Justin's HOPE healthcare tumblelog

Interesting article worth reading. Was the adverse event avoidable?

“…The version I advocate is: the standard for getting compensation is not showing that negligence occurred but that the injury was avoidable,” Mello said. “There are many things that are not considered negligent because they happen often but that we would say are avoidable. But if the system were designed better they wouldn’t happen.

In fact, avoidable injuries are twice as common as those borne of negligence, she said.

Another example: A patient suffers harm after a miscommunication between doctors or nurses during a shift change. Were the medical professionals negligent? Perhaps not. But there still may be a case if the hospital should have had a system in place to prevent the injury, whether through an electronic medical record or a protocol…”

Please register and read entire article:

“….Patients “don’t want to be abandoned. They just want to know what happened,” Mayer said.

And despite disclosures, “we have not seen the financial Armageddon that everyone expected to see when you’re open with patients,” McDonald said. “The whole point of this is to learn from our mistakes.

Learning from mistakes and being open and honest with patients and families have been the goals of safety advocates and providers who have been involved in painful hospital experiences (Nov. 2, p. 6, and Sept. 7, p. 6).”

Great insight into barriers to progress: “…Third is to be authentic about teamwork across professions. In the medical culture at large, there still is too much focus on turf issues between doctors and nurses. I believe in the long run new safety initiatives will be fostered by teams working at unprecedented levels of collaboration, reaching across traditional boundaries….”

Lack of teamwork is where I see much of the problem, as well. As I’m invited further into the behind the scenes work and healthcare conversations, there are still turfs and those that just won’t budge to let someone new or different step into their territory.

The orchestra isn’t playing in harmony. Wouldn’t it be awesome to establish new collaborations with artistic partners that get the right results. Here’s a lesson for students: http://artsedge.kennedy-center.org/content/3952/

The financial and personal ramifications that come when a doctor apologizes to a patient. Wonderfully written article by Rahul Parikh. Thank you!

“…I didn’t know any of these things about disclosure or apologies when I was taking care of Andy. I just knew that I had to make amends. Soon after Andy recovered, I called his mother. I could hear the resentment in her voice when she picked up the phone. I swallowed hard and told her what she had already figured out—that I had missed the swelling in Andy’s eye. I said how sorry I was for what had happened and for my mistake. Most of all, I told her, I was sorry for putting Andy through any pain. After what happened, I spent a great deal of time reviewing photographs of papilledema and checked the eyes of every patient I could to make sure I knew what a normal optic disc was supposed to look like. I had no intention of making this mistake again…”

Thanks to Marie Bismark, Robin Youngson, IHI and the New Zealand Medical Journal for spreading the word!

Please click on title and read and share Marie’s wonderful article with your staff. Have a discussion and use it in medical/nursing/pharmacy schools. I am honored to work with this wonderful group of compassionate leaders. Join our facebook group, as well, Compassion in Healthcare-The Heart of Healing. Robin is the founder of The Center for Compassion in Healthcare in New Zealand. http://www.compassioninhealthcare.org/

Marie writes: “An apology to the patient following an adverse event can bring comfort to the patient, forgiveness to the health practitioner, and help restore trust in their relationship. Yet, for many practitioners saying “I’m sorry” remains a difficult thing to do. This article explores the key elements of a full apology and when they should be used, and how to support practitioners in making an apology to patients who have been harmed.”

Many thanks to the Joint Commission for including MH information in this new publication! Since I’m on the MHAUS Board of Directors, I’ve had the privilege of working with this wonderful group of professionals with patient safety as their top priority. I selfishly enjoy being privy to the case discussions on their listserv because it validates the kindness and compassion that these physicians feel following a hotline call, complication or a death. Their words are healing for me.

This new JC publication provides a case study on how the MHAUS MH Procedure Manual is used by an Ambulatory Surgery Center. Please purchase the book for your facilities and universities.   

You can also find new patient/physician surveys or our MHAUS site or join us on facebook or twitter.

 http://medical.mhaus.org/index.cfm/fuseaction/newsletter.view/newsletterId/34.cfm#article_128

“Patients will have to consent to having their procedures captured on video. The monitoring equipment will be used to analyze the hospital’s safety procedures. You can read all the details for yourself in this  letter that the state health department sent to Rhode Island Hospital yesterday.”

Several of us have been advocating for this for years. We were told that physicians said that it would be an invasion of THEIR privacy…not the patients and they refused.

