The Vanderbilt Nurse

The Medication Error on the News

The recent news about the Vanderbilt University Medical Center nurse is getting on-going attention.  While I try not to comment on specific cases, I want to comment on this because it is constantly in my news feed and is deserving of a comment.  Recognizing we don’t have all the details (and probably never will) this is what I want to say.

Many people sympathize with the nurse who allegedly broke rules and gave the patient the wrong medication which supposedly was the cause of death. Nurses rally around her for support.  They have raised thousands of dollars for her defense fund on GoFundMe. There is nothing good to come of this and there will be no happy ending so let’s look at another perspective.

Who is rallying around the family of the 75-year old woman who died?  Where is their support system?  Can they be told how this happened, treated with dignity to understand or are they being made to look the bad guys?  Are the malpractice attorneys’ part of this media blitz to get a faster settlement for the family and bring attention to this case? 

Has the nurse made numerous mistakes before, broken rules and injured or killed many people?  If so, shame on that hospital for keeping her on.  If she has never done this before, then shame on them for not showing sympathy to the family, offering full disclosure, a settlement and a description on how changes will be made for improvement and even retraining the nurse.

For goodness sake if you have ever looked at your cell phone when driving, you can injure or kill someone.  And because you are breaking the law you are held accountable and will be treated as a criminal.  Does anyone really think this nurse committed a crime?  Maybe she’s just not a very good nurse, was in a rush or just made a mistake of poor judgement – does that make her a criminal?

As long as we keep medication errors, medical injuries and patient safety a secret from the public, it will stay newsworthy when someone dies and causes this sort of media attention.

Could this have been avoided if the patient had an advocate and new what medication the patient was supposed to get?  If the patient’s advocate sat with the patient during her treatment could the problem have been found sooner?  We will probably never know.

As long as the healthcare system and medical professionals are the only one’s responsible for patient’s safety and working in silos with the patient and family looking in from the outside, you bet this problem will continue.  As a parent who lost a child from medical error and was chased down by attorney’s calling my home for days wanting to take the case but doors closing from the medical community, I will tell you to this day, years later, all I ever wanted was an apology and an explanation and to move on.

I’m wondering what this family really wants and how this all got to this point.

Words to Help Communicate

Critical Communication and Words to Help

When I went to visit the woman at the hospital because she was not getting her medication, her questions were not being answered and she was barely able to speak and eat, she shared how angry she was at the lack of attention she was getting.    It is understandable being alone, scared and as someone always in control, having your independence taken away.  Anyone would be vulnerable in this situation.  She was calling people down the list of phone numbers of people who worked in the hospital she received and in her weakened voice from a painful condition affecting her voice. She told me she screamed “Help, help!!” into the phone.

By the time I got there and cleared up the problems she was having, I explained that yelling “help” into the phone, or in a hospital, may actually get people to turn the sound off in their head.  They may think of you’re as crazy, or annoying, I told her and like many of the buzzing sounds and alarms that scare or annoy us, they can tune sounds out – or, if someone needs them more, that’s where they will go and yelling help will only annoy other patients and staff.

Instead, what patients can do is let them know that you don’t feel that you are part of the care.  Patient centered care is a term that professionals use to keep the patient in the center of the care team.  Nurses shift changes should not be at their desk or in the hall. The patient should expect the shift change at the patient’s bedside so you can help answer questions or share concerns.  Don’t hesitate to let the staff know that the care does not feel “patient centered” if it, in fact doesn’t.    

Yelling help also doesn’t give specifics such as letting them know if you don’t feel “safe”.  Feeling unsafe because you’re not getting your medication, or the proper medication, your doctor has not come around while you are awake to speak to you about your diagnosis, treatment plan or answer your questions are real reasons to feel your safety may be at risk because you are not being included in the planning.

A clear explanation of your needs is important for the medical staff to know what you need and of course, if you can’t get out of bed having a friend or family member help you is important.  If the person visiting you can’t do this, think now who that person will be, before you need them. 

Now available seminars and programs Critical Communication  

www.icorina.com  

Accountable or Responsible: Who is Monitoring the Medication?

Medication Safety and Management

I attended a presentation today by a hospital pharmacist.  Most of the people in the audience of about 50 professionals were representing nursing homes, home care agencies and people who work with older adults.  The presentation was very informative about understanding some of the complications and interactions that older adults experience with their medications.

