Saturday, July 28, 2007

Medication Safety Report one Year Later

A year has past that the Institute of Medicine of the National Academies reported that “Medication errors are among the most common medical errors, harming at least 1.5 million people every year”. On July 20th, 2006 the report read that extra medical costs of treating drug-related injuries occurring in hospitals alone conservatively amount to $3.5 billion a year, and this estimate does not take into account lost wages and productivity or additional health care costs.

Do you feel safer a year later? Do you have knowledge of what can be done to protect yourself from medication errors at home or in the hospital? The report estimated that on average, there is at least one medication error per hospital patient per day, although error rates vary widely across facilities. Not all errors lead to injury or death, but the number of preventable injuries that do occur is estimated at least 1.5 million each year.

The report provided consumers with information to become more interactive in their own care such as asking questions about how to take medications properly and what to do if side effects occur. This is not always possible if a patient is sick or injured. But this is obviously important enough for consumers to have an advocate available to help with this life-saving information.

Also included are actions consumers should take, such as requesting that your providers give you a printed record of the drugs you have been prescribed. Patients should maintain an up-to-date list of all medications you use -- including over-the-counter products, herbals and dietary supplements -- and share it with all your health care providers and the pharmacist. This list should also note the reason you take each product and drug or food allergies you may have.

If patients are too sick to do this on their own, PULSE of New York, a grassroots patient safety advocacy organization encourages family members to help each other. Other tips for patient safety can be found at

Our government spent hundreds of thousands of your tax dollars on this study, won’t you expect them to at least share this information with you?

Thursday, July 26, 2007

How Heroes Are Made

I often think back to 1997 as I stood up high on a stage with a large curtain behind me and looked down upon over 100 adults over the age of 65 drinking coffee and eating bagels at a local senior center. I was to be their guest speaker about being active participants in their healthcare for the best possible outcomes. As my colleague handed out literature about patient safety, I spoke about the lack of information available to the public about healthcare. This was even before the Institute of Medicine report came out in 1999 that made safety, a bit more common term in healthcare.

For the years that followed, I continued these speaking engagements any place I was asked to speak. Out of these presentations came lessons I would learn, that I could share with the next group I would be able to speak to. In the years that follow that fall morning that I stood on a stage, I have always wondered who that works in healthcare will ever back me up on the numbers and statistics that I share.

There are many leaders in healthcare who acknowledge there is a problem with medication errors, infections and bad outcomes. They often talk amongst each other and lecture to rooms full of other medical professionals. But, it’s the public who must be aware of the problems associated with care also so they can play a role in improving outcomes. Were there no leaders who would do this?

On June 6, 2007 I was invited to speak at the New York City Health and Hospital Corporation Community Advisory Board Annual Meeting. Each facility associated with NY City HHC has a Community Advisory Board or CAB. The CAB is made up of community leaders who work together for the improvement of the hospital for the community.

On this date, I was going to speak to the CAB members about patient safety. I’ve done this hundreds of times before, but never with the support, full support of a hospital or healthcare systems leadership. On this evening, after everyone was well fed, I was going to tell them that people die in hospitals from medical errors, infections and other complications that shouldn’t happen. I was going to tell them that it could be them or someone they love next and I was going to tell them that the hospital leadership knows this. I would tell them true stories about people who have died in hospitals, how it could have been avoided and what they should do to participate in their own care. And, I hoped to even be able to make them laugh at some of my stories, experiences and audio-visuals.

As the early part of the evening went on, I sat next to Mr. Alan Aviles, HHC President and CEO. I asked him if he was ready. “There will be no turning back” I told him almost feeling sorry for him.

He made a comment about full transparency and shook my hand. “Full transparency” I thought. You can’t get any more transparent than this.

Mr. Aviles was introduced to his community and he was supposed to speak for 5 minutes. The 5 minutes turned into much longer as I listened, heart pounding and palms sweating as the Chief Executive of one of the nations largest healthcare system stood in front of his community members, customers of his services and told them exactly what I would have said. “Medical errors kill as many as 98,000 people a year in hospitals”.

He told them the truth. He told them about errors, infections, deaths and injuries. As my heart beat with anticipation, I watched the audience staring in awe, some with their mouths wide open, some with their face all twisted, all listening intently. I sat at the edge of my seat waiting, waiting to see what else he can say. He continued to tell the truth.

I wasn’t sue the rest of the audience knew how courageous Mr. Aviles was that day. I am sure his staff there knew. He didn’t sugar coat the problem and he spoke directly to those who use his healthcare system. This bravery to me has never been matched. Now when I go to speak with his staff or work with the patients of NY Health and Hospital Corporation I will do so with the same respect he showed everyone that day. His patients deserve the best and he wants them to have the best. Shouldn’t we all be there to help him along? To fix a problem, we have to acknowledge a problem and that’s how heroes are made.