Monday, September 13, 2021

The Letter

This is an actual letter sent to an urgent care facility. I believe that if we all sent letters that consisted of constructive comments to help improve care, maybe one day, these "little" issues will be improved enough so care will be improved.

The letter unedited:

This letter is being sent to share my recent experience at one of your urgent care facilities. It is intended to be informative and hopefully helpful to you in making improvements, by highlighting some areas which I believe need addressing. I do not intent to escalate this if you can share how changes will be made to improve the safety of your patients and compliance by staff.

I am a caregiver and professional patient advocate for a man who became ill over the weekend with what seemed like a chest cold. It was not getting better so I took him to your urgent care facility, which we chose because of distance, insurance, and most of all because we trusted the logo on the front of the facility that indicated it should be a trustworthy urgent care center.

When we arrived, we were told to stay back (the 6-foot marker) and the gentleman behind the desk asked why the patient was there. This, I thought, was a personal question that should not be shouted from six feet away. He then asked for the patient’s name and address. I stopped him and suggested that this is personal information: why does the patient need to yell it so the other person in the waiting room can hear? He asked for the insurance information and then continued with the check in.

I would probably stop there but another concern was that no one washed their hands — not the person who took his vitals, or did his x-ray, or the Physician’s Assistant who came to see him. Only the woman who did the EEG washed, because I asked her to. No one introduced themselves except the PA (very quietly after standing in the background observing).

The patient was asked to lie on a bed, shirtless, with no sheet or paper. using two pillows with no covers. I wiped them all down with my own cleaning supplies but have no idea if anyone else would have done the same.  

As I watched people come in and leave the room (Exam Room 1) I noticed they were sliding the door that was touched by each person (including a sick patient) with bare hands. With my own cleaning supplies, I washed down the door and the fingerprints, which were many.

When medical history was taken, we were asked for a list of medications and since he is on over twenty, we asked if the information could be found in a portal. We were told “no”: they are affiliated with a health system but cannot see information in its portal, they can only feed information into it. I retrieved another copy of the patient’s medication list and offered it to the PA who said they had gotten them off the portal and had the list.

While the patient got his x-ray, I stepped into the hallway and heard the conversation of a woman who came in just as we did earlier. She was asked for her information as we were. Though I was standing at least 10 feet away, I clearly heard that she was there for a bladder infection, her name, and her phone number as well as additional conversation about her need for a bathroom.

When we left, we received no discharge information, though I did ask for a business card. We were not told, until I called back later, that we can get such information off a portal. 

When we went to get the patient’s newly-prescribed medication from the pharmacy, the pharmacist came to the window to explain that the medication which was prescribed, mixed with a current medication, could “stop his heart”. The pharmacist said she called the doctor and explained that there is a problem mixing these medications, and suggested an alternative.

Though your website says that you provide “world class care” at over 150 locations nationwide, I would suggest you may want to start looking at one location at a time to review your standards and policies.

Here are some suggestions:

• Conversation with a patient at the desk should be private (or have the patient fill out forms). Ask if they need help (because many people can’t read or write.)

• Staff should be introducing themselves by name and title when arriving to see a patient.

• Staff should be washing their hands before putting on gloves. Antibacterial lotion is not enough and in this case was not used by anyone.

• Medications should be reviewed with the patient if a new one is being recommended, to be sure all medications are correct.

• The cot where patients will be sitting in the exam room should be clean and covered.

• Patient should be offered a gown for modesty or leave top on and not be told to “remove your shirt”. (In our case he sat in a chilly room, so I did not let him remove his shirt.)

• Patient should be asked in private if the family member or advocate should be there. (Some patients may not want a family member or friend there but are uncomfortable or unsafe saying so in front of them.)

• Patient and/or family member should be given paperwork or information on how to access the patient portal with information about the visit. This patient left with nothing and had never accessed the portal before.

Thank you for taking time to review this letter. I hope to hear from you that any changes suggested are worthy of review.


Ilene Corina, BCPA

President, Pulse Center for Patient Safety Education & Advocacy

Thursday, July 8, 2021

Mikey's Birthday

Today is My Son's Birthday

Today would be my son’s birthday.  If he were alive, I’m guessing we would celebrate in some way.  Truthfully, I don’t miss him anymore and I’m not ashamed to admit that.  I’m happy with my life.  I have two perfect sons.  Michael’s life, and death has given me a bigger cause, so I think of him every day.

How many people do we know who have said that the doctor made a mistake, a loved one died from a preventable medical error, they have suffered their life with the aftereffects of a hospital acquired infection?

Yet still, there is no education for the general public about safe patient care.  Books continue to come out on safe patient care from medical professionals or injured people which is where we are expected to be educated.  Is the public reading academic research on safe patient care?  The public needs to be more responsible but we won’t take that seriously until one day you too are saying, it happened to me.  Truth is, I don’t belong to a cancer group or march to stop gun violence.  It hasn’t affected me or my family.  Medical error did.  Michael died following his surgery because of the doctor’s mistake.

Imagine a campaign for all people to be more responsible for their own safety.  As we buckle up on an airplane, we know to stop at a red light, we learn early to stop, drop, and roll if we catch on fire.  Why not have 5 Steps to Safer Health Care for your family to follow, for your employees to do, for your faith community to help each other?

We do!  In memory and in honor of all those who wish they knew that they too could have done more, saved a loved one or spoke up.

Let's talk

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.