Patient Safety Awareness Week 2010

Patient Safety Awareness Week 2010


Yesterday, I had the wonderful opportunity to speak at the Long Island Veterans Affairs Medical Center for Patient Safety Awareness Week. I spoke on the topic of the patient’s role in patient safety. It was a crowd of about 150 people who gathered and in the back of the room were the poster presentations of the hospitals safety initiatives all year. Fall reduction, infections and Root Cause Analysis were but just a few of the important topics addressed through poster displays.

The participants at this conference, mostly staff of the VA were reviewing their colleagues work after listening to my presentation and the presentation of long time friend to PULSE Dr. Mark Graber, Chief of Medicine. Dr. Graber was the person I first turned to, to get Patient Safety Awareness Week started back in 2002. Without hesitation he went to his colleagues in the VA and soon the whole country was supportive with the leadership of the National Patient Safety Foundation.

I still would like to see more community partnership in patient safety. Patient Safety Awareness Week was developed so the hospitals and healthcare providers can take pride in their work around safety but also, so they can tell us, the community what they are doing to keep us safe. Without the community knowing about fall prevention programs, hand washing initiatives or the work being done in the other areas of patient safety, we still are not in a position, as a society to “question” our care. If the only place patient safety is being discussed is behind the closed walls of the healthcare system, than where do we, the patients and families fit in?

Unfortunately, we’re not there yet. I have lots of ideas how we can get there but until we as a community are not part of the solution, well then, you know the rest…………………….



(Photo L-R Anna Gaeta, Patient Safety Officer VAMC, Me, Florence Fallon RN, Recently Retired Patient Safety Officer VAMC)

My Trip To Guam

My Trip To Guam, a Life Changing Experience

I handed the woman in the audience the microphone, “I advocate for children every day in my job and parents are giving their children medication that makes them aggressive,” she told the crowd of 300. “Parents must speak up and not just give their children medication without questioning their care.” Her eyes welled up and she began to cry. “We need this education!” The audience applauded her courage. These sentiments were shared throughout the day at the Guam conference where I spoke for an entire day on Saturday, March 6 teaching the people of Guam how to be patient advocates for themselves and their family.

Medical professionals from the Naval Hospital, the local community hospital, nursing school and community members gathered to learn how to “Speak Up and Be Part of Your Healthcare Team.” This conference was being sponsored by the Guam Healthcare and Hospital Development Foundation founded by my host Peter Sgro. People of the villages of Guam were going to learn that they can speak up and it wasn’t going to be considered “disrespectful” to question their medical care and treatment.

The conference covered the true stories of medical injuries of patients and the families who have contacted PULSE over the years. We discussed F.I.L.M.S., Falls, Infections, Literacy, Medication and Surgery safety and communication. After each topic, I asked if anyone had an experience they wanted to share “because by sharing experiences we can learn how to prevent them from happening again”. Encouraging transparency with no fear or embarrassment and talking about their experience should help encourage future conversations. The morning session was the first time most of the people in the room ever heard of the Institute of Medicine report of 1999, where studies show that as many as 98,000 people die in hospitals every year from preventable medical errors.

The morning session covered communication and listening skills as a patient, family member or a provider. We practiced listening and reviewed the feelings and needs the patient has and the feelings the doctor might have being questioned by a patient. Reminding the audience that I was only there for a short time, it was up to them to keep this conversation going.

One man stood at the microphone and said he is afraid of speaking up and asking the doctor to wash his hands. “He may hurt me if I do,” he said sharing an obvious concern that others in the audience kept to themselves. I asked him why he thinks he will be physically harmed if he was polite. Handing the microphone to a physician in the audience, I asked him “can you tell this man how he can ask you to wash your hands without offending you”? The physician, from the local naval hospital dressed in his crisp, white uniform stood up and addressed the man directly. "Would you ask a food handler to wash if you saw they didn’t wash before touching your food”? When the man replied he would, the doctor reminded him it should be no different talking to his doctor.

