Thursday, August 24, 2017

System Errors or Human Errors

When Errors Happen is it The System?

When I am hired by a hospital or medical facility to speak to the staff about patient safety, my first thought is that this is a facility that cares about safety and patients.  Since my work is primarily about patients and their safety, it must mean they are serious.  Why else would I be there?

Still, there is never a guarantee.  I spoke a few years ago and a hospital.  Once for senior leadership and then for the “hands-on” patient staff.  A double presentation because they are “that serious” I thought to myself.  Unfortunately there is no guarantee no matter how hard they try, that patients will be safe.  I just read an article about that hospital and a patient who died because of the care he received.  Although there may be many others, this one made the news.  I truly believed that this hospital, in another state, was serious about patient safety and though I believe the people I was involved with there were serious, there are so many opportunities for errors to happen.

Most people in healthcare call the errors or unplanned deaths “system errors” not enough staff, distraction by a nurse or pharmacist or any number of reasons a mistake can happen.  In this case, as in many cases, this hospital’s system, in my opinion was working.  Instead someone may have cut corners or not went to leadership about the problems that ultimately caused this patient’s death.

When a family members calls to talk about a bad outcome at a local hospital, I suggest they speak to the hospital leadership.  The people who are running the facility may not even know that an injury occurred or why.  They need to know where the system, or people are failing.  I also looked carefully at this article – without all the facts and saw where a trained family member may have been able to save this patient’s life.  A trained family member may have been in a position to speak up and alert someone that something doesn’t seem right.   They didn’t and the patient died.  If they did, how would that be measured?


Saturday, August 19, 2017

Listening Skills Learned


Is the Country's State a Practice in Listening?

As a patient advocate, it is my job to be objective and nonjudgmental.  I listen to the patient and their family and listen to the doctor or nurse explain to the family  whatever it is they need to explain.  It is not up to me to make decisions for the family.  It is not up to me to agree or disagree with the care plan.  It is up to me to be sure that information is given in a way that the patient and family understand and that if they don't, they can ask questions.

In my work, I often listen to patients who have special and unique needs to learn what their obstacles are for safe, quality medical care.  People with severe illnesses, families of people with dementia / Alzheimer's, young single mothers to name a few.  I learn from them what it's like to be them, though I don’t pretend to always understand it.   I also get to spend time at the bedside with families and to be with them during this often, difficult time of pain, sorrow and vulnerability.  Advocates who take our training learn the importance of these
skills.

So, what’s my point?  I also listen to conservative radio and liberal news, speak to people who have opposite views from my own and want to learn what makes them think the way they do.  I want to hear what makes people so different in their thoughts and ideas. There is a lot to learn about different viewpoints.   People are angry and frustrated with the way things are in today’s political setting.   

What is concerning is when people use words with no appropriate relationship to what they really mean.  Name calling, making fun of someone’s appearance, or using words not related to the problems being addressed.


As soon as people use, as part of their dislike for someone the way they look, walk, dress, their facial expression or hairstyle it takes away from the important facts that we need to concentrate on.  How boring this world would be if we all agreed.  For those of you who want to moderate, mediate and / or advocate for others, there is plenty of practice opportunities in today's daily conversation.

Friday, July 28, 2017

Helping at the Hospital

When a Patient Needs Support

The surgery went well.  There was no infection.  The medication was correct and the patient didn’t fall.  So why was this 24-hour hospital stay so awful that the patient talked about it for almost an hour as one of the worst experiences this patient ever had?

The humane and respectful behaviors we all expect from those caring for us were missing.  A cup of coffee when the patient requested it, the phone and remote within reach, retrieve a  fallen pillow on the floor, some crackers, a response to the call bell are just some of the things that can make a patients experience better in the hospital.  We all recognize that hospital staff are often overworked or short staffed yet a friendly response to a patients request can mean the world.

Families often need to work or go to school and can’t sit by the patient’s bedside.  But having someone available to meet these needs can really change the patient’s perspective of how their care was. And yes, it can mean a better outcome.  If the patient got out of bed to reach what fell on the floor and fell, that could cause serious injury and a substantial cost to the hospital and patient’s insurance.  Eating inappropriate food brought in by loved ones because the patient didn’t  have anything else to eat, might cause a problem with healing causing a longer hospital stay.


So, even though a patient may be sharing that there was the lack of comfort care, there are some concerns of patient safety that can be addressed.  If you know someone going to the hospital,  even if you have no patient safety training, consider bringing a book and sitting in the waiting room and check on the patient every 15 minutes.  You won’t be a burden and you can be sure the patient is getting what they need.

Wednesday, July 19, 2017

Let the Little Boy Cry

You Don't Know What I'm Thinking

A little boy about 10 years old fell off his bike and ran to the grownups to be patched up.  His mother and the other adults told him “don’t worry, you will be fine” without ever asking him what’s on his mind.

The next day his bandages had blood on them and it seemed his cuts may have opened up.  He brought his concerns about a bloody bandage to the grownups.  Again he was told don’t worry and this time was told no one ever died from blood on the bandage.  This was a second time the grownups decided he could not speak about his concerns.  Did they or he, even know what they were?

A wet, bloody bandage should not be OK on a hospitalized patient.  It should not be OK on a boy riding his bike.   Blood seeping through a bandage should be questioned.  Telling a child he /she won’t die because they have a cut or worse, is not addressing what they are concerned about.  Are we raising children to not question the care they receive because when they want to cry, they are told things like “you won’t die from that”?

Play this same scene out when a 60 year old woman has indigestion that seems ”weird” and the doctor says no one ever died from indigestion so she stops in her tracks from questioning the care she received. An adult questions that maybe she is getting the wrong medication - and a nurse says “stop worrying so much”.

