Is it Really the Pharmaceutical Company?

I just read a cute cartoon about doctors prescribing medication to their patients and taking gifts from the pharmaceutical industry. The cartoon was labeled The Hippocrates Oath. I have to wonder whose responsibility it is to take the medication or do the research about the medication the doctor prescribes.

Years ago I may have medicated my son if I didn’t test him myself that his behavior seemed to be based on the amount of sugar he consumed. He was born sick and premature and had a nurse caring for him the first 3 years of his life. She helped monitor his food. I’m not sure that I would have been able to do that myself if I had to. It was time consuming and a lot of extra work. But, he was worth it and he never took any mind altering drugs even though he had bad tempers and behavioral problems. Now, he is a wonderfully well adjusted (so far) teenager.

I can’t say the same for myself. It is easier to take a pill to lower my blood pressure than to exercise. Although, in the last few months I have really thought about getting off my medication, I still make the choice to take pills each day. Many of us know what we have to do to, we just don’t do it. We don’t even ask the doctor about alternatives to the medication.

So, I’m not sure I can blame the pharmaceutical company for the medication I take. We may have to look deeper at ourselves, in many cases.

Woman Dies

The video of a woman dying on the floor of a New York hospital has caused an uproar with many patient safety advocates. The fact that it was filmed, made it fairly simple to figure out what happened. The hours leading up to her death, the death itself and what happened following her death were all on film.

What wasn't filmed, is what the thought process was that led a security guard to ignore this woman and other staff to allow this woman to die alone on the floor of the emergency room just feet away from qualified staff to help her. Until we know what people are thinking at the time, as well as what actually happened, we will not understand or solve the patient safety problem in this country.

Letter from a Doctor

I just received a letter back from the doctor who didn't wash his hands.

He wrote in his letter; "I certainly agree with you that hand washing is an important rule to infection control. Health care professionals should certainly wash their hands or use some type of disinfectant gel after completing a patient encounter. Sometimes I will perform one of these methods of hand hygiene immediately after examining the patient while other times I will walk to an adjacent room and perform hand hygiene. On other occasions I may enter am examination room and perform hand hygiene prior to the exam".

I now understand the different methods this doctor uses to perform hand hygiene. He has educated me and explained the procedure he uses. But his thoughtfulness is how he ended the short note:

"As a result of your letter, I believe I will have an even greater appreciation for the importance of hand hygiene in both the office and the hospital setting."

I'm not sure if I would use him again but I surely would like to shake his hand. There's nothing wrong with stopping infections one person at a time. We have to start someplace.

Fountain of ….Youth?

What is the real fountain of youth? It is where people stay forever young, no?

The National Patient Safety Foundation congress in Nashville Tennessee offered many of us the real fountain of youth. It was a beautiful 3 layered fountain, set back in the area where people gathered, that we were to put flowers in as we remembered those who have lost their struggle or continue to live with their struggle of medical error, adverse medical events or unplanned outcomes in care.

It was a beautiful opportunity to remember why we were all there. To remember bad outcomes and avoid them in the future.

The NPSF has been a leader in keeping the patients voice in patient safety. The patient can mean the one’s who have used the healthcare system and received less than acceptable results. The family can mean the people who lost someone close to them from an untoward event or who help their family through the complicated medical care as part of the team. In this case, with the “fountain” which I will call the fountain of youth, has given us the symbolic gesture of seeing how many were there because of whom they lost or who they wanted to honor. A patient, friend or family member, we were there for the same reason. To remember and make sure it doesn’t happen again.

I hope the NPSF continues this symbolic tradition to help us remember publicly or privately, why we are there. This is the Fountain of Youth because those who have lost the battle from a medical error will stay young forever..........in our hearts.

Letter to Doctor Who Didn't Wash His Hands

Dear Dr.

On May 16, 2008, on the recommendation of my trusted pediatrician, I brought my son to you to look at his sore throat.

Though initially impressed by the short waiting room stay – just ten minutes, the exam room experience was not acceptable. It went like this:

You had a conversation with my son and myself, wrote your notes and very quickly grabbed your headgear and tools. You checked his ears and nose tore open a wooden stick for his mouth and examined his throat with a stick that touched your ungloved and unwashed hands.

Your actions were so quick I did not even have time to stop you other than to scream which would have upset my son terribly. All the while I assumed at some point you would have stopped to wash your hands, use gel or practice some sort of hand hygiene. It never happened.

This lack of proper hand hygiene broke all policies and standards per Joint Commission, Agency for Healthcare Research and Quality, Institute of Healthcare Improvement, National Patient Safety Foundation and Centers for Disease Control, for infection control. If these are your office practices, the hand hygiene practices in your surgical and hospital settings may be equally at-risk.

There are over 90,000 deaths a year from hospital acquired infections. Hand washing is the simplest rule to infection control. Health care professionals must be setting examples and practice basic hand hygiene to promote the reduction of spread of infection.

This happened in your office of 875 Old Country Rd, Plainview, the same building that only months earlier there was a protest and press about Dr. Harvey Finkelstein’s unsafe infection control practices gaining national public attention. As a mom, and a patient safety advocate educating patients and families on their rights for safe, quality and competent care, I am disappointed at myself for not speaking up sooner. Even more so I am deeply troubled that you would treat my child with such disrespect and unsanitary practices.

If this was not a standard patient interaction for you can you help me understand how it could have happened at all? May I share with you much of the information I have as a patient safety advocate for the past twelve years?

This experience will be a great springboard to share with others the importance of proper hand awareness in my patient safety education workshops. I just hope this does not cause a new concern in my son’s health care, or with others you or he may come in contact with.

