One and Only

Safe Injections

I went to get a vaccination today and as the woman came into the room with a needle, wrapped in cellophane and a vial in her other hand,  I asked her, will you be reusing a syringe or the vial?

“This?” she asked as she held up a small glass container that looked about the size of a thimble.  “There is only one dose in here”.  She told me that some medications have more than one dose but in this case,  it is a single dose and then will be thrown out.  She asked me why I was asking.

Disposable Needle and Syringe

 “I just attended a program on safe injection and learned about one needle and one syringe.”  I told her I was curious if she ever heard of that.  She hadn’t, but showed me the whole needle and syringe gets thrown out after it’s used. She displayed the packaging  that she just opened to retrieve a new, unused needle and syringe.   I was grateful for this real time discussion on safe injections.  I could now say I practice what I preach.

I asked if she knew of others who may reuse the syringe or is it pretty standard to use disposables.  She said she didn’t know what others do but was confident that in this doctor's practice only disposable needles and syringes are used.  I felt reassured and just before she walked out the door she said “not only is it unsafe, but to not throw them away is gross”. And she was gone.  I barely felt her giving me the shot.

To learn more about the Safe Injection Campaign, read about it here:  One and Only

NPSF and Patient Safety

Patient Safety from the Top

Next week I will be at the board meeting for the National PatientSafety Foundation.  From there, the NPSF Congress which is a yearly event that attracts patient safety leadership from all throughout the country, and very often other countries.  The NPSF was the first group of almost all medical professionals and hospital administrators who thought the patient’s voice was important to patient’s safety - but also gave us a voice.

About eight survivors of bad medical outcomes like myself gathered in 1999 at an early conference of about 200 people.  They were mostly risk managers and others representing the medical field.  I heard first hand from doctors and hospital administrators who also experienced the loss of family and colleagues at the hands of medical professionals.  Many who were overworked, distracted, didn’t have the right tools or information to do the best for their patients.

I remember learning how it is the system that is at fault, usually not an individual and how systems in healthcare are not built to avoid injury.  Healthcare is often compared to the airline industry and if we looked at the airline industry we could improve. 

For one thing, it doesn’t matter what airline you use, Delta, United, Jet Blue, the safety policy, going into the plane is the same.  We are screened the same and we remove our shoes, belts and laptops.  If there is a problem at Delta, every airline changes policy and learn from the incident.  In hospitals, in most cases the problems are handled internally and repaired.  Flyers are shown safety video’s or are asked to read the safety handout before flying. In hospitals we are lucky to find safety literature in our admission packets when we get home from surgery.

The airlines interview the passengers.  Hospitals have been known to close the doors when patients have questions after a bad outcome.  The pilot dies if there is a crash, doctors don’t.

Since 1996, even before I went to my first patient safety conference I have been teaching the public about patient safety.  What we, as the patient need to know to participate in our care to stay safe.  In the past 15 years much has happened in healthcare and the patient and their families voice is being heard louder and more clearly.  We have a unique opportunity to continue growing on the popularity of patient’s voices.

To learn more about patient safety and how you can be involved vist www.pulseofny.org or call (516) -579-4711

Patient Discharge - What Did You Say?

Speaking Up for the Advocate

I was invited to be at the hospital before the patient went for surgery and was confident I would have time to stay following her surgery.  I knew her husband would be there so it was important that I didn’t try to “replace” him.

My role is to be sure he has his voice as the husband and primary caretaker for the patient when she comes home the same day she has surgery – probably too soon.  When I got there I saw that her body was marked, she had a warm blanket, she was getting antibiotics and they had the patient’s list of allergies and medications.  Everything seemed to be going fine.

I left with the husband, he went to have lunch.  I came back in a couple of hours.  The surgery was successful he told me and his wife was sleeping.  He got to see her following the surgery.  He had no questions.  I thought we waited long enough.  I suggested we go see her and we were greeted by the nurse while the patient  was groggy  in the hospital bed slowly coming to.