The audience questions and comments focused primarily on who is responsible for monitoring the medication and reviewing medication.  The “responsibility” seemed to fall on the pharmacist or nurses in the nursing homes, rehabs, assisted living etc. Then the question about the home care agency in the patient’s home – who is checking on the medications?

The Food and DrugAdministration estimates that 1.3 million people are injured by medication errors annually in the U.S. 

With numbers this high, there needs to be some responsibility of the patient and their family in this discussion.  When I brought up that this presentation should be offered to the public, others seemed confused.  When things go wrong, the public has no clue of the complexities in medication management or other areas of medical care.  We only know that if something goes wrong, someone will be held accountable.  These silos have to stop and the public must be more involved in not just their health, but their healthcare and that means opportunities to hear a pharmacist present on medication safety and management.

A Nurse's Error at Vanderbilt Kills a Patient: My Perspective

Nurses Error Kills a Patient at Vanderbilt

In this article about a nurse who killed a patient because she gave the patient the wrong medication silently explains how such a terrible mistake could happen.  So many people who work in healthcare know how these mistakes happen, and happen, and happen.  No one asked my opinion so here it is:

And now what?  

If we look at the ‘airline industry” as so many people in patient safety do, because in 2001 one person came onto a plane with an explosive devise in his shoe, we, as travelers have been taking our shoes off before boarding a plane – because of ONE incident where NO one died.  How about all the support the patient’s family would receive if the patient died from cancer, heart disease or even a fall. 

What are people saying to the family now?  Probably expecting a lawsuit, a fight, punishment or accountability.  If it were an auto accident there would be insurance so the patient’s family could get compensation and they could move on – no less sad or angry but at least compensated.

In medical care there are so many reasons for these errors to happen and if you are someone who works in the industry you obviously see this.  Yet, as a patient or family member we don’t see how this could happen because no one is explaining this to the public.  So, how can the public possibly be sympathetic to an overworked, underpaid and probably very caring healthcare professional?

My work in patient safety started because of the death of my son but what I learned is that there are so many obstacles to safe care.  If we all, healthcare professionals, patients and the public were all part of the conversation – changes could finally be made.  Writing about this on Facebook – where I found this story - is not enough – there is too much to do and pumping resources into hospitals to keep doing things the same way did not help this patient who died and surely didn’t help this nurse who made the mistake.    

Join us and learn more at https://pulsecenterforpatientsafety.org/

Read the article here

https://tinyurl.com/y9r2u8ql  

Fire Prevention Week

What We Can Learn From Fire Prevention Week

It was Fire Prevention Week.  Did you notice all the school fire drills?  Everyone left the building, moved away and waited for direction. 

I happened to be in a class in NY City teaching high school kids about patient advocacy / safety when the alarm sounded.  First there was an announcement to be prepared for the alarms and everyone must use the stairs to leave the building.  (I was not thrilled to be on the 3rd floor).  The children, teachers and administration all followed in order and walked to the other side of the street.  Everyone was quiet and behaved.  When some of the teachers gave the signal, hundreds of people walked back into the school and to their classes.

It makes me wonder again why everyone is involved in so many safety issues except patient safety.

Imagine if an announcement came over the loudspeakers at noon in the hospital. 

“Patients please make sure all staff are washing their hands.  Patients make sure you know what medications you are being given and that includes the IV bag as well as the pills in the cups with no labels (that are supposed to be labeled). Hospital staff, be sure the patient’s tray tables are within reach and you are not disrupted when getting your patients medication.”

Nah, will never happen – besides patients need to rest……….

Sexual Assaults and Medical Care

Sexual Assaults Involve Medical Practice Too

If you are being examined by your doctor and something doesn’t seem “right” it may not be. The arrest and conviction of Michigan State University and USA Gymnastics team physician Larry Nassar earlier this year, reminded me why I started talking to young people in high school and middle schools about being an involved and informed patient. In 2006 I was talking to a group of high schoolers about patient safety and speaking to their doctors when two sisters called their doctor “creepy.” That was a surprising term and it set off my antenna. I invited a gynecologist and then a pediatrician to talk to the children and their parents about appropriate exams. Even as adults we rarely have any reason to speak about what our exams are like and don’t know what similarities — or differences — are happening behind that closed door.

