Patient Safety?

Patient Safety For All

How do you tell a mom whose child is strong and violent that she must also remind the healthcare providers to wash their hands? How do you tell a mom whose child is scared of loud noises, bright lights and is nonverbal that she must also make sure her child is cared for safely in the hospital? Now tell a parent who can’t control their child’s outbursts that they will have to sit in a waiting room in a doctor’s office with other “normal” children and control her own. These are some of the conversations I had this week with the people of local community organizations learning about patient safety.

Many people are avoiding the healthcare system because of the problems they see going into it.

How do you tell a young woman who doesn’t speak English that she can ask for a second opinion when she can’t even explain what the problem is to the doctor? A woman shares the story of how, when she first came to this country and didn’t speak English, she struggled with the nurses aid in the hospital who made her get up, even though she was in terrible pain. The nurse’s aid didn’t understand how much pain she was in and the wound from her abdominal surgery opened causing severe problems to the patient.

A woman, who doesn’t speak English, tells me, through a translator that she had a lot of pain. She could only get an appointment for three months later. She had a urinary tract infection and was pregnant. The infection spread and they took the baby. She said she felt the baby was alive but no one understood her. Through her sobs she told the translator that she couldn’t make herself understood the urgency of her pain. She still has kidney problems from neglecting the infection.

These are just some of the stories I am hearing about our medical system as it relates to patient’s safety. Focus group after focus group I am learning more than I can possibly teach these people who only want what we all want, safe, quality healthcare. Story after story I am informed of how communication or lack of training keeps patients and providers from focusing on the patient’s individual needs.

Whether disabled, lack of language skills or any number of reasons patients don’t seek care, we need to know that we, as a nation must focus in on the individual needs of the patients before our whole system collapses.

We all want and need affordable healthcare but if the words safety, and quality aren’t part of the dialogue, the costs will rise worse than we can ever imagine and everyone will suffer.

I was invited by Steven Pegalis Esq. of Pegalis and Erickson to attend a lecture at NY Law School in Manhattan hosted by his law firm. More and more medical malpractice firms are showing concern for patient's safety. The speaker, Dr. Paul Gluck is a founding member of the National Patient Safety Foundation and an OB/GYN from Florida. Hardly the person I would expect to see on the agenda as a guest of a medical malpractice law firm. Although I don’t always agree with Dr. Gluck he has always been respectful, friendly, warm and welcoming to me as we both are on the board of the National Patient Safety Foundation and I thought it would be nice to surprise him.

Expecting this to be an interesting evening, I invited Steve Goodstein, a registered nurse, professional mediator and a board member of PULSE to join me. Assuming there would be conversation around law suits and blame, I was hoping we could see what doors would be opening for alternatives to litigation through this program.

I was greeted warmly by Dr. Gluck and was genuinely glad immediately that I made the trip to see him. The room was filled with attorneys with a scattering of medical professionals, judges and hospital executives.

The information Dr. Gluck shared, how errors happen, the history of patient safety and studies of how no one is usually at fault seemed to be better suited for other medical professionals. I’m not sure this was an audience who wanted to steer away from lawsuits.

I was told ahead of time that I would be called upon to speak following the presentation so I was a bit concerned when I was called upon to introduce myself and then told that the opinions would come from the “professionals” in the audience. Suddenly, with this new audience, my opinion wasn’t important. But, when the conversation following the presentation went to the lawyers vs. the doctors, I couldn’t be stifled any longer.

No one was asking the patient if they wanted to sue, no one is giving them (us) a choice. I explained that when my son died I had no choices, sue or don’t sue was it. Lawyers didn’t want to take the case of a little boy who died from a tonsillectomy and they still don’t. There is no financial compensation to cover the cost of a lawsuit. So, no one talks about it, no one learns and no changes are made to improve future care.

When a lawyer greeted me later and said he would have taken my case, I snapped back, as respectfully as possible, “what if I didn’t want to sue?” I didn’t need the money. There were no more birthdays or holidays. What I needed, and so many patients and families need is answers.

First, I explained, we need to know what the term “I want to make sure it never happens again” means. To patients and families it can mean making changes. To others it means hitting them in their pocketbook.

Either way, it needs to be the choices the patient and / or family makes, not society looking in at half the story. Maybe some doors will open - even in New York.

