Visiting Long Island's Patient Safety Institute

Patient Safety Intitute at North Shore LIJ Health System

The Patient Safety Advisory Council held a recent meeting at the North Shore LIJ Patient Safety Institute. Participants were obviously impressed with the program developed so healthcare workers are no longer “practicing” on patients. We were given a tour of the many rooms that held patients which are actually mannequin simulators under a blanket, in a bed set up in a hospital room that was so authentic looking you can easily forget about the office building we walked into to get there.

The tour consisted of about 3 rooms with a mom and newborn baby and full sized, fully functioning adults. Kathleen Gallo, RN, PhD, MBA Senior Vice President and Chief Learning Officer North Shore-LIJ Health System and Alan Cooper, PhD, MBA gave us the tour and the history of the program. Dr. Gallo explained that they can make almost anything happen that could happen in a real hospital room as training for the many medical professionals who come through this center which is about 4 years old.

One of the scenarios, Dr. Gallo explained is that the mom could have a baby in distress, and then the dad could faint and injure himself too. Also using real live actors to go with the simulators, leaves the opportunities open for more dramatic events.

We were given a full demonstration by the staff at work with the simulators and the very important debriefing following the 15 minute demonstration. This is where staff get to talk about what happened and how they did. Did they do what they were supposed to do at the right time? How did they feel and how did it go? Alan Cooper led the debriefing.

One of the interesting parts of watching the events unfold during the simulation demonstration was that everyone cooperated. We would never know who was in charge or who got along with whom. The focus was truly on the patient and how will they, as a team gets that patient better.

We were able to ask questions about why they did some of the things they did. The patient, obviously having a heart attack was given aspirin to chew when suddenly the patient said “I can’t take aspirin, did you just give me aspirin?” With no chart available, no one could find it; they now had to watch for what the patient’s reaction may be to aspirin. Did the nurse wait too long to call for help and how would the Rapid Response Team that was called handle the situation knowing nothing about the patient?

The nurses and doctors treating the patient do not know what will happen. "The Wizard" as the person is affectionately called, behind the glass, is making the patient speak and react using controls, with no warning to the staff on the other side. When the patient lost consciousness, I felt my adrenalin respond with the fear that they were losing the patient. They were still moving at a speed with accuracy and professionalism as if choreographed for them. No one stepped on each other and no one barked orders. The patient survived - and we were left with a new appreciation for modern medicine, patient safety and the incredible training available at the Patient Safety Institute on Long Island.

Health System Grand Rounds

Grand Rounds for Everyone

North Shore LIJ Health System on Long Island is hosting a series of Grand Round presentations once a month. The system, one of the largest in the north east invited me and members of the Long Island Patient Safety Advisory Council to attend.

This week the speaker talked about patient safety rounds. High level administrators take one day a week and spend a good part of the day going to a department or floor of their hospital looking for problem related to patient safety. The speaker, from another New York health system talked about how important it is for every level of staff to know about patient safety and be involved in the patient safety process. “It’s not about the Joint Commission survey” he explained. “It’s about the patient”.

A member of the PSAC who couldn’t come asked representative from her organization to come. Kyle works in the emergency room of a Long Island hospital and is a paramedic with the local ambulance corp. Although Kyle’s specialty is not patient safety, he was very aware of the information being discussed and even answered some questions that were asked to the audience about patient safety procedures.

I have known about patient safety rounds for awhile because I am involved daily with patient safety and am very often at the “cutting edge” of what’s new in patient safety. I was, in fact surprised to learn that all hospitals are not presently doing patient safety rounds. But, I am just happy to see that they are starting.

The presentation, though interesting, I feared may be too clinical for someone who does not specialize in patient safety. So, I was deeply thankful when I asked Kyle what he thought and he said that it is important for the community to know that this is happening in hospitals.

The speaker talked about a young doctor who made an error prescribing medication that very seriously injured a patient. The “no blame culture” encouraged this to be a lesson for the physician. She was not fired but instead was retrained and had to do a paper on the topic of her retraining. This punishment would probably do a lot more to improve patient safety than firing a doctor but what about the patient who was injured - and the family. I hope they know that this doctor did not go back to work the next day as if nothing happened.

Transparency in healthcare is not just about the conversation following an unplanned event. It should at least be that we, the patient and community know what is being done to keep us safe to begin with.

Death Can't Always Be Avoided

Death When It's Meant To Be

The patient died. It was no one’s fault but my friend who works in the emergency room told me about it and he was sad. People in healthcare recognize their own mortality when someone dies or may feel like they failed the patient and their family. Whatever reason, people who work in hospitals, I am convinced, have feelings. They love, they hurt and they anger. But we often don’t see that as the patient. We just want to get well and that’s what we go to the hospital for.

This becomes more of a reason for transparency. More of a reason I need to know what is happening in the hospital and the people in the hospital need to include the patient in the decision making and treatment plan. As part of my Fellowship with the American Hospital Association and National Patient Safety Foundation Patient Safety Leadership Training I am reading articles written for the medical professional about transparency. It is written for the healthcare workers but there can be much more for the public to help understand how errors happen.

If we felt we understood how errors happen, we can be more of a part of the team to help avoid them. A survey we are doing now is giving more and more input into medical errors. Patients and families who have been to the PULSE training are reporting what they see. By making patients and families aware of what to look for and how to speak up to avoid errors, we can play a role in stopping them. I am reading now how our training has stopped the error from reaching the patient. Hooray!

