Saturday, March 1, 2014
Patient Safety Awareness Week 2014; Sad or Celebrate?
Patient Safety Awareness Week is a bittersweet time. It can be a time to celebrate all the work being done in safe patient care but it is also a time to reflect what we have lost and what had gotten us into this “mess”.
As my youngest son graduates college with a bachelor’s degree in business management and moves on to become a chef at a very prestigious hotel many miles away from me, I can’t help but remember with pride how he came into this world. Barely hearing his cry at just over 1 pound and 10 inches long, some say he was born too early. Obviously they were wrong. He was born just right. At 23 weeks, he wasn’t “supposed” to survive. But one doctor said I had a choice. I chose to try to save him. It was obviously the right decision.
His stubbornness to survive was also the same personality that got him his bachelor’s degree in 2 ½ years, got him the job he wanted as an intern chef in Kansas City and now at 20 years old, the job he wanted since he was 4 years old and told me he was going to be a cook like his grandpa.
I am reminded over and over of the nurses who took care of my baby, allowed me to hold him against the rules and allowed me to sneak up a friend for moral support. The consent forms I had to sign for experimental medications and procedures that would ultimately save his life. Months on a ventilator has left little scars and the poking and prodding that was done left marks only a mother could see. I am proud of him and grateful every day to the hardworking, caring, sensitive and loving nurses, doctors and support staff who gave him life.
How difficult it is, at the same time to recognize at any moment, these wonderful caring people can make an error or be involved in a situation that can cause the traumatic death or an injury because of a medication error, an infection or a procedure that may go wrong.
I have not forgotten that it is the death of my first son from a preventable medical error that began my journey into patient safety but I also don’t want people to forget that there are many lives saved every day because clinicians take chances.
We would probably be more forgiving of the error were we treated with dignity and respect following an unplanned outcome. I believe most people are not as angry at the error itself but at the way patients and their family members are treated following the event that can cause injury and harm. We rarely think about the pilot who gets us to our destination safely. But, were there to be an unplanned outcome, that pilot would be under the microscope.
As we approach Patient Safety Awareness Week this year, I hope we all can think about how we can celebrate patient safety and all the good that is happening to help make sure there are no more bad outcomes. And if there are – we need to all be part of the discussion to make sure it never happens again.
Posted by Ilene at 4:05 PM
Saturday, February 15, 2014
Ronald M. Wyatt, M.D., MHA medical director at The Joint Commission to Address the Public
In 1996, when I was informing the public about their “rights” to information about their doctor’s background, the small group of volunteers I was working with knew that the one place that cared about patient’s safety, before the words were very popular, was The Joint Commission, (known at that time as JCAHO). I knew that The Joint Commission was a place that patient’s could report harm and feel that the reporting was taken seriously. After all, that is what The Joint Commission did. If they didn’t look into reported problems, injuries or unplanned deaths, than who would?
We were surprised when we invited The Joint Commission to speak at a “conference” we were holding one evening at a local congregation, that we couldn’t afford them. The meeting was to be at the South NassauUnitarian Universalist Congregation, in the heart of Freeport Long Island. PULSE of NY was started there as a support group for medical injury survivors. For many years we would meet on a Sunday afternoon, once a month to help each other and learn from each other. We thought of ways to raise the money to bring a speaker in to New York but we couldn’t make it happen. The audience was the hospitals and the healthcare organizations accredited. Today, there are 20,000 organizations accredited by The Joint Commission. Accreditation by The Joint Commission is a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
I spent almost the next decade working to educate the public about patient safety. Nine years later, I found myself on the board of The Joint Commission. As a commissioner, I make up one of the seven public members, not representing a healthcare organization.
And now another nine years later, The Joint Commission has graciously offered to send Ronald M. Wyatt, M.D., MHA medical director in the Division of Healthcare Improvement at The Joint Commission to come speak at the PULSE of NY Patient Safety Symposiumon Diagnostic Errors addressing the public.
I suggest you don’t miss out on this historic event. Register now before it’s too late. Registration open through February 25, 2014. To see the sponsors and register go to http://www.patientsafetypartners.org/
Posted by Ilene at 11:51 AM
Wednesday, February 12, 2014
What’s in a Title?
I learned today that a non-doctor group won’t support a symposium sponsored by PULSE of NY, because the title has the word “doctor” which, in this group’s opinion, excludes other medical professionals. The title of the symposium “Medical Diagnosis: Help Your Doctor Help You, Patients Involved in Healthcare, The role of Patient Engagement in Error Prevention” may be long, but it’s not “wrong” and doesn’t exclude anyone.
The fact is many diagnoses are missed by doctors. In a USNews article some 5 percent of autopsies find condition missed by doctors that, if treated, might have saved the patient's life. Webmd.com has a story offering “8 Ways to Help Your Doctor Make the Right Diagnosis.” And, the NationalInstitute of Health explains that it is your primary care doctor who will diagnose asthma. The Parkinson’s Disease website also shares information about getting a diagnosis titled: How does your doctor make a PD diagnosis?
Since physicians, physician’s assistants and nurse practitioners can treat and diagnose illnesses, we need to be sure they are all getting it right. According to Society to Improve Diagnosis in Medicine “Diagnostic error is the leading cause of medical malpractice claims in the US, and is estimated to cause 40,000-80,000 deaths annually. One in every ten diagnoses is wrong and one in every thousand ambulatory diagnostic encounters results in harm.”
There is no doubt that this symposium to help patients and families understand how errors can be made in diagnosis could have been called Help Your Nurse, Physicians Assistant, Medical Team, Provider or Clinician Help You - but it isn’t. That’s because it’s usually the doctor that patients talk to when receiving a diagnosis and if it’s wrong, it’s the doctor who is held responsible.
