I had the absolute honor of addressing the HRET American Hospital Association and National Patient Safety Foundation Patient Safety Leadership Fellowship last week. I myself have submitted an application to work along side the most committed group of people in this country when it comes to patient safety.
My presentation was almost 3 hours if you consider the 45 minutes my colleague Ken discussed compassionate communication. Being a small group, there was plenty of interactive discussion and sharing. They mostly shared their commitment to their patients and their patient’s safety, but when I returned home, I received heartfelt e-mails about their own experience with medical injury to themselves or their families. It really does support my claim that it isn’t “if” you or someone in your family has experienced harm, it is “when”.
I hope my presentation reached some of them to consider patient safety as a lifestyle, not just a job. I was pleased that NY City Health and Hospital Corporation played such a big role as participants in this program as they met in NY City as part of their year long commitment to the program.
Unfortunately, no one from any of the many Long Island hospitals participated in this years Patient Safety Leadership Fellowship. This may just be a reason I can worry using the hospitals in my own community.
Tuesday, February 24, 2009
Tuesday, February 17, 2009
Remembering the Medical Injury
Have you ever wondered why people who have experienced medical injury seem to remember for many years later the conversations with healthcare providers following the incident? A 60 Minutes program about the medication called Proprandol that can block painful memories for post traumatic stress also mentioned how post traumatic stress or PTS happens. Another article on the same subject has just surfaced.
Adrenaline is released when an incident happens that makes you angry and emotional and this adrenaline actually makes you remember better.
Those who experience medical injury remember the details of the incident itself. However, it is often the conversations that follow the incident, with the medical personnel in which answers are not honest and forthright, that the patient and their family remember and focus on. I call this “he said she said”. Although it is better to focus on facts so others can learn from the incident, it is the conversations that follow that get the most focus.
Example: a patient may have had a delayed diagnosis because no one called about her test results. This alone is very traumatic and has a lesson - we should always call to get our own test results if we do not hear from the doctor’s office. But, the conversation may continue, “I asked the doctor why they didn’t call and he said he would look into it.” This may seem a reasonable answer, but this answer may be what has actually traumatized the patient long after she received her treatment, even with good results, because this conversation is what caused the adrenalin to be released. Additional conversations are also remembered in detail and are as painful.
Although there is no proof, it does seem like something worth knowing. Studies have shown repeatedly that honest disclosure and upfront compensation or an apology reduces the chance of a lawsuit. It may be another reason that patients experiencing medical injury should be treated fairly and with honesty from the beginning. Maybe treated with respect and honesty will keep that adrenilin from flowing.
Adrenaline is released when an incident happens that makes you angry and emotional and this adrenaline actually makes you remember better.
Those who experience medical injury remember the details of the incident itself. However, it is often the conversations that follow the incident, with the medical personnel in which answers are not honest and forthright, that the patient and their family remember and focus on. I call this “he said she said”. Although it is better to focus on facts so others can learn from the incident, it is the conversations that follow that get the most focus.
Example: a patient may have had a delayed diagnosis because no one called about her test results. This alone is very traumatic and has a lesson - we should always call to get our own test results if we do not hear from the doctor’s office. But, the conversation may continue, “I asked the doctor why they didn’t call and he said he would look into it.” This may seem a reasonable answer, but this answer may be what has actually traumatized the patient long after she received her treatment, even with good results, because this conversation is what caused the adrenalin to be released. Additional conversations are also remembered in detail and are as painful.
Although there is no proof, it does seem like something worth knowing. Studies have shown repeatedly that honest disclosure and upfront compensation or an apology reduces the chance of a lawsuit. It may be another reason that patients experiencing medical injury should be treated fairly and with honesty from the beginning. Maybe treated with respect and honesty will keep that adrenilin from flowing.
Thursday, February 12, 2009
The Bus Driver and the "System"
I just read a story about a 7 year old boy left behind on a school bus. What surprised me was that the driver and matron were arrested and charged with a misdemeanor.
You may be wondering what this has to do with patient safety but just this week I heard about a child who died because someone who is not permitted to distribute medication in a hospital, did and it was a massive overdose. This careless act caused a child her life. There were no misdemeanor charges. This is a ‘systems” failure the medical industry calls it. No one is to blame because the system was set up for failure. This mother called to ask about getting policies changed within the hospital that caused her child’s death. I had to tell here there are policies, but once again they were not being followed.
If these are system errors, shouldn’t we say that maybe the bus driver was part of the bus companies system? In the case of the 7 year old boy he, and his family may be traumatized but he’s not dead – unlike in the medication case.
It may just be that the bus company doesn’t have a big enough “system” to fight this charge.
You may be wondering what this has to do with patient safety but just this week I heard about a child who died because someone who is not permitted to distribute medication in a hospital, did and it was a massive overdose. This careless act caused a child her life. There were no misdemeanor charges. This is a ‘systems” failure the medical industry calls it. No one is to blame because the system was set up for failure. This mother called to ask about getting policies changed within the hospital that caused her child’s death. I had to tell here there are policies, but once again they were not being followed.
If these are system errors, shouldn’t we say that maybe the bus driver was part of the bus companies system? In the case of the 7 year old boy he, and his family may be traumatized but he’s not dead – unlike in the medication case.
It may just be that the bus company doesn’t have a big enough “system” to fight this charge.
Saturday, February 7, 2009
The Flight
A pilot lands a plane in the Hudson and all the passengers are safe. The pilot is hailed a hero and the public is made aware of how dangerous it could be if the pilot is not experienced and the plane is hit with birds. Still, flying is considered the safest form of travel. Thank goodness. Because I still fly.
What is not revealed is that these passengers were taught ahead of time what to do if they have to land in water. They are told where the life jackets are and where the emergency exit doors are. I noticed that they were wearing their life jackets coming out of the plane and someone opened the door quickly to help everyone out. This was a well orchestrated evacuation because flight crews teach the passengers what to do before it ever is needed.
When I flew last week I looked for the exit doors and realized I missed the presentation about where my life jacket was. I asked the man next to me "where did she say the life jacket is?" It never mattered before.
Imagine if patients and their families were taught before they went to the hospital how to stay "safe" since so much more can go wrong in hospitals than in the sky.
Ask if the surgeons use the surgery checklist , ask who will mark the site of surgery and when, ask if the hospital has around the clock pharmacists or what the nurse patient ratio is. Ask what the infection rate is or see if the hand gels are filled and working in the hospital.
Why wait until after something happens to become educated. Imagine if those passengers didn't know where the emergency exit was.
What is not revealed is that these passengers were taught ahead of time what to do if they have to land in water. They are told where the life jackets are and where the emergency exit doors are. I noticed that they were wearing their life jackets coming out of the plane and someone opened the door quickly to help everyone out. This was a well orchestrated evacuation because flight crews teach the passengers what to do before it ever is needed.
When I flew last week I looked for the exit doors and realized I missed the presentation about where my life jacket was. I asked the man next to me "where did she say the life jacket is?" It never mattered before.
Imagine if patients and their families were taught before they went to the hospital how to stay "safe" since so much more can go wrong in hospitals than in the sky.
Ask if the surgeons use the surgery checklist , ask who will mark the site of surgery and when, ask if the hospital has around the clock pharmacists or what the nurse patient ratio is. Ask what the infection rate is or see if the hand gels are filled and working in the hospital.
Why wait until after something happens to become educated. Imagine if those passengers didn't know where the emergency exit was.
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