Tuesday, May 11, 2021

Another Patient Safety Conference

A Patient Safety Conference; About Patients But Not For Patients

I sat on zoom for hours today to attend a patient safety conference. A PATIENT safety conference.  The first one I went to was in 1999 when I heard healthcare professionals share their stories of their own lost loved ones.  Some, over the years, have even shared with me in secret what they have gone through.  The pain, the anger, the struggle, and grief of losing a loved one because of the system they worked for.  I don’t even know how many I have gone to since then.

Today I heard about human factors and how we all make mistakes.  A nurse makes a mistake and the patient dies.  Should she be fired? What should the punishment be when a doctor injures a patient because of the wrong diagnosis? The popular Swiss Cheese Model that anyone can plug up a hole and keep the mistake from reaching the patient.  Yes, there was talk about family involvement, but extraordinarily little, and only after the patient arrives at the hospital.  Who is teaching the patient or family about plugging up that hole?

We will keep blaming hospital staff when they get it wrong because no one is even suggesting that the PATIENT needs to take some responsibility for their own safety.  Sharing their allergies – accurately - prepare your symptoms - accurately – full medical history – accurately – list of medications – accurately and yes, even demand that the room is cleaned, and hands are washed to avoid infection.    This is not rocket science. 

One speaker brought up the airline comparison that when there was a bird strike, as annoying as it was to be delayed, they played it safe and changed planes.  The pilot, he said showed concern for the passenger’s safety first.  Well – go figure, maybe it was the pilot’s own safety that concerned him….

Two more days.  Maybe something good will come out of all this.

Saturday, May 1, 2021

Are You to Blame When Errors Happen?

Who's to Blame?

I will be the first to suggest that when an error in care occurs, the patient or their family should start at the place that made the error, and suggest that they fix it. But if they don’t share the incident any further, could that error be just hidden away, only to happen again with someone else?

Following injury or death from a medical treatment, many people will say they want to make sure the same thing doesn’t happen to another family. For years, I would suggest that the patient or family write a letter and also suggest what can be done to fix the “system” that caused the unplanned outcome. But what if there are rules and policies and training in place, yet problems still arise? 

Here is what happened. Not a physical injury, but enough to make me lose faith that a “system” can work without filing formal complaints.

The short version: at a psychiatrist’s clinical practice, the patient and I dropped off the patient’s full list of medications, the HIPAA form and a letter stating that I would be assisting the patient throughout their medical care. Two days later, the information still had not found its way to the psychiatrist, who had an outdated list of medications for this patient. When I suggested that the list he was reading from was wrong, the psychiatrist said, “Well, I don’t know if it’s accurate. There is a list, I don’t know who loaded it in, so I’m not going to confirm it that it’s accurate.” Days later the information we had handed in showed up. This doctor wasn’t curious about where it had gone in the meantime, nor was it a major concern to me because the info was now correct.

Now, several months later, it has become a concern, because the same patient received a packet of personal mental health records and notes, medications and diagnosis, and along with this patient’s information was another patient’s information, with name, medications, psychiatric notes and diagnosis.

Just one patient, and two incidents only months apart. Is this a coincidence? Or is it the result of a careless system that has seriously violated a patient’s privacy? Am I guilty because I ignored the first incident? (Where did the envelope we dropped of actually go?)

Should we assume this is not the first time a breach like this happened? If I just throw out the other patient’s private health information (there is no phone number to let the other patient know of the breach) this patient may never know. If we tell the clinic what happened, can we assume that “it will never happen again”?

So, who is to blame? Careless staff? A system that lacks training and policy? Should we blame no-one because of the system that failed these two patients? Should we assume that this breach will be taken seriously?

I would love your thoughts and welcome your opinion. Yes, I will be filing a formal complaint because if it happens again, I’m to blame.

Saturday, April 3, 2021

So, You Think You are Helpful


Now that there is a COVID-related policy in many hospitals and nursing homes that families can’t be with their loved ones, I’m going to touch on a topic that may make many people angry – but I expect that, deep down inside, many of you will agree.  Maybe, just maybe, you aren’t the best person to support a loved one in the hospital.

It is often assumed by family members that they need to be there to support their sick loved one who is hospitalized. That’s not always the case. I have been with people who are hospitalized and have been asked to keep a husband or wife away. They may be bossy, loud and feel it is their job to demand everything their family member wants or needs without thinking of the nurse’s position or the other patients.

You may just imagine hearing a father raising his voice to a nurse: “I said, my daughter needs her pain medication!”  There is no reason to think a nurse doesn’t want to get a patient pain medication. Yelling at a nurse usually doesn’t help.

