NPSF and Patient Safety

Patient Safety from the Top

Next week I will be at the board meeting for the National PatientSafety Foundation.  From there, the NPSF Congress which is a yearly event that attracts patient safety leadership from all throughout the country, and very often other countries.  The NPSF was the first group of almost all medical professionals and hospital administrators who thought the patient’s voice was important to patient’s safety - but also gave us a voice.

About eight survivors of bad medical outcomes like myself gathered in 1999 at an early conference of about 200 people.  They were mostly risk managers and others representing the medical field.  I heard first hand from doctors and hospital administrators who also experienced the loss of family and colleagues at the hands of medical professionals.  Many who were overworked, distracted, didn’t have the right tools or information to do the best for their patients.

I remember learning how it is the system that is at fault, usually not an individual and how systems in healthcare are not built to avoid injury.  Healthcare is often compared to the airline industry and if we looked at the airline industry we could improve. 

For one thing, it doesn’t matter what airline you use, Delta, United, Jet Blue, the safety policy, going into the plane is the same.  We are screened the same and we remove our shoes, belts and laptops.  If there is a problem at Delta, every airline changes policy and learn from the incident.  In hospitals, in most cases the problems are handled internally and repaired.  Flyers are shown safety video’s or are asked to read the safety handout before flying. In hospitals we are lucky to find safety literature in our admission packets when we get home from surgery.

The airlines interview the passengers.  Hospitals have been known to close the doors when patients have questions after a bad outcome.  The pilot dies if there is a crash, doctors don’t.

Since 1996, even before I went to my first patient safety conference I have been teaching the public about patient safety.  What we, as the patient need to know to participate in our care to stay safe.  In the past 15 years much has happened in healthcare and the patient and their families voice is being heard louder and more clearly.  We have a unique opportunity to continue growing on the popularity of patient’s voices.

To learn more about patient safety and how you can be involved vist www.pulseofny.org or call (516) -579-4711

Patient Discharge - What Did You Say?

Speaking Up for the Advocate

I was invited to be at the hospital before the patient went for surgery and was confident I would have time to stay following her surgery.  I knew her husband would be there so it was important that I didn’t try to “replace” him.

My role is to be sure he has his voice as the husband and primary caretaker for the patient when she comes home the same day she has surgery – probably too soon.  When I got there I saw that her body was marked, she had a warm blanket, she was getting antibiotics and they had the patient’s list of allergies and medications.  Everything seemed to be going fine.

I left with the husband, he went to have lunch.  I came back in a couple of hours.  The surgery was successful he told me and his wife was sleeping.  He got to see her following the surgery.  He had no questions.  I thought we waited long enough.  I suggested we go see her and we were greeted by the nurse while the patient  was groggy  in the hospital bed slowly coming to.

“I went over all the discharge information with the patient” the nurse told us.  I asked the husband if he knows the plan.  He shook his head.  “Since the patient slept through your instructions, I suggest you now tell her husband” I told the nurse.  She wasn’t happy but explained the plans to both of us.  It’s no wonder there are so many problems at discharge!