The audience was eager to learn communication as a patient or to help family members as their advocate. I shared with them ways they can be involved with keeping medication records, lists of allergies and past procedures.

The afternoon session started with a proclamation from Guam’s 19 Mayors declaring March 7 – 13 Patient Safety Awareness Week. They never before celebrated Patient Safety Awareness Week but now had a reason to.

The Proclamation reads in part:

• One in five Americans report having experienced a medical error.....
• Medical errors lead to unnecessary readmission's to hospitals and thousands of deaths each year....
• Reports support the position that having patients and their families become a member of their own healthcare team results in better outcomes.....
• We encourage patients and their families to take a more active role in their on healthcare to ensure their safety and well being....
• Our island's ability to solve its health care crisis depends in no small part on whether our political and private sector leaders can articulate a shared vision of the kind of healthcare system that will meet the needs of all thoise who call Guam home..............

In the afternoon, we viewed the video “The Faces of Medical Error, From Tears to Transparency; The Story of Lewis Blackman.” Lewis was a 15-year-old boy who died from medical error at a South Carolina Hospital. The viewing of the video was followed by a panel discussion of five medical professionals answering questions about how this could happen and what steps are being taken to prevent a death like this from happening again. The audience seemed relieved when I asked a pharmacist on the panel if she ever heard of the story of Lewis Blackman and she said “yes” it has been used as a teaching tool for pharmacist. Again, I reminded the audience about how talking about problems such as Lewis’ death is how we will keep them from happening again.

Earlier in the week I did a press conference, radio show and television talk show. Before the radio program a man walked into the room where Peter and I sat waiting. This man was so happy that he didn’t need the triple bypass surgery he expected. The visiting cardiologist on Guam told him that his scheduled triple bypass was no longer needed. This man believe that prayer, prayers he told us his church offered, friends and family offered and his wife went out to seek for him.

With so few specialty doctors, there is only one cardiologist on Guam who makes the decisions. Many residents wait for visiting doctors to come and diagnose or treat a problem. In this case, I am sure it wasn’t prayer that changed the plan for this man’s medical care.

Sadly, patients often have to leave the island to get care. Families are often left behind because of the high cost to travel. Peter tells me the story of a young boy being treated for cancer on the mainland leaving his family behind. Having loved ones close by is supposed to help patients heal faster. Though they proudly display the American flag, there is such a primitive way about Guam’s healthcare system. Someone mentioned that it’s not much different than a third world country.

Guam may well be one of the most beautiful places in the world with such beautiful beaches, magnificent trees and warm weather. A small island of 160,000 people it was hard to not go someplace that Peter was not recognized or greeted. But, hidden under all that beauty is community desperate for information and knowledge on things we take for granted – our rights to speak up for safe, quality care.

My Trip To Guam, Day 1

I just returned from a long walk in Guam. I walked up and down the hills but never made a turn. Those of you who know me know that it can be the end of me if I make one turn, I may never find my way back to my hotel! So, I just walk straight thinking about my day, looking at the beautiful view and passing the many stores with familiar names where tourists gather like Gucci, Prada and Rolex.

I am brought half way around the world by a gentleman with the same passion as I have; to give our family, friends and community safe quality healthcare. Peter lost his mother a few years ago. She was treated in the hallway of the emergency room at the only community hospital in Guam. With much less than 200 beds and a small emergency room, this hospital with no room for expansion treats almost all of Guam’s 170,000 residents. Many, who don’t have health insurance come to the emergency room sicker than they need to be were they to get regular medical care. Peter doesn’t blame anyone for his mother’s death as he explains the long delays to her surgery. She would be ready to go in early in the morning but not be seen until 7:00 at night. Peter explained that in Guam, families take care of each other. They live nearby and when someone is sick, the family is there.

Following his mother’s death, Peter turned to his wife and said something has to be done to improve healthcare on the island of Guam. He gathered 22 people together, got the support of the Mayors, and started the plans to build a new hospital. The foundation is raising the money and after 3 years, are about ready to sign with the contractors and the architect. Imagine someone in New York saying “I don’t like the way the hospitals run” or “the hospital is too small so I am going to build a new one.”