But, not all deaths are because of an error. And I want to still be sad for my friends in healthcare who are part of death, even when it was meant to be.

Medication Distribution

Medication Distribution and the Patient Safety Advocate

An all too common practice in hospitals is still an ancient custom that the nurse brings the medication to the patient in a cup, out of the wrapper. I have seen this in numerous hospitals in numerous states. When asking about this, it seems to be easier for the nurse to prepare the medications at his or her work station and then bring them to the patient.

I questioned some of the experts in this field and was given a big thumbs down to this practice. Medication should always be in its original wrapper when given to the patient.

Grena Porto, from QRS Healthcare Consulting remarked “this system that you described leaves no room for patients to participate in their care and in error prevention. Even without state of the art technology, there is still no reason that a nurse can’t go into a patient’s room with the meds still in their wrappers and confirm them with the patient.”

A nurse can be distracted easily, and walk into the wrong room with medications. Or, while preparing the medication, she can mix then up. This error would be completely preventable but unknown to us until it’s too late. Without the patient’s name on the medication themselves the nurse is working completely off memory.

When asked the best way to handle this dilemma, I received this response from Michael R. Cohen, RPh, MS, ScD President Institute for Safe Medication Practices “I think the patient (or advocate on behalf of patient) should ask to see the packages if they are not brought into the room. Just let the nurse know this expectation right up front and they could put on the med sheet or Electronic Medication Administration Record (e-MAR)”

How we speak to the medical staff is important. Hospitals are stressful enough. Jennifer Gold, a Pennsylvania nurse gave this advice ” you could say ‘Would you mind bringing the pills in it's original packaging because it is very helpful for me to keep track of everything." If you said: "You should bring the pills in the original packages because you could easily make a mistake.’ Then the nurse would become defensive, because she would feel like you were telling her what she was doing wrong.”

All great information and great advice. Now we need to make sure we speak up.

Listen and Learn, The Patient Representative

The Patient Representative

What is the Patient Representative supposed to do? Place the “blame” in the right department ? No, I should hope not, but let me back up a bit.

The family of an adult patient calls PULSE of NY. The patient was admitted less than 24 hours ago. Injured from an accident the patient is in ICU and unable to speak.

I meet with the family and we discuss the care and important patient safety information.

The next day I get a call that the patient has bedsores. The family is mostly concerned because they feel they are being “blamed” by the nursing staff for causing them by removing a pillow from the patient’s legs. Already I recognize that there is a misunderstanding.

Being just days before a holiday weekend, I offered to call the patient representative at this local, Long Island hospital. I explained who I was and why I was calling. My concern is to make sure, that an already irate patient or family do not get a list of dead end phone calls to make. Usually, when I get started, I get people who are on vacation, not available or have to find out who will handle this particular situation. All I do is explain how much I know, which may or may not be enough to find the right person, but I do get a person, in the end.

This conversation was somewhat awkward. I explained that there is a patient’s family, who contacted me because we are a grass roots patient safety organization. The family is concerned because they were told the patient has a bedsore. Here is the abbreviated conversation with the patient rep:

PR – When did the patient arrive?

Me – 2 days ago

PR – What was the condition of the patient before he arrived?

Me – He was hit by a car.

PR – Was he generally healthy?

Me – I don’t know

PR – I need this information. Where was he before he arrived did he come from another hospital? We need these questions answered.

I tried to explain that I was only trying to make the connection for the family to the appropriate staff. I need to ask the family to call her and she could do her fact gathering with them. “It seems” I told her “that you are looking to blame someone for the bedsores. We only want to know that they are being addressed”. The communication breakdown became apparent when she defended her questioning.

The listening has to start from within. No one was looking to blame, the family wanted the bedsores gone.

Thank goodness I knew the people in quality and safety at this hospital and was able to reach them. They were able to look into the problem which was taken care of. This is not the first time my experience with a patient representative has been questionable. Yes, there is an answer but it won’t come from within the hospital walls.

Hospital Visit For Family Centered Patient Advocacy

I was called recently by a patient’s family. The patient is hospitalized and in ICU. A recent visit to the hospital for the family was to help the family ask questions, navigate the system and even look for things like hand washing, communication with the medical staff and comfort for the patient.

We were all pleased with the care but this family has experienced bad outcomes in the past making them more suspicious and concerned than the patient and family who has had only positive experiences using the health care system. My visit is often to help the medical staff as well as the patient and family so the whole experience is smooth and free of unplanned outcomes.

I showed the family how to wipe down the bed rail, door and other items after the nurse or visitors touch them. I asked them to wash their own hands. I suggested they don’t wait in the lounge for the doctor while he visits with the patient as the family was instructed to do, but stay by the door, if not inside, and sure enough the doctor tried to leave without speaking to the family. We wrote down names of doctors and the time of the visit and what he or she diagnosed. We asked the nurse for a list of all the medications the patient is taking so it becomes a record for his medical history.

I suggested they allow the nurse to explain what the doctor ordered. Never say, “yes I understand” always say “please explain it again”. This way the family knows if the orders are the same or, if they really didn’t understand maybe they will now when the nurse explains it in her words. The family was fighting traffic and arriving at 9 AM. I suggested they come at 5 AM. This way they can be there for the change of shifts, a common time for errors.

Most important, allow the patient to rest. Families often feel that they need to chatter and stimulate the patient. There is no need for that. Sitting quiet is the best way to be appreciated.