Thursday, February 18, 2010

Pharmacist Released From Jail

Jailed Pharmacist is Released

A pharmacist has been released from jail because he was involved in the death of a little girl given a wrong dose of chemotherapy mixture.

Medical professionals involved with patient safety are celebrating his release but saddened that he was actually jailed. Patients and families who have lived this sort of medical error experience are celebrating his arrest, conviction and sentence.

I have mixed emotions. I can comment because I have lived it. My son was killed by a physician who allowed him to bleed to death following his tonsillectomy. Did I want him jailed? Sure, maybe jail was even too good. Did I believe jail would have helped? Probably not.

It’s not unlike hitting the dog when he messes in the house. It gives us a sense of satisfaction and release of tension but it solves nothing. This pharmacist, I believe is not a criminal, he was careless but not a criminal. He did not belong in jail. Human error will not stop because a man was jailed because of an error. Systems won’t change because of this experience. He was the dog that was hit, but, by not finding out why the dog messed in the house, it will just continue and create an angry dog.

I had a recent conversation with a hospital administrator about how people with disabilities are handled at his facility. He said that staff is taught to take extra time, be available and be careful. “But” I asked him, “Are you willing to take patients away from the nurse who has a disabled patient so she can actually spend more time caring for this patient or, do you just tell the nurse to be more careful?”

He agreed that his hospital was not lightening the load, just going through the words. So when a disabled patient falls or is injured, will the nurse be “blamed?” Hospital administrators know where the problems are. They sometimes need to address them from the “grassroots” level (see yesterdays posting).

Chances are the hospital administration knew that there was trouble in the pharmacy at that Cleveland hospital but by allowing it to continue a little girl died. If they didn’t know there was a problem, shame again that no one told them. Either way, a little girl is dead and a pharmacist will never work as a pharmacist again. No one wins – will anything change?

You can read more details about the case here from the Institute for Safe Medication Practices.

Wednesday, February 17, 2010

Communicate at Top

Hospitals and Corporate America;
Communicating with Those at the Top

As part of my Patient Safety Leadership Training I have to read many articles and stories about patient safety, statistics, corporate America and human life. The information isn’t often directly related to me or my work as I don’t work inside a hospital or corporate America, although I have in the past.

Hospitals are really no different than other corporations and the hard work that goes with being at the top. You have to be smart, strong and stable to make your way to the top of, and succeed in a corporate world. The problem is the layers in between. How difficult is it for the people who make the rules to decide what rules need to be made? Do they have access to the problem that needs addressing?

In the grassroots world, our work is often scattered amongst the most knowledgeable and those willing to help. The same people who see the problem also address it. The difference is we don’t always have the power or the money to make the changes in the larger world, so it often stays at ground level and like grass seed, will flourish and make a beautiful lawn, but maybe not a complete garden.

I think the most successful corporations are the one’s that allow the staff to have some control. The most successful leader is the one who allows others to lead and are willing to follow. In corporate America, egos are very tender. After all, they work hard to get to where they are and want to feel confident that they will stay there.

I see many conversations among hospital leadership still doesn’t include anyone from the outside. As an “outsider” there are things we can do to help improve care. We, the patients and the families see things differently than the staff do. Each person in the hospital has their job and takes pride in their department but as guests or visitors we see many departments and the services we use spread over many different areas.

Sometimes it’s as simple as looking at the website of the hospital. How easy is it to find someone to answer a question at 9:00 at night or 8:00 in the morning? Websites are often the place a family member may go to find a contact to help respond to a problem when they can’t be there. Is the name and contact information easily accessible to the CEO or Executive Director? If the patient wants someone in charge, how can they find them within the hospital?

When a call comes in with a problem, how good is the person taking the call listening? Do they ask irrelevant questions or are they trying to address the problem at hand?

Is the social worker, nursing director, pastoral care or patient representative easily accessible or are their jobs described for the patient? Who would we go to if we have an immediate concern about a family member in the hospital? If we want to know if we can stay overnight or if we want to know how a patient with special needs will be addressed?

These questions can be the start of a relationship between the hospital and the patient or family and may not be addressed if the people who make the rules don’t know if there is a problem or concern. A simple letter or reminder about how to improve services is always helpful to the person who wants to know “how are we doing?”
Corporate America, and hospitals need to have access to community and rely on their input for improvement. But sometimes we have to know what we are looking for and what questions to answer. That has to come from the top.

Tuesday, February 9, 2010

Error or Negligence?

Error or Negligence: Does it Change the Families Right to Know?

The following news information was on a local
television news story this week; a woman was “being treated for lung cancer when she suffered an accidental overdose of radiation” at a Long Island hospital. The hospital, the family said in the news piece is calling “it human error," the family is quoted as calling it “negligence."

Human error or system failure, the patient died a painful death because of this medication error. The family is demanding the technician be fired but because the technician is protected with privacy, the public nor even the patient’s family know if any changes have been made, or what they are.

I recently heard a speaker at a hospital conference tell the story about a physician who made a terrible medication error. The physician went back for training, and did a paper on the situation that caused the error. My initial reaction was that because of this institutions reaction, this physician is probably the best person to treat patients with this condition and medication and of course should NOT be let go. But, unfortunately that family also will never know what the discipline process was to the physician.

In this case, the chances are the hospital did react but are not letting the public know. In the very least they should sit down with the patient’s family and explain what the process was for making sure this mother did not die without someone paying the consequences. The privacy issue to protect the medical professional is not doing much to comfort the public and until there is transparency not only in disclosing the error, but also in resolving the public’s trust, we still aren’t there yet.