“I went over all the discharge information with the patient” the nurse told us.  I asked the husband if he knows the plan.  He shook his head.  “Since the patient slept through your instructions, I suggest you now tell her husband” I told the nurse.  She wasn’t happy but explained the plans to both of us.  It’s no wonder there are so many problems at discharge!

Rapid Response Teams

The Rapid Response Team

While sitting in the waiting room at a hospital waiting for the patient to come out of surgery, I heard over the loud speaker, “Rapid Response Team to 2 west, Rapid Response Team to 2 west, Rapid Response Team to 2 west”.  The words broke the otherwise silence of family waiting patiently reading or texting.

They were unaware of the importance of the words they just heard.  The excitement ran through my body because in the middle of a sunny afternoon, hospital staff were acting on a fairly recent system to save patients who might otherwise die.

The Rapid Response Team, also known as the Medical Emergency Team is in place at many hospitals to be called by patient, family or staff when a patient is in need of fast intervention.  Unexpected cardiac arrests in hospitals are usually preceded by signs of instability (1) and these patients are often cared for by junior staff. (2)

Following the Australian model the Rapid Response Team or RRT brings ICU level care to the patient’s bedside using interdisciplinary teams.(3)

Although there is still some controversy such as would this method be abused or are highly trained physicians being taken away from one patient to care for another(3), those of us know the importance of the RRT also know that we would rather be in a hospital that uses them, than not.

Look for the signs on the wall of your hospital and see if there is a RRT in place.

1.       http://chestjournal.chestpubs.org/content/98/6/1388?ijkey=7401141a409d505da84eaca67df498c09826d1c8&keytype2=tf_ipsecsha&linkType=ABST&journalCode=chest&resid=98/6/1388

2.       http://www.bmj.com/content/324/7334/387.abstract?ijkey=627eb37a84ed65585ace104c27ed907ef3177b72&keytype2=tf_ipsecsha

3.       http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2687898/

Health Literacy at it's Worst!

The High Cost of Health Literacy

I have been following the story of John Gonzalez, a 70 year old man from Long Island who spent six months in jail after killing his elderly mother.  He was let out with time served and will have five years probation.  The reason he was let go is because the judge and everyone on the case felt bad for him because he was diagnosed with cancer and thought he would soon die.  He was the only person who could care for his mother and out of desperation, took her life and tried to take his own.  The Newsday article by Andrew Smith reads in part; He suffered from diabetes, joint pain and other maladies. Then, when he got a letter from his doctor informing him that a spot on his hand was skin cancer, his poor English led him to believe he was going to die soon and no one would care for his mother, Brown said.

I can only imagine how many other times Mr. Gonzalez has used the healthcare system and didn’t understand the diagnosis and treatment.  The article also reads:  After she died, he tried to kill himself by taking all the insulin he had and slashing his wrists. He was unconscious for four days and, as a result of the insulin overdose, he wrecked his kidneys and now needs dialysis at least three times a week.

So now, not only is a woman dead, but Mr. Gonzalez will be getting medical treatments that will cost the economy plenty – just because he didn’t know where to go for proper information or an interpreter who could help him understand.

More to come – You can count on it!

C. diff

Washing Hands Can Make a Difference

Wash your hands before eating takes a whole new turn after reading this article in LI Newsday.

A recent article in Long Island’s Newsday by Delthia Ricks explains in detail the problems with the bacterial infection Clostridiumdifficile, also known as C. diff.  This bacterial infection, known to cause severe pain, diarrhea and high fever is a serious problem in hospitals throughout the country.   In 2009 there were 337,000 cases Ricks reports in the article, more than doubling the number from the less than ten years earlier.

The spores can live for months and can be spread if not killed with bleach in a room where the spores might be living in a patient’s room.  To clean hands from the spores soap and water must be used.  The hand sanitizers won’t do it.