Patient Safety Awareness Week 2010

Patient Safety Awareness Week 2010


Yesterday, I had the wonderful opportunity to speak at the Long Island Veterans Affairs Medical Center for Patient Safety Awareness Week. I spoke on the topic of the patient’s role in patient safety. It was a crowd of about 150 people who gathered and in the back of the room were the poster presentations of the hospitals safety initiatives all year. Fall reduction, infections and Root Cause Analysis were but just a few of the important topics addressed through poster displays.

The participants at this conference, mostly staff of the VA were reviewing their colleagues work after listening to my presentation and the presentation of long time friend to PULSE Dr. Mark Graber, Chief of Medicine. Dr. Graber was the person I first turned to, to get Patient Safety Awareness Week started back in 2002. Without hesitation he went to his colleagues in the VA and soon the whole country was supportive with the leadership of the National Patient Safety Foundation.

I still would like to see more community partnership in patient safety. Patient Safety Awareness Week was developed so the hospitals and healthcare providers can take pride in their work around safety but also, so they can tell us, the community what they are doing to keep us safe. Without the community knowing about fall prevention programs, hand washing initiatives or the work being done in the other areas of patient safety, we still are not in a position, as a society to “question” our care. If the only place patient safety is being discussed is behind the closed walls of the healthcare system, than where do we, the patients and families fit in?

Unfortunately, we’re not there yet. I have lots of ideas how we can get there but until we as a community are not part of the solution, well then, you know the rest…………………….



(Photo L-R Anna Gaeta, Patient Safety Officer VAMC, Me, Florence Fallon RN, Recently Retired Patient Safety Officer VAMC)

My Trip To Guam

My Trip To Guam, a Life Changing Experience

I handed the woman in the audience the microphone, “I advocate for children every day in my job and parents are giving their children medication that makes them aggressive,” she told the crowd of 300. “Parents must speak up and not just give their children medication without questioning their care.” Her eyes welled up and she began to cry. “We need this education!” The audience applauded her courage. These sentiments were shared throughout the day at the Guam conference where I spoke for an entire day on Saturday, March 6 teaching the people of Guam how to be patient advocates for themselves and their family.

Medical professionals from the Naval Hospital, the local community hospital, nursing school and community members gathered to learn how to “Speak Up and Be Part of Your Healthcare Team.” This conference was being sponsored by the Guam Healthcare and Hospital Development Foundation founded by my host Peter Sgro. People of the villages of Guam were going to learn that they can speak up and it wasn’t going to be considered “disrespectful” to question their medical care and treatment.

The conference covered the true stories of medical injuries of patients and the families who have contacted PULSE over the years. We discussed F.I.L.M.S., Falls, Infections, Literacy, Medication and Surgery safety and communication. After each topic, I asked if anyone had an experience they wanted to share “because by sharing experiences we can learn how to prevent them from happening again”. Encouraging transparency with no fear or embarrassment and talking about their experience should help encourage future conversations. The morning session was the first time most of the people in the room ever heard of the Institute of Medicine report of 1999, where studies show that as many as 98,000 people die in hospitals every year from preventable medical errors.

The morning session covered communication and listening skills as a patient, family member or a provider. We practiced listening and reviewed the feelings and needs the patient has and the feelings the doctor might have being questioned by a patient. Reminding the audience that I was only there for a short time, it was up to them to keep this conversation going.

One man stood at the microphone and said he is afraid of speaking up and asking the doctor to wash his hands. “He may hurt me if I do,” he said sharing an obvious concern that others in the audience kept to themselves. I asked him why he thinks he will be physically harmed if he was polite. Handing the microphone to a physician in the audience, I asked him “can you tell this man how he can ask you to wash your hands without offending you”? The physician, from the local naval hospital dressed in his crisp, white uniform stood up and addressed the man directly. "Would you ask a food handler to wash if you saw they didn’t wash before touching your food”? When the man replied he would, the doctor reminded him it should be no different talking to his doctor.

The audience was eager to learn communication as a patient or to help family members as their advocate. I shared with them ways they can be involved with keeping medication records, lists of allergies and past procedures.

The afternoon session started with a proclamation from Guam’s 19 Mayors declaring March 7 – 13 Patient Safety Awareness Week. They never before celebrated Patient Safety Awareness Week but now had a reason to.

