Monday, March 31, 2008


I just returned from a trip to the beautiful Massachusetts where I was asked to present at the Healthcare for All conference. I was invited by Linda Kenney of MITSS, Medically Induced Trauma Support Services who lives in Massachusetts and founded MITSS after her own tragic event there.

I was deeply flattered that she invited me. After all, this was her community, but her expertise is the support following an unplanned outcome in care. I joined her at a meeting of the MITSS Task Force where a group of women discussed how they would work together to get the MITSS Mission out and help more people.

I loved the way each of these participants took ownership of MITSS. From the quietest person in the room, to the young animated chair of the committee, each participant seemed to feel responsible to the future of this organization. The energy in the room was wonderful and really very positive.

Something felt right there. We got to spend some quality time with two staff of theNational Patient Safety Foundation who were also on their way to the conference. Our late night dinner allowed us some time to chat and even laugh – something I realized I don’t do very often any more.

It reminded me how we are really all connected. And, if we aren’t, we should be. It is often our own sad experience, fear of having a bad experience or just the knowledge of knowing how dangerous, the present state of healthcare is today in this country that has made this movement grow at all. If we stay connected and pool together our work, knowledge and resources, surely we can grow strength across America to improve healthcare. But, like many of us, we need to have a voice in our own backyard first.

Sunday, March 23, 2008

Case Gone to Trial

I ran into a woman this week at the supermarket that couldn’t wait to tell me about being on jury duty for a medical malpractice case. She is not in the “patient safety network” so didn’t know anything about medical errors or patient safety. It was fascinating to listen to her for 15 minutes describe her first, second and third reactions to the world of medical malpractice from her first time perspective.

The case was of a woman who had a mastectomy. She saw her original doctor a few times early in the year who watched the calcifications in her breast not change for repeated mammographies. She had many more tests for safety than would have been expected. Finally, the doctor said don’t worry, come back in a year. The following year, the patient changed doctors and it was found she had cancer and had a mastectomy.

Of course there is 2 weeks of information I am not filling in. They settled out of court for a fairly large sum of money.

The woman in the supermarket told me the entire jury was siding with the doctor. She was surprised they settled because they all really believed the doctor did all she could with the information she was given. It was a difficult case. The woman in the supermarket was in turmoil, clearly distressed but also amazed at what she learned in just these few weeks. She was glad she said “that the woman got something”.

I asked why since the money wouldn’t change anything. She didn’t know, it just seemed like it was the right thing to do for all her suffering.

Then I asked the question that could not be answered. “How do you know if the woman actually needed a mastectomy or if the doctor didn’t just do it because it was easier than treating the patient”? I went on to ask this woman in the dairy department “Did anyone interview the surgeon and ask what was the basis for the drastic surgery?”

Thursday, March 20, 2008

There is no I in Tameka

I received a letter from the NY State Department of Health signed by Patricia Jones, RN,MN Deputy Regional Director about the complaints about the care of Tameka at a NY hospital while she suffered eleven months of infections following surgery. The letter is dated March 14, 2008 and reports that there were no violations of state regulations at any of the facilities that treated Tameka so no action is being taken. Tameka died March 13.

I can’t imagine that they looked very close or carefully since in my letter THEY DIDN’T EVEN SPELL HER NAME RIGHT!

Sunday, March 16, 2008


I went to the wake of Tameka today to see her husband Joseph and Tameka's very loving family. They displayed her wedding gown and wedding photos. Their young son ran around the funeral home oblivious to the pain that others held in their heart.

Tameka struggled for 11 months following a botched surgery and numerous other surgeries to repair the error. Tameka suffered from many, many infections. I have to wonder how things will ever change. How could this young, vibrant woman who had so much to live for die from something so preventable.

For eleven months this hospital became her home. Joseph spent as much time with her as humanly possible. I was privileged to be called in to help and get to know this family through Joseph's stories and memories of his wife.

In my conversation with the head of risk management a few months ago I was told that the husband isn't giving me the whole story. I never asked for stories or information. I wanted to make sure the husband had the information he wanted and his questions answered. Obviously, he had a right to be concerned. Now that Tameka is dead, I would like to tell them at the Long Island College Hospital "I told you so". But I wouldn't do that. It'S easy to find fault and demand answers following the treatment and yet another preventable death.

The Department of Health went in and found no violations. I went in and witnessed Tameka being treated by someone with no gloves and he never washed his hands. The nursing director pointed to her own photo on the wall when I asked her if she was in charge. When I asked each nurse their name, they scrambled for their name badges. One had to find it in another room. Not that any of this matters now.

I suggested that Joseph ask the doctor if we can find help for him to make better decisions. He told Joseph no, he was seeking advice from doctors within the same hospital. I reached out to the medical community for help. There was nothing they could do. Joseph was afraid to move his wife. She was too sick but that may have saved her. If she died because of the move, none of us could have lived with the guilt.

There is no easy answer. Joseph is warm, kind and a gentle soul with a lifetime of love left inside of him that he was supposed to share with his wife. Tameka, for many in that hospital she may be another statistic. But I will not soon forget her and what could have been if we were able to save her.

Joseph will go back to work in his hospital where he is employed to the loving community that surrounds and supports him. But love and caring just doesn't save lives. We have to start demanding better treatment or this will continue. We can not allow this to continue!