The Foundation Peter founded and the Mayors Council have agreed that they want the public to know and understand patient safety so they can be partners in their care. They have invited 300 community members to an all day conference for free to learn about patient safety. Today we did a television show and a press conference. Tomorrow will be a 90 minute radio show and on Saturday, March 6 I will be addressing over 300 people including medical professionals, nursing students and people from Guam about what they need to know to help ensure their safety and the safety of their family in the hospital. Who would have thought that Guam is even more progressive than New York?

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.

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.

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.

Visiting Long Island's Patient Safety Institute

Patient Safety Intitute at North Shore LIJ Health System

The Patient Safety Advisory Council held a recent meeting at the North Shore LIJ Patient Safety Institute. Participants were obviously impressed with the program developed so healthcare workers are no longer “practicing” on patients. We were given a tour of the many rooms that held patients which are actually mannequin simulators under a blanket, in a bed set up in a hospital room that was so authentic looking you can easily forget about the office building we walked into to get there.

The tour consisted of about 3 rooms with a mom and newborn baby and full sized, fully functioning adults. Kathleen Gallo, RN, PhD, MBA Senior Vice President and Chief Learning Officer North Shore-LIJ Health System and Alan Cooper, PhD, MBA gave us the tour and the history of the program. Dr. Gallo explained that they can make almost anything happen that could happen in a real hospital room as training for the many medical professionals who come through this center which is about 4 years old.

One of the scenarios, Dr. Gallo explained is that the mom could have a baby in distress, and then the dad could faint and injure himself too. Also using real live actors to go with the simulators, leaves the opportunities open for more dramatic events.

We were given a full demonstration by the staff at work with the simulators and the very important debriefing following the 15 minute demonstration. This is where staff get to talk about what happened and how they did. Did they do what they were supposed to do at the right time? How did they feel and how did it go? Alan Cooper led the debriefing.

One of the interesting parts of watching the events unfold during the simulation demonstration was that everyone cooperated. We would never know who was in charge or who got along with whom. The focus was truly on the patient and how will they, as a team gets that patient better.

We were able to ask questions about why they did some of the things they did. The patient, obviously having a heart attack was given aspirin to chew when suddenly the patient said “I can’t take aspirin, did you just give me aspirin?” With no chart available, no one could find it; they now had to watch for what the patient’s reaction may be to aspirin. Did the nurse wait too long to call for help and how would the Rapid Response Team that was called handle the situation knowing nothing about the patient?

The nurses and doctors treating the patient do not know what will happen. "The Wizard" as the person is affectionately called, behind the glass, is making the patient speak and react using controls, with no warning to the staff on the other side. When the patient lost consciousness, I felt my adrenalin respond with the fear that they were losing the patient. They were still moving at a speed with accuracy and professionalism as if choreographed for them. No one stepped on each other and no one barked orders. The patient survived - and we were left with a new appreciation for modern medicine, patient safety and the incredible training available at the Patient Safety Institute on Long Island.

Health System Grand Rounds

Grand Rounds for Everyone

North Shore LIJ Health System on Long Island is hosting a series of Grand Round presentations once a month. The system, one of the largest in the north east invited me and members of the Long Island Patient Safety Advisory Council to attend.

This week the speaker talked about patient safety rounds. High level administrators take one day a week and spend a good part of the day going to a department or floor of their hospital looking for problem related to patient safety. The speaker, from another New York health system talked about how important it is for every level of staff to know about patient safety and be involved in the patient safety process. “It’s not about the Joint Commission survey” he explained. “It’s about the patient”.

A member of the PSAC who couldn’t come asked representative from her organization to come. Kyle works in the emergency room of a Long Island hospital and is a paramedic with the local ambulance corp. Although Kyle’s specialty is not patient safety, he was very aware of the information being discussed and even answered some questions that were asked to the audience about patient safety procedures.

