Waiting Almost 2 Decades

Ronald M. Wyatt, M.D., MHA medical director at The Joint Commission to Address the Public

In 1996, when I was informing the public about their “rights” to information about their doctor’s background, the small group of volunteers I was working with knew that the one place that cared about patient’s safety, before the words were very popular, was The Joint Commission, (known at that time as JCAHO).  I knew that The Joint Commission was a place that patient’s could report harm and feel that the reporting was taken seriously.  After all, that is what The Joint Commission did.  If they didn’t look into reported problems, injuries or unplanned deaths, than who would?

We were surprised when we invited The Joint Commission to speak at a “conference” we were holding one evening at a local congregation, that we couldn’t afford them.  The meeting was to be at the South NassauUnitarian Universalist Congregation, in the heart of Freeport Long Island.  PULSE of NY was started there as a support group for medical injury survivors.  For many years we would meet on a Sunday afternoon, once a month to help each other and learn from each other.  We thought of ways to raise the money to bring a speaker in to New York but we couldn’t make it happen.  The audience was the hospitals and the healthcare organizations accredited.  Today, there are 20,000 organizations   accredited by The Joint Commission.  Accreditation by The Joint Commission is a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

I spent almost the next decade working to educate the public about patient safety.  Nine years later, I found myself on the board of The Joint Commission.  As a commissioner, I make up one of the seven public members, not representing a healthcare organization.

And now another nine years later, The Joint Commission has graciously offered to send Ronald M. Wyatt, M.D., MHA medical director in the Division of Healthcare Improvement at The Joint Commission to come speak at the PULSE of NY Patient Safety Symposiumon Diagnostic Errors addressing the public.

I suggest you don’t miss out on this historic event.  Register now before it’s too late.  Registration open through February 25, 2014.   To see the sponsors and register go to http://www.patientsafetypartners.org/

Symposium Should Be About Patients

What’s in a Title?

I learned today that a non-doctor group won’t support a symposium sponsored by PULSE of NY, because the title has the word “doctor” which, in this group’s opinion, excludes other medical professionals.  The title of the symposium “Medical Diagnosis: Help Your Doctor Help You, Patients Involved in Healthcare, The role of Patient Engagement in Error Prevention” may be long, but it’s not “wrong” and doesn’t exclude anyone. 

The fact is many diagnoses are missed by doctors.  In a USNews article some 5 percent of autopsies find condition missed by doctors that, if treated, might have saved the patient's life.  Webmd.com has a story offering “8 Ways to Help Your Doctor Make the Right Diagnosis.”  And, the NationalInstitute of Health explains that it is your primary care doctor who will diagnose asthma. The Parkinson’s Disease website also shares information about getting a diagnosis titled: How does your doctor make a PD diagnosis?  

Since physicians, physician’s assistants and nurse practitioners can treat and diagnose illnesses, we need to be sure they are all getting it right.  According to Society to Improve Diagnosis in Medicine “Diagnostic error is the leading cause of medical malpractice claims in the US, and is estimated to cause 40,000-80,000 deaths annually. One in every ten diagnoses is wrong and one in every thousand ambulatory diagnostic encounters results in harm.”

There is no doubt that this symposium to help patients and families understand how errors can be made in diagnosis could have been called Help Your Nurse, Physicians Assistant, Medical Team, Provider or Clinician Help You - but it isn’t. That’s because it’s usually the doctor that patients talk to when receiving a diagnosis and if it’s wrong, it’s the doctor who is held responsible.

If I stayed away from every conference, meeting or program that didn’t sound like it pertained to me, I would have stayed on Long Island the last 20 years and learned nothing.

To learn more go to http://www.patientsafetypartners.org

 

 

The Patient Safety Foundation Movement 2014

The Patient Safety Movement

If the words on the huge screen in the front of the room are correct, and every hour 20 people die from preventable medical errors, in less than 24 hours, the deaths from preventable medical errors would be equivalent to every participant at this conference.  Over 400 people were filled into the room at the beautiful hotel on the beach in California.  They were all there as part of the Patient Safety Movement – where clinicians, hospital administrators and patient advocates pledge to reach the goal of zero preventable patient deaths by the year 2020.

In partnership with The Joint Commission, the Patient Safety Foundation began the Patient Safety Movement to offer solutions, share best practices, share stories and save lives.

Joe Kiani , founder and CEO of the Patient Safety Movement Foundation is the CEO of Masimo, a global medical technology company.  Admittedly Joe Kiani has never had a medical injury himself or lost a family member from a medical mistake but is passionate about patient safety.  He started the patient safety movement last year with the first conference in 2013.