If I stayed away from every conference, meeting or program that didn’t sound like it pertained to me, I would have stayed on Long Island the last 20 years and learned nothing.
To learn more go to http://www.patientsafetypartners.org
Posted by Ilene at 11:05 PM
Wednesday, January 15, 2014
If the words on the huge screen in the front of the room are correct, and every hour 20 people die from preventable medical errors, in less than 24 hours, the deaths from preventable medical errors would be equivalent to every participant at this conference. Over 400 people were filled into the room at the beautiful hotel on the beach in California. They were all there as part of the Patient Safety Movement – where clinicians, hospital administrators and patient advocates pledge to reach the goal of zero preventable patient deaths by the year 2020.
In partnership with The Joint Commission, the Patient Safety Foundation began the Patient Safety Movement to offer solutions, share best practices, share stories and save lives.
Joe Kiani , founder and CEO of the Patient Safety Movement Foundation is the CEO of Masimo, a global medical technology company. Admittedly Joe Kiani has never had a medical injury himself or lost a family member from a medical mistake but is passionate about patient safety. He started the patient safety movement last year with the first conference in 2013.
At both conferences President Bill Clinton was the key note speaker and after he spoke Clinton was interviewed by Kiani. When asked by Joe Kiani why he agreed to be part of this movement, Clinton described it as being offered a ride in a Rolls Royce. President Clinton was obviously impressed with the enthusiasm and compared this movement to taking a ride in a fine automobile. Clinton described his work around the world saving lives. This is something he is excited about.
Others who spoke during the two and half day conference was Dr. Mark Chassin, President, Joint Commission, Dr. Patrick Conway, CMO Centers for Medicare and Medicaid Services and Sir Liam Donaldson World Health Organization Envoy for Patient Safety amongst others.
|Alicia Cole, Actress and Patient |
Safety Advocate describes her injuries from a
hospital acquired infection
The difference between this and other patient safety conferences is that this was about solutions. People didn’t come here unless they were serious. This was a conference to save lives, make a commitment, break down the silos, share ideas and we are all in this together.
The panel discussions had experts on just culture and spoke about transparency and disclosure. Alicia Cole, an actress and California patient safety advocate shared her heart breaking story about her hospital acquired infection and how it changed her life. Hand hygiene, we learned is only 40 % compliance among healthcare workers. It costs $20,000 to treat a patient with a surgical site infection and $6-$8,000.00 to treat a patient with a urinary tract infection. Over and over we heard comments like “just wash your hands” The stories went on…..After each panel, a speaker would then talk about how they saved lives so others can learn from them and even copy what other hospitals are doing.
The Joint Commission and Center for Transforming Healthcare is all about solutions. Once only known for surveying healthcare organizations, they have come a long way. Not just what may need help for improvement but now here are the tools to make the improvements.
I walked over to a young man filming the program from the back of the room. “Are you freelance?” I asked him. He told me he was. “What do you think of what you have heard so far?” He is, after all the people we need to connect with. The people who we need to reach to take an active role in their care. Our neighbors and friends, the woman in the supermarket, the office worker and those who know nothing about these problems being addressed in healthcare services. Matt, I later learned was his name, took his head phone off, bent down from his platform so we were face to face and looked me in the eye and said “wow, I think I have sleep apnea. After listening to the story about the guy who died from being given medication with untreated apnea I am going to go to my doctor and get it treated”. He went on to say that the story of John LaChance, who died from medication given without monitoring his sleep apnea, had made an impact on him. John’s wife told her husband’s story in a video at the summit. I brought Matt over to John’s wife so she can see how she may have helped someone by sharing John’s story. It is after all, why we do this.
Posted by Ilene at 4:43 PM
Monday, December 30, 2013
Just My Opinion
A child goes in for atonsillectomy and comes out of surgery “brain dead”. The family wants answers, the hospital wants to disconnect her from life support. The family wants to move the child to another facility. The hospital wants to disconnect her from life support.
This story is eerily similar to another case I know intimately. Over 20 years ago my only child at the time went in for a tonsillectomy. He didn’t come out brain dead but he did die a week later from blood loss after 4 different doctors on 5 different occasions told me don’t worry, the bleeding stopped and he’s fine. What an awful way to prove doctors wrong. (By the way, I have had about 10 calls over the years from families who lost a loved one from a tonsillectomy)This is another opportunity to show not only how dangerous surgery, including the tonsillectomy is, but it also shows that there is a problem with communication between the patient (in this case family) medical providers and the press.
Here are my thoughts. There are 24 hours in a day. There is a lot more happening in that 24 hours than the media is telling us. We aren’t getting the whole story. What I am getting is that this family is not getting the answers they want nor are they getting the respect they deserve. If they were, chances are they would never go to the press and if they were, the press wouldn't be interested.
If in fact, this was a medical injury, caused by the care she received, it would be great if the hospital did everything and anything the family wanted - including keep her heart pumping, get her to a different facility and get counseling for the family and staff. But, it is probably too costly to do that. Plus a medical malpractice case would cost more if she does live and needs more, long term care.
I would think that this would be a great case for medical mediation. The family, the hospital and their lawyers would need to approve of a conversation / dialogue to each be heard. What are the needs of each involved? Honest, open, confidential dialogue that can be kept out of the press should be part of the families and lawyers suggestion. If in fact this is a local hospital, that this family may need again, why would they want to be wrapped up in a lawsuit for years?
Through mediation, the family can ask for financial compensation an apology, answers and even a way to make sure someone learns from what happened and not close it away someplace so patients can’t learn nor can the medical system learn.
I wish they had that available 20 years ago.
Posted by Ilene at 9:36 AM