Saturday, February 6, 2016

Swiss Cheese and Patient Safety

What Does Swiss Cheese Have to Do With Patient Safety?

I don’t comment on specific medical error cases. Too often details come out later that we are unaware of.  We rarely get all the details in the media.   But, it does seem like the fact here is that a child had the wrong procedure done in the hospital and the doctor apologized.  Mix-Up Leads to Surgical Procedure on Wrong Baby

When it comes to patient safety and medical errors, these are the exact stories we are talking about that even patients and families can learn from.

In the PULSE of NY Family Centered Patient Advocacy Training, participants will learn about the SwissCheese Model of patient safety.  With all the safety process in place, how can this error reach the patient?  Too often it does and we, the patient and our families MUST learn how and why this happens so it doesn’t continue.  At any time anyone, including the patient or family must feel empowered to say “stop” something doesn’t seem right. 

At any time patients, their family and / or their advocate must understand the Swiss Cheese Model so they are aware of how errors happen.  Whether it is getting the wrong medication, the wrong procedure or even when hospital staff start discharging the wrong patient, if we don’t talk about it, it will continue.  Yes, these incidence will make the news but sadly not for the right reason.  We MUST use these stories to educate and advocate for patient safety.
Over and over again the healthcare system proves that they need the patient and family involved but sadly too often we are excluded from the conversation.


If you can join us for the next conversation and training, please register now – we always fill up.  Family Centered Patient Advocacy Training

Friday, February 5, 2016

Communication for Better Care

Respect and Communication in Medical Care

It’s not always about medical errors.  There are many opportunities for care to be less than OK when we use the healthcare system.  I have said it before, and I will say it again; no two cases are identical when it comes to unplanned results. So many problems can stem back to communication, and poor communication can be perceived as poor care.

A man does not want to leave the hospital and waits for a conversation with the social worker.  Hours go by and he is still waiting.  A person with nothing to do counts the minutes while the social worker is trying to help, without reporting back, the patient feels ignored. The hospital visit begins to spiral out of control because the patient is angry.



The patient doesn’t keep track of when he receives his medication and the nurse doesn’t tell him what medications he is getting.  When the patient thinks he was double dosed on his medication, the rest of his hospitalization is spent looking for additional errors.

A patient has questions but the nurse leaves the room before he gets to ask.  Now he feels ignored.

A patient needs to use the bathroom.  When it takes too long, according to the patient, for someone to come, the patient feels ignored and neglected.  An apology could have helped the patient feel respected.  If the CNA was apologetic instead of annoyed, the patient may have actually been sympathetic to the overworked nurse assistant.

How patients are treated very often make up the patient experience.  Kindness and respect can go a long way and may actually change an outcome.  A nurse who is rushed, a doctor who is not approachable may be closing doors to a patient sharing important information.

Hospitality in healthcare,  whether a smile or hello need to be taught early in training and reinforced constantly.  Patients and their family should “assume good intentions” and give staff an opportunity to be kind and respectful and be kind and respectful back.

As an advocate,  the intervention may be just to keep communication open, apologize for each side, and remind each party of the stresses during this time.  We should not be telling someone not to be angry, but instead acknowledge the anger and frustration and then offer to help get answers.  Telling someone how to feel is once again taking their independence away.  Allow a patient to be angry and frustrated.  Once their feelings are justified, they can usually be easily become more reasonable.

Wednesday, January 13, 2016

Planning for Home Care x

Listening to Her Words

When I answered the phone I could hear the panic and desperation in the woman’s voice.  I have met her at programs PULSE has hosted and knew that she is highly educated and by my standards very bright.  What could she possibly be so frantic about?

Her husband was hospitalized and coming home needing home care services.  Now she needs surgery and will be off her foot for a few weeks.  How will she care for her elderly husband?  Her concerns were reasonable but who can she share this panic with that she felt was unreasonable?

This woman, who has always been in control was feeling out of control.  A very reasonable feeling when already scared for her husband and now herself.  She didn’t want to hear the words “don’t worry” which is the reaction of most people.  She didn’t know it, I did, that she wanted to know how to get back in control.  That’s what we did.  I was surprised to learn she already had a home care agency picked out to help around the house for herself and her husband.  So what was I there for?

By allowing her to talk, prompting her with questions, I learned the representative of the home care agency was coming to visit.  By listening, I learned she was not prepared for that interview.  Together we thought of questions and what her, and her husband’s needs might be.  Interviewing the people from the home care agency as well as having a stranger in her home caring for her husband what was causing anxiety.  Helping her control this situation, unrelated to her surgery or her husband’s illness is what helped her through.