…”Errors don’t erode trust. The way we act after the errors does.”

I’m beginning to think that the feeling of indifference plays a huge part in all this. The feeling that our loved ones don’t matter to those that we trusted to care for them and that this behaviour is accepted.

Following the release of another article that I assisted with, a physician wrote an op/ed to criticize its contents. The physician compared appeasing parents whose children had died to appeasing Hitler, stating that apologies and discussions were useless. What kind of mentality would even write such a comment? And, he’s a pediatrician in th UK.

Helen Keller:

Science may have found a cure for most evils; but it has found no remedy for the worst of them all — the apathy of human beings.

Hopefully, those of us that expect better will continue to fight the good fight and we will win.

Changing course

A few well-publicized cases of medical errors have led the hospitals involved to transform how they approach patient safety.

By Jean DerGurahian

Posted: November 2, 2009 - 5:59 am EDT (click on title for story-sub req)

This is the second part of a two-part series on the effects of patient-safety advocates. Part one of the series, which ran Sept. 7 (p. 6), described how three women went from parent to patient-safety advocate as a result of medical errors.

My friends have received some results after much hard work:

“…In the past five years, St. Luke’s has formalized a disclosure policy that calls for attending physicians to talk with families after care that resulted in unanticipated outcomes. It’s not an admission of guilt, and it’s not just about medical errors, but deals with any results that were unexpected, Hill said. That brings the human element back into patient care. “To do nothing about it is unconscionable….”

Sadly, our story has had little impact or connection with the involved hospital in Justin’s care so I have decided to change course, as the article states, after almost 9 years and focus on working with those that have an interest in change. Our waiting for CEOs, PR folks or physicians to return phone calls needs to stop so I can continue to be instrumental in my goal of saving more lives from harm. I’m done waiting.

Please join me. Changing a culture is difficult but your children and family are worth your effort.  Dr. Peter Pronovost quotes Margaret Mead in his emails to me: “Never doubt that a small group of thoughtful committed citizens can change the world. Indeed, it’s the only thing that ever has.”

Any other hospital in NY, or elsewhere, is more than welcome to contact me for guidance. I’ve consumed myself in this topic of safety and disclosure following adverse medical events and would love to help you move foward! 

“Never before in the history of the US healthcare system has there been a more opportune time to engage the full spectrum of stakeholders in a comprehensive effort to improve the manner in which we deliver health care to our citizens.  The commitment of the Administration to health care reform affords a welcome opportunity to accelerate improvements in patient safety, a discipline that utilizes a systems approach to improving health care processes and, therefore, outcomes….”

Tom is one of the experts in the field of disclosure following an adverse medical event and has written and presented on the topic globally. 

Australian Commission on Safety and Quality in Heath Care shares his recent presentations: 

“Dr Tom Gallagher is practising physician and Associate Professor of Medicine at the University of Washington and is renowned for his work in the field of open disclosure.” Informative ppts. (click on title for link)

“IHI periodically receives urgent requests from organizations seeking help in the aftermath of a serious organizational event, most often a significant medical error. In responding to such requests, we draw on learning and examples assembled from many courageous organizations over the last 15 years who have respectfully and effectively managed these crises.”

Thank you!

I happen to agree with Bob on this post although I have often recommended patient empowerment books and organizations that promote that behavior. There is a difference between becoming partners in your care and becoming an activist that gets in the way of good care. I’ve seen/met both and I favor the partnering primarily because of my career in pediatric health. I’ve been there and even after all of the horific stories that I’ve heard, I know that there are still wonderful, caring people working in healthcare who know what they’re doing. 

I understand when health caregivers are trying to do their job and an obnoxious relative is actually causing so much stress that more harm may be caused by the encounter than good. They’re always looking over their shoulder for the “intruder”  to cause an incident at the expense of focusing on their profession and their patient.

Speaking up when you don’t feel that something is right is necessary or if you see the caregiver not washing their hands or using unsanitary practices, you MUST jump in respectfully. There is a fine line here and my hope is that patients and families will become aware but back off when they really don’t know what is best and trust the physician or nurse to do what they were trained to do.

Seeing too many skeptical relatives oversee care may just cause the opposite effect and more errors will be made. Tread lightly and be cautious but don’t think that you are the educated one in this complicated field of medicine when you’re not. The time has come to partner not destroy relationships totally. Ask questions, be prepared, research, ask questions again but don’t become the activist that makes providers turn away when they see you coming.