I have known about patient safety rounds for awhile because I am involved daily with patient safety and am very often at the “cutting edge” of what’s new in patient safety. I was, in fact surprised to learn that all hospitals are not presently doing patient safety rounds. But, I am just happy to see that they are starting.

The presentation, though interesting, I feared may be too clinical for someone who does not specialize in patient safety. So, I was deeply thankful when I asked Kyle what he thought and he said that it is important for the community to know that this is happening in hospitals.

The speaker talked about a young doctor who made an error prescribing medication that very seriously injured a patient. The “no blame culture” encouraged this to be a lesson for the physician. She was not fired but instead was retrained and had to do a paper on the topic of her retraining. This punishment would probably do a lot more to improve patient safety than firing a doctor but what about the patient who was injured - and the family. I hope they know that this doctor did not go back to work the next day as if nothing happened.

Transparency in healthcare is not just about the conversation following an unplanned event. It should at least be that we, the patient and community know what is being done to keep us safe to begin with.

Death Can't Always Be Avoided

Death When It's Meant To Be

The patient died. It was no one’s fault but my friend who works in the emergency room told me about it and he was sad. People in healthcare recognize their own mortality when someone dies or may feel like they failed the patient and their family. Whatever reason, people who work in hospitals, I am convinced, have feelings. They love, they hurt and they anger. But we often don’t see that as the patient. We just want to get well and that’s what we go to the hospital for.

This becomes more of a reason for transparency. More of a reason I need to know what is happening in the hospital and the people in the hospital need to include the patient in the decision making and treatment plan. As part of my Fellowship with the American Hospital Association and National Patient Safety Foundation Patient Safety Leadership Training I am reading articles written for the medical professional about transparency. It is written for the healthcare workers but there can be much more for the public to help understand how errors happen.

If we felt we understood how errors happen, we can be more of a part of the team to help avoid them. A survey we are doing now is giving more and more input into medical errors. Patients and families who have been to the PULSE training are reporting what they see. By making patients and families aware of what to look for and how to speak up to avoid errors, we can play a role in stopping them. I am reading now how our training has stopped the error from reaching the patient. Hooray!

But, not all deaths are because of an error. And I want to still be sad for my friends in healthcare who are part of death, even when it was meant to be.

Medication Distribution

Medication Distribution and the Patient Safety Advocate

An all too common practice in hospitals is still an ancient custom that the nurse brings the medication to the patient in a cup, out of the wrapper. I have seen this in numerous hospitals in numerous states. When asking about this, it seems to be easier for the nurse to prepare the medications at his or her work station and then bring them to the patient.

I questioned some of the experts in this field and was given a big thumbs down to this practice. Medication should always be in its original wrapper when given to the patient.

Grena Porto, from QRS Healthcare Consulting remarked “this system that you described leaves no room for patients to participate in their care and in error prevention. Even without state of the art technology, there is still no reason that a nurse can’t go into a patient’s room with the meds still in their wrappers and confirm them with the patient.”

A nurse can be distracted easily, and walk into the wrong room with medications. Or, while preparing the medication, she can mix then up. This error would be completely preventable but unknown to us until it’s too late. Without the patient’s name on the medication themselves the nurse is working completely off memory.

When asked the best way to handle this dilemma, I received this response from Michael R. Cohen, RPh, MS, ScD President Institute for Safe Medication Practices “I think the patient (or advocate on behalf of patient) should ask to see the packages if they are not brought into the room. Just let the nurse know this expectation right up front and they could put on the med sheet or Electronic Medication Administration Record (e-MAR)”

How we speak to the medical staff is important. Hospitals are stressful enough. Jennifer Gold, a Pennsylvania nurse gave this advice ” you could say ‘Would you mind bringing the pills in it's original packaging because it is very helpful for me to keep track of everything." If you said: "You should bring the pills in the original packages because you could easily make a mistake.’ Then the nurse would become defensive, because she would feel like you were telling her what she was doing wrong.”

All great information and great advice. Now we need to make sure we speak up.