Over the years women have mentioned that they thought they might be getting what they felt were inappropriate exams. Often unsure whether they were imagining it or what to do about it, they never shared this secret until Pulse came along. I visited a police station and asked what the procedure would be if a woman claims to be assaulted or inappropriately touched by her doctor. The policeman behind the desk said that if it were a licensed physician, the accuser would need to go to the state department of health and licensing board to file a complaint.

Now fast forward ten years and there is the #Metoo Movement, the Olympic gymnasts’ case, the sex abuse and assaults by movie and television celebrities such as Bill Cosby and Harvey Weinstein. Politicians and high-ranking officials are making the news and priests are being accused and convicted of sex abuse from years ago to the present.

With all this happening around us, why couldn’t clinicians — for whom we are expected to undress and expose our bodies — also be part of this abuse and scandal? When we see a clinician, we are already feeling vulnerable because we may be hurting or injured, not feeling well, wanting to get better, and trusting that whatever is happening is appropriate. Especially because we willingly removed our clothing and subjected ourselves to an exam, how could a woman now “complain” about being touched inappropriately?

I am no stranger to the feeling of an “assault” by a doctor. I knew on two different occasions by two different doctors that what they were doing was not appropriate. When I left the exam room I knew I would never go back and that was the end of it. Or was it?

I have been impacted by this behavior and it helped me form my work today as a patient advocate. I understand why people come forward many years later. Although I don’t personally feel compelled to share the names of those who took advantage of me, I understand the rights of others to do so.

Although I would not share those doctors’ names, I would be devastated to see them put in a leadership position anywhere. I am confident that there are more “victims” out there who would rather just forget about their experiences as I did and as so many women do. We need to talk about what an exam is like and what to expect. We need to be unashamed to share an uncomfortable experience. We need to be able to encourage and support filing a complaint and getting or sending someone for support or counseling. Even if the people I have heard from don’t go back in time and relive what happened many years ago, we can use this as a platform to move forward and make it safer for other girls and women. By talking about this and forming a coalition of groups in support of those who have been assaulted by clinicians 30 or 40 years ago, we can make it safe for women today to say, “It happened to me last week” . . . . because we believe you.

Learn more here: http://doctors.ajc.com/

Dependency Based on Better Communication

Opioid Dependency and Addiction Could End with Better Communication

Would you be surprised if someone you know didn’t know what LGBT stood for?  Lesbian, Gay, Bisexual, Transgender may be common terms used – when you are speaking about someone’s sexual orientation and / or gender.  But what if that subject never came up for someone?  I was surprised too recently to find out someone wasn’t sure what the term meant.

The word “mortality” rate also means the death rate.  A cardiologist is a doctor who specializes in the heart and pulmonology is a specialty of the lungs.

New York Mayor Rudy Giuliani thought he was free from cancer when his doctor told him his tests came out positive – mixing up the word positive to mean a good thing.

When we label this information as health literacy we are putting the responsibility completely on the patient to understand what is being said to them.  If they don’t know – that they don’t know – than how can someone possibly know what to ask?

Patients who are being discharged from the 

hospital or ambulatory setting are given pain

medication and told to take it as needed every XXX hours, up to XXX times a day (you can fill in the blanks). They leave with a medication that if they know they could become addicted or dependent, might choose not to take it at all and may decide on some other medication.

Now, think of all the ads and news about the opioid epidemic and I wonder how many people think that might not include them?

A commercial shows a man who tries his mother’s medication called Vicodin and becomes addicted.  He uses the name of the medication in the commercial and now that he is addicted, he is shown slamming his arm in a door to break it so he can get more.  The announcer uses the word opioid.  “Opioid dependence can happen after just five days”.  Why aren’t they using the name of the medication?  “Opioid dependence such as Vicodin and other pain medications can happen after just five days”.  Maybe we need to start putting these words together at discharge, at the pharmacy and in commercials to be sure that all people know that opioids is the type of medication – not the name of a medication. 

Test Your Advocacy Skills

One Way to Test Your Advocacy Skills

Could you be a “good” patient advocate? Here is one way to find out.

In today's society of mixed opinions, what is your reaction? Are you angry at the people who don’t agree with you? Do you find yourself calling people who don’t agree with you names like idiots or stupid; quietly or aloud?

Have you blocked your friends from Facebook or no longer accept calls or invitations from people who don’t agree with you? Are you spending time proving you are right and they are wrong? Maybe you find something on the internet and then tell people who oppose your views that they are wrong.