So how does this change what we already know?  As a patient safety educator I will let people know that soap and water must be used when someone enters the room to treat a patient.   If you feel uncomfortable asking someone to wash their hands, carry this article with you and tape it to the patient’s wall. 

When a family member or friend visit – leave the flowers home and bring a container of Clorox wipes.  Grab some gloves and wipe down the room.  The tray table, bed rails, door and door knob, TV remote, call bell and sink.

Wash your own hands repeatedly with soap and water and if you touch anything wash again.  Your hands may be clean when you come in but anything you touch can be contaminated which will start the process of contamination over again.

A recent discussion at a group training caused an outburst by a woman when I suggested that unless hands are noticeably soiled, antibacterial lotion can be used.  She was upset by this comment because her mother suffered from C. diff.  Her knowledge on the subject made me and my colleague Jeff, who has been offering these programs with me, to rethink how we discuss infection prevention.  If C. diff is as big a problem as it is said to be then we have a right to insist on soap and water.

NY State information on C.diff http://www.health.ny.gov/publications/1495/
Pamphlet on C.Diff http://www.health.ny.gov/publications/signature/1495.pdf

A Patient Advocate

The Many Roles of a Patient Advocate

A patient advocate isn’t always someone who sits at the patient’s bedside and in many cases watches them sleep, or someone who helps with bill payment, insurance coverage or medical chart explanations.  A patient advocate can wear many different hats and, if patient advocacy is something you want to do, I suggest you think about the best way you can help.

I received a phone call this week from a social worker who received a call from one of her clients who was hospitalized.  The client didn’t want to have a procedure the hospital wanted the patient to have.  If the patient didn’t get the shock treatment, the patient would be institutionalized the hospital staff told the patient.  This is something the patient feared.

The social worker called PULSE of NY to find out how to find a patient advocate within the hospital to help her client.  I explained that if there is one, just call the switchboard and ask to speak to the patient representative or patient’s advocate and she would be connected.  If there isn’t one, she will get connected to the person doing that work, which may be in the quality department or nursing department.

The social worker said she couldn’t find the contact information on the website; something I have found frustrating for years.  The social worker didn’t want to get too involved because she understood the HIPAA laws.  (HIPAA, HIPAA, HIPAA!!)

I went on to explain that she can play an important role right over the phone and HIPAA had nothing to do with it.  Here’s what I explained she should do:

Get the patient advocate / representative from the hospital involved.  Ask NO questions about the patient.  Just explain who you are and that you are encouraging further conversation between someone in the hospital and the patient.  Immediately after contacting the patient representative the social worker should call the patient and let the patient know that contact has been made.  Have the patient contact the social worker while the patient and the advocate / nurse or doctor are in the room.  The patient can hand the phone to them and ask the hospital staff to explain to the social worker what is happening or put the call on speaker – no HIPAA violation if the patient does it.

Now, the social worker and the patient can have a conversation and together decide what is best for the patient.  The social worker, acting as an advocate can help build that bridge for better communication.  The additional time spent with the social worker, in many cases is a welcome relief to hospital staff if they are not making headway with a patient.

Now at least they will feel they are getting actual informed consent or, if the patient still refuses treatment, they know they did everything possible.

There are two sides to every story.  The social worker is only hearing what the patient wants to tell her.  There may be alternatives the patient didn’t hear or the patient may be acting out.  Whatever it is, the patient needs a trusted, neutral, supportive and calming voice to help the team get through this.  In many cases patient may not have family to help them through a hospitalization but that doesn’t mean there is no support.  With phones available in every room or patients with cell phones, friends, families and even patient advocates can be helpful from miles away.

Patient and Family Advisory Council

Patient Safety Awareness Week

As a decade of Patient Safety Awareness Week celebrations come to a close, it’s a reminder of what we are actually celebrating.  I spoke yesterday at a major metropolitan hospital about the patient’s role in patient safety and we I had an opportunity to meet with their patient and family advisory council’s patient safety committee.  Years ago it would not be “safe” to have a community member (who is not on the hospital board of trustees) know that there are errors made in the hospital.  Now, it would be unsafe to not have a patient or their family member there, in the trenches, to look, listen and share what is happening.