Respectfully,

______________________________
Ilene Corina,

How Do I Say Thank You?

I have said before that this is lonely work. I'm never sure how many people are helped or if this work is appreciated although I do know that we are saving lives just by the e-mails and letters I receive.

I have known Tony Smith from SAS Real Estate for many years, even before the death of my son which propelled me into patient safety work. First, I knew Tony as a local businessman while I worked at the post office. Then, when I left, we stayed in touch and he became a big supporter and friend of PULSE. It means a lot when people get behind our work since our work is about people.

What a surprise when I looked at the back cover of our local community newspaper and Tony from SAS took out a full page ad about our upcoming Family Centered Patient Advocacy Training Workshop. How do you thank someone who puts their reputation on the line for you? Tony has a great business and has been around a long time. He surely doesn't need my push for him to sell homes. But people need to know what it means for a company to stand behind a groups struggling to do the right thing, for the right reasons and then have a power house give a push.

Thank you Tony!!

Rate Success of Patient Safety

Am I successful? Is PULSE of NY successful? Are we, as a community based patient safety organization successful? I was recently asked to think about this.

I think it depends on how we describe success. We can’t really measure our success because there are no standards on what we would measure it. Perhaps, I can think that PULSE is successful in this way:

We have probably saved lives. That is a good thing.
We are recognized by our colleagues as doing good work.

We are recognized by national leaders in patient safety as doing good work.

There is a wonderful group of people who support us either in their time, knowledge, expertise or financially.

I am busy almost every minute of every day either fulfilling our mission or finding ways to fulfill our mission. We stay on topic.
Our programs are up and running and in the communities.

These are all good things but still, the corporate world wants measurement. Something we may never do. We may never be able to rate our success. We may never have more than a few months money to help us survive. We may never even know how many lives we have saved.

So, if I am to “measure” success, I would prefer to hear it from you, my readers or feel it in my heart.

Health Literacy

I just returned from a conference in New York City sponsored by AIG and the National Patient Safety Foundation. The topic was on health literacy. This topic of health literacy is is near and dear to my heart so I was thrilled to be able to attend. As someone who spends time with people who work in healthcare it is not uncommon to wonder what the discussion is going on when the "jargon" being used is often in terms I can't follow and don't understand. Never being one too proud to say "what are you talking about" I found it refreshing to learn that health literacy has moved away from the written word and has moved towards communication skills too.

For many, it's not about not being able to read, but it's about not being able to understand what is being said. This happens every day, in every profession. It only makes sense that literacy focuses on the whole manner of communication.

The program was wonderful and left the attendees the tools to make comprehension work for the patient. It wasn't just a lecture but the tools were described to be used.

Most of this addresses the doctor patient relationship but in this case, as in many of these conferences, there wasn't a single doctor in the audience. Hopefully they are getting this education elsewhere...............or are they?

High School Germs

My son thought it was hysterical when I shrieked and dropped the pen in his high schools attendance office when I signed him out sick yesterday. “Ugh”, I heard myself yell out. “The person who signed out last had pink eye!” I continued to sign my name and immediately went to scrub my hands. The nice women there explained that the mother of the sick child signed her out.

It didn’t matter to me who signed the girl out, the fact is the germs are all over and simple precautions could have been taken to change pens or at least be aware of the germs people are carrying. I am not a germ “freak” but I do know that they are coming from somewhere and I don’t feel like getting them.

What if that woman is going to visit a friend or family member in the hospital? Would she know enough to wash before touching her friend or anything in the sick friends room? Have we become so casual with germs that it’s ok to use a shared pen with possible germs lingering from pink eye?

These infections are coming from somewhere and finding their way into our hospitals to attack our most vulnerable citizens. If we, the public don’t declare war on these germs, they will win.

My Dad's Hospital Stay

My dad was recently hospitalized in a Florida hospital. I’m not sure if it’s this work or my own past experience with medical care and the death of my son from errors in healthcare that put me into that gut wrenching feeling that hospitalization can mean a death sentence. I guess it’s something many medical error survivors feel even many years after their experience.

In this case, my mom called me with the name of the hospital and the doctor’s name. He wasn’t in for anything too serious but that shouldn’t matter. Every hospitalization should be treated serious when we know how dangerous it could be.

The hospital seemed to have won all kinds of awards and was as “good” as a hospital could probably be. But, when I looked up the doctors name on the Florida Department of Health website it read “This practitioner does not currently hold staff privileges at any hospital/medical/health institution in Florida”.

This statement on his self reported profile was as equaling troublesome:

Professional and Postgraduate Training: This practitioner has not completed any graduate medical education.

A gastroenterologist, I would have thought there needs to be some additional training.

I immediately called the Department of Health and only after speaking to 5 people, was anyone able to tell me for certain that this doctor could not practice in the state of Florida as per this profile. Calling Quality Assurance at the hospital I asked them about this information and they told me they had different information and I was mistaken. “I am not mistaken” I explained and faxed her what I was reading. “I will ask my mother to have that doctor removed from my fathers care until you can explain why this doctor can not practice in Florida”

They found another gastroenterologist to treat my dad but before he ever saw him, the first doctor called me to ask what I found and seemed completely oblivious to the states profiling website.

He went on to tell me all his credentials and his good name and then allowed me to offer to help him fix this “mess”. He gratefully accepted and continued as my fathers doctor knowing that we are empowered with information he may not (or may) have known about.

Although I am still concerned that this information was not accurate or just wrong, I was glad that we had this conversation and the practices that I preached worked. We had an open conversation, cleared the air, discussed my concerns and continued the relationship.

I will give him two weeks to fix it.