President Bill Clinton speaks at
Patient Safety Movement Summit

At both conferences President Bill Clinton was the key note speaker and after he spoke Clinton was interviewed by Kiani.  When asked by Joe Kiani why he agreed to be part of this movement, Clinton described it as being offered a ride in a Rolls Royce.  President Clinton was obviously impressed with the enthusiasm and compared this movement to taking a ride in a fine automobile.  Clinton described his work around the world saving lives.  This is something he is excited about.

Others who spoke during the two and half day conference was Dr. Mark Chassin, President, Joint Commission, Dr. Patrick Conway, CMO Centers for Medicare and Medicaid Services and Sir Liam Donaldson World Health Organization Envoy for Patient Safety amongst others.



Alicia Cole, Actress and Patient
Safety Advocate describes her injuries from a
hospital acquired infection

The difference between this and other patient safety conferences is that this was about solutions.  People didn’t come here unless they were serious.  This was a conference to save lives, make a commitment, break down the silos, share ideas and we are all in this together.



The panel discussions had experts on just culture and spoke about transparency and disclosure. Alicia Cole, an actress and California patient safety advocate shared her heart breaking story about her hospital acquired infection and how it changed her life.   Hand hygiene, we learned is only 40 % compliance among healthcare workers.  It costs $20,000 to treat a patient with a surgical site infection and $6-$8,000.00 to treat a patient with a urinary tract infection.  Over and over we heard comments like “just wash your hands” The stories went on…..After each panel, a speaker  would then talk about how they saved lives so others can learn from them and even copy what other hospitals are doing.

The Joint Commission and Center for Transforming Healthcare is all about solutions.  Once only known for surveying healthcare organizations, they have come a long way.  Not just what may need help for improvement but now here are the tools to make the improvements. 

I walked over to a young man filming the program from the back of the room.  “Are you freelance?”  I asked him.  He told me he was.  “What do you think of what you have heard so far?”   He is, after all the people we need to connect with.  The people who we need to reach to take an active role in their care.  Our neighbors and friends, the woman in the supermarket, the office worker and those who know nothing about these problems being addressed in healthcare services.  Matt, I later learned was his name, took his head phone off, bent down from his platform so we were face to face and looked me in the eye and said “wow, I think I have sleep apnea.  After listening to the story about the guy who died from being given medication with untreated apnea I am going to go to my doctor and get it treated”.  He went on to say that the story of John LaChance, who died from medication given without monitoring his sleep apnea, had made an impact on him.  John’s wife told her husband’s story in a video at the summit.  I brought Matt over to John’s wife so she can see how she may have helped someone by sharing John’s story.  It is after all, why we do this.

The Tonsillectomy

Just My Opinion

A child goes in for atonsillectomy and comes out of surgery “brain dead”.  The family wants answers, the hospital wants to disconnect her from life support.  The family wants to move the child to another facility. The hospital wants to disconnect her from life support.

This story is eerily similar to another case I know intimately.  Over 20 years ago my only child at the time went in for a tonsillectomy.  He didn’t come out brain dead but he did die a week later from blood loss after 4 different doctors on 5 different occasions told me don’t worry, the bleeding stopped and he’s fine.  What an awful way to prove doctors wrong. (By the way, I have had about 10 calls over the years from families who lost a loved one from a tonsillectomy)

This is another opportunity to show not only how dangerous surgery, including the tonsillectomy is, but it also shows that there is a problem with communication between the patient (in this case family) medical providers and the press.

Here are my thoughts.  There are 24 hours in a day.  There is a lot more happening in that 24 hours than the media is telling us.  We aren’t getting the whole story.  What I am getting is that this family is not getting the answers they want nor are they getting the respect they deserve.  If they were, chances are they would never go to the press and if they were, the press wouldn't be interested.

If in fact, this was a medical injury, caused by the care she received, it would be great if the hospital did everything and anything the family wanted - including keep her heart pumping, get her to a different facility and get counseling for the family and staff.  But, it is probably too costly to do that.  Plus a medical malpractice case would cost more if she does live and needs more, long term care.

I would think that this would be a great case for medical mediation.  The family, the hospital and their lawyers would need to approve of a conversation / dialogue to each be heard.  What are the needs of each involved?  Honest, open, confidential dialogue that can be kept out of the press should be part of the families and lawyers suggestion.   If in fact this is a local hospital, that this family may need again, why would they want to be wrapped up in a lawsuit for years?

Through mediation, the family can ask for financial compensation an apology, answers and even a way to make sure someone learns from what happened and not close it away someplace so patients can’t learn nor can the medical system learn. 

I wish they had that available 20 years ago.