The participants of this focus group shared their work and even some of their own unplanned outcomes and disappointments in their care.  But, what they all had in common is the utmost respect for the facility as well as the people who run it.

How could it not be wonderful for senior administrators to have volunteers who are available to be the eyes and ears of the hospital from the ground up.  As a bedside advocate with over 600 hours bedside time, this is really where we can see how errors happen.  I remember seeing a nurse stop preparing medication because I asked for a pitcher of water.  I have seen how the medicine cart, supposed to be at the patient’s bedside doesn’t fit through the door.  I have seen a nurse have a conversation with the wrong patient and a family member correct the chart – no, the surgery will be on the left side, not the right side.

To report these as “near misses” becomes tedious and there is paper work, but patients or community members understanding where things can go wrong can also be a set of eyes and ears to help improve the system.

We've come a long way baby!

What's in a Word?

A 17 year old who is living with me was desperately in need of a tonsillectomy. I made the choice to go through it with him even though my child bled to death, for 8 days following his tonsillectomy a number of years ago. Repeated trips to the emergency rooms were halted with the doctors saying "don't worry". Years later, I realized it is my job, as a parent, to worry and those words, used by a healthcare professional are worse than fingernails on a chalk board............... now what?

The surgeon answered all of our very suspicious questions about his history of tonsillectomies very eloquently until I asked the young man to leave the room and shared my own personal experience with the doctor. He looked me in the eye and said "I understand your concern".

Imagine my shock when the child I am caring for, on day five, began spitting up dark red blood. When I reached the surgeon by phone, he again said "I understand your concern" and again said it after he treated him at the hospital. Not until about 2 days later did I realize this physician has never used the term "don't worry".

I thought it important to share this and let people know how important words can be when there is an emotionally charged situation. 

The words "don't worry" can be seen as an order - or being told what to do (or not do). They leave no room for dialogue unless someone who is scared wants to put up a fight. Rarely will someone stop worrying because someone tells them to. They will, instead hold back their true feelings and concerns, maybe pleasing the medical professional who doesn't want to explain any more??

This surgeon was justifying my feelings. By recognizing he understood, I had no reason to pursue my concerns because he heard me.

I hope people in the medical field will throw out the words "don't worry" and try using, instead, "I understand your concern".

Accredited and Complaints

Accredited Facilities

I was always pretty confident that I would recommend a Joint Commission accredited facility instead of one that is only inspected by the state.  Joint Commission standards are higher than the state and the state can easily say they are overworked and don’t have the budget to hire more people to check on problems.

As I visited a local healthcare organization recently which was not accredited by The Joint Commission, the differences started to unfold in front of me.  Although I am far from being an expert, the whole feel of cleanliness and care was very different than any place I ever visited.

Besides the fact that almost none of the staff say hello, greet the patient or visitors with anything but a “did you call?” or even smile when I smile at them, they seem unhappy having a job and particularly working in this facility.

I went to the nurse’s station and asked a woman if she had an antibacterial wipe that I can use to wash a television remote that fell on the floor.  She handed me a container that was empty.  I showed her it was empty and asked if she had antibacterial wipes.  These, I explained do not say they kill germs and are for hands, not objects.  She stared at me for a moment and handed me another container of the same product.

I can’t be sure that if this facility was accredited by the Joint Commission it would be any different, but when I started to see areas of concern, I thought about who the patient or their family would complain to.  The state has reported being low on funds.  What if they never got to my complaint?  Who would I complain to then?  The Department of Health is not going to go out of business, even if they are backed up for years.  Organizations like The Joint Commission are independent and would have to hire more people if the problem got out of hand.

I wouldn’t say that a facility not accredited by the Joint Commission is a better choice or not.  What I am concerned about is what if things aren’t going smoothly.  Who would you want on your side