Or, do you find yourself listening to people, radio and television shows that don’t share your belief or point of view? Maybe you engage people in conversation so you can hear what they have to say knowing it may be different than your point of view. Have you researched information that someone told you, to see if it is true and then keep this to yourself or share it once and move on?

Do you find yourself interested in what people who have different beliefs have to say?

If you can listen to others and know it may not agree with your values or beliefs, and not get angry or frustrated, you probably would be a good patient advocate.

You may be saying to yourself that when a patient makes a decision it doesn’t affect society, lives, the country or_____ you fill in the blank. That’s true. But by listening to what someone is saying, it helps to build a strategy and move forward not by emotion but instead by facts and clearly thinking. Who will listen when we speak out of anger and with words we don’t know are true? To help in a dialogue we need to be better listeners and maybe not try to change opinions unless we are armed with good facts and willing to listen to how others hear what we have to say.

This could be helpful whether we are speaking about politics or someone’s healthcare.

If the person you are caring for does not want a treatment or procedure you think is important, you can tell them over and over why it’s important through your experience or material you have read. If you don’t listen to why they say what they say or why they feel the way they do, you will continue talking to someone who is not listening and has learned to close you out.

Are Your Complaining?

Complaining?

We use the word “complain” sometimes and I wonder if its actually the best word to use.

When someone goes to the doctor “complaining” of a back pain or stomach ache, are they actually complaining?

One explanation from the dictionary is express dissatisfaction or annoyance about a state of affairs or an event.

To say someone is complaining, doesn't that makes them a complainer?  Now we have put a judgement on the person who is explaining a situation that has them concerned or upset.  If I tell someone that she has been complaining of a headache for a week, could that person say that I am calling her a complainer and become defensive or even angry?  Why not say that person has said she has had a headache for a week?

A woman called me recently to talk about her experience with her doctor and asked how to file a complaint.  I asked her what she hoped would happen.  She actually wanted a relationship with her doctor and was angry that her doctor treated her cold and distant.  The caller kept apologizing for complaining.  It seems the doctor moved her practice to another part of the state and the woman still wanted to see the same doctor.  Visiting years later, she was upset that the doctor treated her like a new patient.  “I was her patient for years” the woman told me and now she was being treated as if the doctor never knew her.

I told her about how I have written letters to doctors about my experiences with them from anything to - they didn’t wash their hands to something they said that was offensive or even when I appreciate them.  Writing letters is helpful if she was willing to take the same amount of time to write a complaint as she was to write a letter explaining what happened, she may actual save the relationship and continue seeing the same doctor.  I suggested that she doesn’t label her experience or concerns a "complaint" and explain what happened using the facts, as she experienced them. 

Stay focused on the facts, explain how it makes you feel, and don’t be so quick to label something negative that someone else may see as a positive.

Remember to Talk to the Patient

Let the Patient Talk

I was recently speaking to a healthcare professional from a hospital about patient safety.  He explained that the biggest problem he sees is at the discharge process.  I understand that to be true for many reasons.  People leaving the hospital are still drowsy following surgery and are given instructions they may not follow or may not understand.  After all, a person can’t drive so why should they be able to understand instructions?  There is usually a lot of information and it’s read quickly to the patient.  Then patients are given a copy of pages to read without anyone knowing if they can understand what they are reading.

A friend or family member is there to take the patient home, but does that mean they understand better, or just that they have a valid driver’s license to drive the patient home? 

What are their “qualifications” to get the person home safely with all the needed information?

I explained that’s why we do advocacy training to help families prepare - either as the patient or support person on what is to be expected throughout a hospitalization.  I asked him if he includes the family in the discharge.  He said “that would violate HIPAA”. 

What do you think?

I explained that HIPAA is not meant to keep important information from people who need it to help the patient.  PRIVACY does.  We all need to respect a patient’s privacy which is very different than a federal law.  He said that when he talks to the family the patient may get angry because the patient doesn’t want the family knowing too much.  DING Again.

I asked him why is he, the healthcare professional talking to the patient’s family?  Why can’t he, the healthcare professional, be the support while the patient tells their own family?  This way, the healthcare professional, nurse, doctor or discharge planner can hear what the patient knows and makes sure they are explaining it correctly and only what is needed is shared, and he has not left the patient out.

What year are we living in that the clinician still doesn’t think to talk to the patient?

Registration now open for Family Centered Patient Advocacy Training!

http://www.pulsecenterforpatientsafety.org/family-centered-patient-advocacy.html