the patient / person is feeling or in ways that make themselves feel better.  They respond with what makes them comfortable in the conversation. 


In our Family Centered Patient Advocacy training tools we use a scenario of a woman screaming in the bed at a hospital that she wants to go home.  Nurses are too busy to release her, the doctor isn’t available and she has everyone on her floor angry at her.  When I asked her why she wants to go home she explained her child will be getting off the bus and she needs to be there.  One phone call to be sure her daughter was met at the bus stop and the patient was fine. No one asked why she was so desperate to leave.  They assumed she just didn’t want to be there.

Not asking what is troubling someone such as tell me why are you upset and crying, what are you concerned about or how can I help make you feel better, is closing the conversation to learning and even more important - building relationships.

Friday, June 30, 2017

On His Birthday



Help Me Celebrate His 30 Year Memory and Birthday

This July, my son Michael Louis Corina would have been 30 years old.  A milestone to many people and their families.  Michael (Mikey) died just before my 30th birthday. I thought I would never celebrate another birthday.  Birthdays became unimportant and even painful. 

Although I never worked at making a day, date or event named after him, he has always been behind almost everything I do.  Patient safety was never about the one boy who died, it’s been about the many children who have died from preventable medical errors and all the families broken because of a medical system that does not include patients (even though
they say it does).


I was not involved in the study that medical errors are the third leading cause of death in the United States.  My work started long before that study was released when I saw this problem was not being addressed. 

Help us continue raising awareness in his memory.

Please consider this year helping make the number 30 meaningful with a donation of $30 (or any amount) which would mean you have thought of my son on his birthday this month.  A recurring donation of $30 will mean you remembered him for a year and will help us at Pulse Center for Patient Safety Education & Advocacy continue our important, lifesaving work.

Its as easy as going to our donation page to make your tax deductible donation!  

And please visit www.pulsecenterforpatientsafety.org to see what we are doing!

Thank you and feel free to pass it on.