IPFCC

Institute for Patient and Family Centered Care

Gentle, compassionate, caring, warm, friendly, kind are just some of the ways patients and their families describe the care they receive at hospitals that are patient and family centered. The skills of the medical team seem to never be addressed.  It is the way people are treated that we remember.  We expect when flying in a plane to get to the destination. So, when the service is extraordinary, the staff friendly and the seating  comfortable, that’s what stands out.  The same goes for hospitals, clinics and at doctor’s offices.  Ask almost anyone what they think of their doctor and they will tell you they like him / her because they are nice, listen or are friendly. 

I had the opportunity to hear similar stories at the IPFCC conference held in Minnesota last week.  It was uplifting, educational and moving.  It was a week of learning ideas that “work” or have worked to make a hospital patient and family centered.  Making for better outcomes often is based on communication and the better communication, feeling of acceptance, respect and treated with dignity builds relationships.  Honest, open relationships can mean better outcomes.

One woman shared the story of going to radiation with a friend and they dressed up in costumes.  (An appropriate story for Halloween eve).  Soon the others receiving radiation were also dressing up in costumes and instead of no one talking to each other, at each treatment there was laughter and friendship.  The presentation ended with a slide show of patients in costumes hugging and laughing.  There wasn’t a dry eye in the room of over 400 people.

What does patient centeredness mean?  It was a common theme of medical professionals, patients and family members at this conference.  Most were representing patient and family advisory councils where the patient or the family members of patients come together and talk about improvements to the hospitals or healthcare system they use. 

Visiting policy, the human touch, talking eye to eye, how patients share their stories were some additional topics.   Work groups were formed over lunch to develop an action plan helping to move each person’s or groups agenda forward. 

Breakfast roundtables were for researchers, PFAC members, nurses, social workers or any group you may want to start, a sign would be ready at a table for you.  Patient and family centeredness can mean something different to anyone, or it can mean a lot to one.

I "vote" for Patient's Safety

Who to Vote For When Your Issue Doesn't Count?

As election-day comes upon us, it is hard for me to choose who I want to vote for.  Campaign promises come and go but my issue is patient’s safety and no one wants to take that up.  This year, I approached the county administration to support the Designated Medication Manager (DMM).  This would offer a tool for the general public to understand how they can help each other reduce medication errors, dependency and misuse of prescriptions, vitamins and herbs.  I was told that that for the county to support  a DMM it needs approval from the medical society.  The medical society’s role is not to protect the public, it’s to protect the physicians (who protect the public).  So, we can be sure Nassau County Executive Ed Mangano is not going to protect the public unless it’s approved by the special interest. 

Tom Suozzi on the other hand was approached when he was in office too.  We asked him to get involved in patient safety.  That too never happened.  As long as $1.00 of Nassau County funds is going to healthcare costs, safety must be part of the conversation.

A recent meeting hosted at C.W. Post campus of Long Island University about the future of healthcare on Long Island didn’t address patient safety.  The conversation didn’t turn to safety until members of PULSE of NY, a community based patient safety organization brought it up privately and interviewed some of the panel members.

There is a tremendous cost to the economy that can be reduced.  Are you tired of hearing that 98,000 people die each year from preventable medical errors?  Well good, because the new number is 440,000. 

Costs of medical errors in the United States of $19.5 billion during the year 2008 according to the report by  The Economic Measurement of Medical Errors  Sponsored by Society of Actuaries’ Health Section.

Imagine that with each death there is the loss of an employee, now someone new needs to be hired and trained.  A patient who misses work and needs a temporary replacement because of a hospital acquired infection, a second surgery or a missed diagnosis.   Life insurance policy payments stop but are now distributed to the patient’s family.  A misdiagnosis is costly when tests must be redone. 

Patient’s health can get worse and not better when there is simple communication problems.  Patient’s who don’t understand what the doctor meant when he said “come back in two weeks” or a patient who doesn’t take his medication because he forgot, didn’t understand instructions or can’t afford the pills for his chronic condition.

Medical errors are not about blaming anyone.  We need the public to know how they happen and how they can be avoided.  Medication errors injure 1.5 million people a year creating huge healthcare costs.  A Designated Medication Manager can help change those numbers but it’s not important enough this year I suppose.

Anesthesia Patient Safety

Jeffrey Cooper PhD

Remember when the biggest fear of dying in a hospital was the anesthesia?  We don’t hear about anesthesia deaths anymore – or at least not too much.  Maybe that’s because the Anesthesia PatientSafety Foundation was formed in 1985.  Through research and the sharing of information, advances have been made and lives have been saved.  Jeffrey Cooper PhD is the founder and Executive Director of the Center for Medical Simulation, which is dedicated to the use of simulation in healthcare.  He is also a founding member of the NationalPatient Safety Foundation and a colleague of mine on the board of governors of the NPSF for many years.