We can’t assume that we know what is upsetting someone.  Believing it was her concern about surgery or her sick husband would have wasted valuable time and would have steered her into a direction she didn’t need to go.

With her list of questions ready for the person from the home care agency, and her requests for how they should behave in her home, she now felt better and back in control. 

Saturday, November 7, 2015

Patient Safety: An Endless Journey, sponsored by King Faisal Specialist Hospital &Research Centre, Saudi Arabia

My Trip to Saudi Arabia

It was a long, but uneventful trip traveling over 6,000 miles each way to Saudi Arabia.  I was invited to speak at the first International Quality & Patient Safety
Conference held in Jeddah.  Titled   Patient Safety: An Endless Journey which was sponsored by King Faisal Specialist Hospital &Research Centre.  The planning for this trip took months.

The planned attendance was about 350 but the crowds at registration on the first morning meant that they were unprepared for the last minute request for entry.  This was a medical community hungry for knowledge and information about keeping patients safe. 

The speakers, over 30 in all were from the US as well as the Middle East.  Topics included the role of the pharmacist, medical student education, employee engagement and the accreditation process.  My role was to include the patient and family in patient safety.

I was not only there to educate, but felt I learned a tremendous amount.  After my presentation I was flocked by women who wanted to know more and were willing to share with me their stories and their culture.  I was able to learn what are some of the things we, in America might take for granted and not understand.

I was sure to explain to my hosts that some of my content might not be what they, in their culture support or believe.  I was not there to give my opinion or try to change theirs.  But the work we do at PULSE with young, unmarried mothers, or the transgender community are ways to learn about communication and honesty.  Were their patients afraid to disclose information, they may not get accurate information from their patients.  

I had another chance to share why I do patient safety work and share my journey.  This seemed to touch the women.  One woman stood up after my presentation and said “This was the best presentation I have EVER heard in my life”.  Her, and a group of women came over after and asked me to pose for photos.  (Far from my area of comfort) They took out their cameras and started doing “selfies” with me.

In this culture, it is expected that children will take care of their elderly family.  They won’t be put into nursing homes.  This opens an important role in advocacy and communication.  Men must sign the consent for a wife to have a hysterectomy a c-section or any fertility treatment.  It is also not unusual for family to receive medical diagnosis before the patient does so they can break the news to their loved one.  Although this was just some of what was shared with me, I understand that there is clarity needed in these examples.  It’s not all that simple. 

In the American “culture” men can’t have 4 wives and women can drive for themselves and wear what they want.  In the Saudi culture woman can get married young and family arranges the marriage.  People may not agree with the way others live but that is an important part of respecting each other.  This is important in health care and treating patients.  It’s another step in the conversation.  I feel honored to have been a part of this first step and introducing the work of PULSE to this new community. 

Saturday, October 31, 2015

Medical Care and the LGBT Community - L.G.B...............T.

Medical Care and the LGBT Community

Hospitals and medical staff are beginning to understand the importance of certain special concerns in treating the LGBT community. This group has special needs and sensitivity issues that may need to be addressed.

In fact, I believe that it is a serious mistake to group together the lesbian, gay and bisexual community with the transgender community – specifically transsexual. No, I am not transgender and I don’t even have family who are (not that I am aware of) but I study this topic, talk to people who are, and have been at the bedside as a patient safety advocate for people who are transgender.

The medical needs of the transgender community, in my non-medical opinion, are very different from those of the LGB community. Who you love — as in being L, G or B — is different from who you are. Just as important, is how transgender people see themselves. A lesbian may be very accepting of her body and may not cringe at the thought of exposing it. 

A transgender person, on the other hand, may have been ashamed their entire life of their body parts. Taking testosterone or hormones may have changed a transgender person’s body dramatically but without surgery; this can be surprising and confusing to healthcare workers who have not been taught about transsexuals and the stages in their transitions.

A woman who needs a prostate exam, or a pregnant man, should not be cause for alarm or even curiosity. This is not part of the lesbian and gay society. Many transgender people started off as gay or lesbian and some have become gay or lesbian. But that’s not always the case: as one friend explained to me, he is just a straight man now – almost.


Ilene Corina is the President of PULSE of NY, a community based patient safety organization and a patient safety consultant. She received a scholarship with the NPSF / AHA Patient Safety Leadership training where she studies patient safety in diverse populations on Long Island. One group she has worked with is the transgender community.