A chatty family member or friend who thinks a patient wants to be entertained instead of sleeping can often not only aggravate the patient, but also roommates who need to rest. If you are visiting the patient, have you discussed how you might be helpful?  When the patient says “I want to ask the doctor or nurses about………….” grab a notebook and start writing these questions, thoughts and ideas so when the doctor comes in, you have the questions, and any new symptoms, ready. Will a visiting family member be polite and check medications,
answer questions to the nurse if you’re resting? Will they repeat back instructions, get information in writing, and work on the discharge early in the care plan? Will they ask who each person entering the room is, and why they are there? Will they make sure staff check a patient’s ID and have the correct patient?  Will they wipe down doorknobs and the TV remote and bed rail after someone touches them? You may be reading in other blog posts or articles that the patient should be doing this, but that’s not always the case and they may feel that being their own advocate can be confrontational. It can be, and that goes for the family too. Practicing to be a caregiver, support person or advocate is important to be good at what you do.  There is more to this than just being there.

I have spent thousands of hours with patients and their family members in the hospital which is why I believe that training that the Pulse Center for Patient Safety Education & Advocacy provides is crucial to anyone who will be a “guest” of a patient.  When you hear someone say that they got what their loved one needed because they are a great advocate and yelled at everyone until they were heard, think again.


Saturday, February 6, 2021

She Had No Intention to Listen


A woman on the phone asked if the class that was being offered would help her handle the terrible treatment her husband received at the hospital recently.  I wasn’t sure how to respond so I asked her what she is looking for the class to address.  The Family Centered Patient Advocacy classes we are offering at Pulse Centerfor Patient Safety on three Thursday evenings in March include hospital policies and procedures, communication skills, understanding and avoiding bias (conscious or unconscious) and other information to help a family member or friend become an advocate for a patient and even help someone decide if being an independent patient advocate is for them as a possible career.

It seems her husband, who was very ill, also had disabilities that made it difficult for him to care for himself.  She did not want to leave him at the hospital without her but she was not permitted to stay at the hospital with him because of COVID-19.   Her voice was raised, she was obviously angry, she used words that were not helpful in our conversation and every once in a while, she would take a breath and ask, “so will these classes help?”  Not waiting for an answer, she would continue in a rage about how terrible this hospital staff treated her.

I was able to get out the question “have you thought about talking to someone at the hospital?”  That started a whole new blast of anger. 

I could start practicing my empathy and my active listening skills but truthfully, I didnt see this conversation continuing.  So, I just listened and when she asked for the fourth or fifth time “so will these classes help”?  I just responded “no, I don’t think so, best of luck” and that was the end of our conversation.

If you want to join us, we would love to have you, but we won’t be solving past problems and communication plays a big role in Family Centered Patient Advocacy.  Communication such as active listening, empathy is a skill that people must want to learn and practice.  Some people want to play an instrument but don’t do it well and may never make beautiful music. They may think they are a musician but others cringe when they hear the sound.  Some people may want to advocate and communicate, but they may never make it without practice.  If you want to learn and practice, I’m happy to help – after the program, we can practice together.  Give me a call and register here:

FCPA Class - Pulse Center for Patient Safety Education & Advocacy

Monday, December 7, 2020

The Missing Link


We Found the Missing Link

By Ilene Corina, BCPA, President, Pulse Center for Patient Safety Education & Advocacy
When my world became about patient safety thirty years ago, it wasn’t only because of my personal experience. It became important because, by talking to others, I heard of many other stories where medical care went wrong or mistakes were made, and though the patients or their families saw it coming, they did not feel empowered enough to say something. Many of these people who lost loved ones or experienced harm worked in healthcare.

Sure, we are in a pandemic now and that is the health emergency we all face. Many in society, myself included, are fearful for our own health and that of our loved ones. No one wants to hear that their beloved family member has Covid. But are you prepared if you or your family were to become patients?

As I began attending medical — primarily patient safety — conferences over twenty years ago (my first was in 1999), I learned how errors happen from the people who were involved with causing them and studying them. I grew passionate about bringing that information back to the public, but it has been futile. Most people — understandably, perhaps — avoid planning for the probability they might ever be a sick or injured patient. But if they wait until its too late, they are not in a physical or emotional state to help themselves.

I have spent many years sitting at patients’ bedsides, so I have seen what can happen. Going on doctor visits, helping people prepare for surgery, sitting with people in wheelchairs, people with limited English, people who are homeless and people who are transgender, I have seen how they were treated and how care can go wrong.

Years ago, I believed that if the world became filled with patient advocates, that would be the missing piece, the link between the sick, injured or aging society and the complex, overworked, error-riddled healthcare system.

The training we have offered the community over the years has helped people with no medical background prepare to help a loved one through the healthcare system or, in many cases, to become professional patient advocates.

Maybe my old dream will become a reality: more advocates are coming and many are here already. Patient advocates can focus on many areas, such as legal, financial, medical and care management. There are the social workers, medical, support, self-trained, and Board Certified. Some specialize in rare diseases, some in geriatrics, and some in pediatrics. You can find them through associations that support patient advocates. Here are a few, and I hope you will join us on December 14th to hear from the founder of Greater National Advocates.