I remember years ago when I visited the simulation lab run by Dr. Cooper in Massachusetts.  I stood behind the glass and watched the physicians as they did “surgery” on mannequins.  The person behind the glass with me would make things go wrong so the anesthesiologist would have to find the problem.  I still remember that it was a mucous plug clogging the breathing tube.  The young physician couldn’t find the problem.  In this case, the patient would have died if it were real.  But it wasn’t real – no one died and I bet that doctor never made that mistake again.  This is what they do daily there – save lives through education in one very important area.

Dr. Cooper received the highest honor from his colleagues at the The American Society of Anesthesiologists, The Distinguished Service Award.  It’s my personal honor knowing him all these years and knowing what an impact he has made in safe patient care. Congratulations Dr. Cooper on this recognition.  I wish it could have come from me!

Who is Responsible for Patient's Safety

Your Telling it to The Choir

Dr. Bob Wachter wrote in his blog Wachter’s World about the recent conference in Chicago on diagnostic errors.  Dr. Mark Graber, a trusted physician and advisor to PULSE of NY for many, many years has been passionate about diagnostic errors in medicine since I have known him.  He founded the Society to Improve Diagnosis in Medicine.  The only thing I think Dr. Graber is almost as passionate about is disclosure to the patient and / or their family when something goes wrong. 

There are a few good, no great medical professionals like Dr. Wachter and Dr. Graber out there who are passionate about patient’s safety.   Some, because of their own experience and some because their fear that their number may be up soon.  With numbers like the recent study that there are as many as 400,000 deaths in hospitals due to preventable medical errors it seems to be only a matter of time that everyone will experience either an unplanned outcome to themselves, a friend or family member.

What I don’t get is why are there constantly conferences for medical professionals to learn better ways of doing things.  There is some improvement, but the focus needs to be more on the public.  When the public learns what WE are supposed to expect, we can start expecting no less. 

A recent program I did for the community of about 20 people brought together a mix of homemakers, business people and blue collar workers.  They were learning for the first time that things can go terribly wrong in hospitals.  I am careful to explain that for every “bad” thing that happens, there are thousands of good outcomes too.  But, would our government and medical societies be pumping patient safety money into a system that works?  I just fear it’s being pumped into the wrong place!

Here is something that can be done: Cautious Patient Communities

Jerod Loeb PhD

I Will Miss Him

A great man died today.  Jerod Loeb worked for the JointCommission.  He was the Executive Vice President for Healthcare Quality Evaluation.  A researcher, scientist, PhD, he was brilliant at his work.  But what made him most special was his humor, the way he explained things and way of speaking to me, a lay person at TJC, in terms and words I understood.  He was always sure to make sure I knew what he was talking about.  Funny and lively, Jerod was a brilliant, but very approachable and not in the least bit intimidating.

The last few years, even more powerful, he became a patient - openly fighting cancer.  He was gutsy enough, time after time to tell his audience, usually of medical professionals, what it was like to now be on the receiving end of sometimes questionable care.  Each time I saw him, he would have stories about his care.  He recorded the past few years on a website so his friends, colleagues and loved ones could follow along.

I didn’t see Jerod often, but I always knew he was someone I can count on.  He had a loyalty to the patients that the customers of the Joint Commission serve -  because he was one of us. 

Rest in peace Jerod.

September 11 Again

Can We Learn From Other Tragedies?

I watched the September 11, news coverage yesterday.  From 8:42 AM when the first plane hit, and in the hours that followed, MSNBC replayed every moment as it played 12 years ago that day.   September 11 is etched in the minds of so many people.   I didn’t see all the reports that day.  I was running to the school to get my children as so many other parents did that morning.   When we hear the numbers 9/11 we think of that day.  When we get on a plane and have to wait in long lines or we can’t carry on liquids in bottles larger than 3 oz. or I see the German Sheppard, bomb sniffing dogs in the city I know it’s for my own safety.  It’s a way of life most of us have gotten used to.

I asked a friend if he watched the news and he said he can’t, it brings up too many emotions.  I thought to myself that he must get it then why I struggle each time I hear a report about a misdiagnosis, hospital acquired infection, surgery that has gone wrong or someone who got the wrong medication.  Each time it brings me back to the pain of losing a loved one because of their medical care.

Changes have been happening in hospitals, but not fast enough.  There is rarely a lapse in sending a customer through the metal detector, or checking their bags or security missing someone getting a gun on the plane.  But, still in hospitals we are expected to ask a nurse or doctor to wash their hands.  When was the last time we had to ask to go through a metal detector?

Imagine if we had to live in a world where we had to remind people what their job is, especially when it comes to safety?