The Proclamation reads in part:

• One in five Americans report having experienced a medical error.....
• Medical errors lead to unnecessary readmission's to hospitals and thousands of deaths each year....
• Reports support the position that having patients and their families become a member of their own healthcare team results in better outcomes.....
• We encourage patients and their families to take a more active role in their on healthcare to ensure their safety and well being....
• Our island's ability to solve its health care crisis depends in no small part on whether our political and private sector leaders can articulate a shared vision of the kind of healthcare system that will meet the needs of all thoise who call Guam home..............

In the afternoon, we viewed the video “The Faces of Medical Error, From Tears to Transparency; The Story of Lewis Blackman.” Lewis was a 15-year-old boy who died from medical error at a South Carolina Hospital. The viewing of the video was followed by a panel discussion of five medical professionals answering questions about how this could happen and what steps are being taken to prevent a death like this from happening again. The audience seemed relieved when I asked a pharmacist on the panel if she ever heard of the story of Lewis Blackman and she said “yes” it has been used as a teaching tool for pharmacist. Again, I reminded the audience about how talking about problems such as Lewis’ death is how we will keep them from happening again.

Earlier in the week I did a press conference, radio show and television talk show. Before the radio program a man walked into the room where Peter and I sat waiting. This man was so happy that he didn’t need the triple bypass surgery he expected. The visiting cardiologist on Guam told him that his scheduled triple bypass was no longer needed. This man believe that prayer, prayers he told us his church offered, friends and family offered and his wife went out to seek for him.

With so few specialty doctors, there is only one cardiologist on Guam who makes the decisions. Many residents wait for visiting doctors to come and diagnose or treat a problem. In this case, I am sure it wasn’t prayer that changed the plan for this man’s medical care.

Sadly, patients often have to leave the island to get care. Families are often left behind because of the high cost to travel. Peter tells me the story of a young boy being treated for cancer on the mainland leaving his family behind. Having loved ones close by is supposed to help patients heal faster. Though they proudly display the American flag, there is such a primitive way about Guam’s healthcare system. Someone mentioned that it’s not much different than a third world country.

Guam may well be one of the most beautiful places in the world with such beautiful beaches, magnificent trees and warm weather. A small island of 160,000 people it was hard to not go someplace that Peter was not recognized or greeted. But, hidden under all that beauty is community desperate for information and knowledge on things we take for granted – our rights to speak up for safe, quality care.

My Trip To Guam, Day 1

I just returned from a long walk in Guam. I walked up and down the hills but never made a turn. Those of you who know me know that it can be the end of me if I make one turn, I may never find my way back to my hotel! So, I just walk straight thinking about my day, looking at the beautiful view and passing the many stores with familiar names where tourists gather like Gucci, Prada and Rolex.

I am brought half way around the world by a gentleman with the same passion as I have; to give our family, friends and community safe quality healthcare. Peter lost his mother a few years ago. She was treated in the hallway of the emergency room at the only community hospital in Guam. With much less than 200 beds and a small emergency room, this hospital with no room for expansion treats almost all of Guam’s 170,000 residents. Many, who don’t have health insurance come to the emergency room sicker than they need to be were they to get regular medical care. Peter doesn’t blame anyone for his mother’s death as he explains the long delays to her surgery. She would be ready to go in early in the morning but not be seen until 7:00 at night. Peter explained that in Guam, families take care of each other. They live nearby and when someone is sick, the family is there.

Following his mother’s death, Peter turned to his wife and said something has to be done to improve healthcare on the island of Guam. He gathered 22 people together, got the support of the Mayors, and started the plans to build a new hospital. The foundation is raising the money and after 3 years, are about ready to sign with the contractors and the architect. Imagine someone in New York saying “I don’t like the way the hospitals run” or “the hospital is too small so I am going to build a new one.”

The Foundation Peter founded and the Mayors Council have agreed that they want the public to know and understand patient safety so they can be partners in their care. They have invited 300 community members to an all day conference for free to learn about patient safety. Today we did a television show and a press conference. Tomorrow will be a 90 minute radio show and on Saturday, March 6 I will be addressing over 300 people including medical professionals, nursing students and people from Guam about what they need to know to help ensure their safety and the safety of their family in the hospital. Who would have thought that Guam is even more progressive than New York?