When people are frustrated, scared or inconvenienced by sickness or an injury, healthcare providers as well as friends or family members often respond to what they, themselves think the patient / person is feeling or in ways that make themselves feel better.  They respond with what makes them comfortable in the conversation. 


In our Family Centered Patient Advocacy training tools we use a scenario of a woman screaming in the bed at a hospital that she wants to go home.  Nurses are too busy to release her, the doctor isn’t available and she has everyone on her floor angry at her.  When I asked her why she wants to go home she explained her child will be getting off the bus and she needs to be there.  One phone call to be sure her daughter was met at the bus stop and the patient was fine. No one asked why she was so desperate to leave.  They assumed she just didn’t want to be there.

Not asking what is troubling someone such as tell me why are you upset and crying, what are you concerned about or how can I help make you feel better, is closing the conversation to learning and even more important - building relationships.

Friday, June 30, 2017

On His Birthday



Help Me Celebrate His 30 Year Memory and Birthday

This July, my son Michael Louis Corina would have been 30 years old.  A milestone to many people and their families.  Michael (Mikey) died just before my 30th birthday. I thought I would never celebrate another birthday.  Birthdays became unimportant and even painful. 

Although I never worked at making a day, date or event named after him, he has always been behind almost everything I do.  Patient safety was never about the one boy who died, it’s been about the many children who have died from preventable medical errors and all the families broken because of a medical system that does not include patients (even though
they say it does).


I was not involved in the study that medical errors are the third leading cause of death in the United States.  My work started long before that study was released when I saw this problem was not being addressed. 

Help us continue raising awareness in his memory.

Please consider this year helping make the number 30 meaningful with a donation of $30 (or any amount) which would mean you have thought of my son on his birthday this month.  A recurring donation of $30 will mean you remembered him for a year and will help us at Pulse Center for Patient Safety Education & Advocacy continue our important, lifesaving work.

Its as easy as going to our donation page to make your tax deductible donation!  

And please visit www.pulsecenterforpatientsafety.org to see what we are doing!

Thank you and feel free to pass it on.

Thursday, June 29, 2017

It's Tort Reform Again

What is tort reform and why should it scare you?  One explanation off the internet is: Tort reform refers to proposed changes in the civil justice system that aim to reduce the ability of victims to bring tort litigation or to reduce damages they can receive.

In other words it lowers your chances of bringing a lawsuit against someone who harms you or your family.  Tort reform limits or caps the type or amount of damages that may be awarded in personal injury lawsuits.  Let’s call them for the sake of this post, malpractice lawsuits.

What many people hear when you say the word “malpractice” is money and compensation and sue the doctor or hospital because people want money.  Well, just as some people want money, there are some healthcare professionals who should probably not be practicing medicine,  Just because someone completed school, maybe even got great marks and has been in the business for years doesn’t make them good at their job.

So let’s not call it malpractice. Instead think of medical injury.  An injury or death caused by the care one received while under the care of a medical team.  It could be because of malpractice; negligent professional activity or treatment. Or it could be because nurses are too busy and overworked and miss something.  It could be because there is broken equipment, test results not given to the patient or a wrong diagnosis is given by a caring and otherwise competent healthcare professional.  The patient is still in the center of all this and though many people want to protect the healthcare team from a lawsuit, who is protecting the patient?

A Johns Hopkins study reported just last year that medical errors are the third leading cause of death in thecountry.  Many studies before that have reported the dangers in care patients receive.  These studies were not reported by attorneys and they surely weren’t done by patients.  These studies come from some of the most highly respected medical teams and researchers.  Yet the conversation goes back to affording the right to a patient or their family to collect compensation when injured.

Most people will tell me “I don’t want the money” or “I don’t want to sue”.  I tell them that it is about the money because your attorney has a right to be paid to get you the answers you want or need. In many cases the healthcare professionals will not talk to the patient or family and on a few occasions when I tried to intervene I was told “let them sue us”.

For years, through PulseCenter for Patient Safety Education & Advocacy (formerly PULSE of NY) I have been trying to raise the money to continue our free community educational programs and our bedside advocacy services. We need to protect patients and inform them and their family members of the dangers that the people in healthcare are already aware of. 

So as we start hearing the conversation arise about tort reform once again and the lawyers and doctors fight it out – think of who is informing the patient and helping the family navigate this system.

Some very final thoughts:  
  • How much is your family member's life worth and should the state decide their price ahead of time?
  • Should this energy be spent on improving medical care by informing the public with patient safety information?  After all isn't it the patient who has the most to lose?
  • Why are we talking about capping payments when there are still such a call for improving patient care?
  • Why are lawsuits looked at as so awful when this is often the way to get answers.
  • Why are the attorneys looked at as the bad guy when it is the healthcare professionals they hire who decide if there is actually a lawsuit / malpractice.
  • Thousands of lawsuits or complaints are turned away because there was nothing that would have changed the outcome and that goes for someone who was ill, elderly or very young too.



Sunday, June 25, 2017

Addiction - The Big Circle

The Big Circle of Addiction and Dependency

A friend who works in healthcare recently shared an experience of a patient screaming that the patient was in pain and needed pain medication.  My friend knows the history of the patient.  The patient is often called a “drug seeker”.  Someone who is addicted and wants “drugs”.

People in healthcare, my friend explained, rarely have sympathy for drug seekers especially when they are disruptive and loud as this patient was.  The people who were working needed to tend to other patients and the other patients needed peace and quiet – not a screaming drug addict.

I listened and understood what I was hearing, yet I don’t like it. 


We can’t force someone to feel bad for others.  Although we can expect people to treat people with dignity.  I assume this happened.  Let me share my point of view.

In many case (of course not all) people become addicted or dependent following an injury, surgery or other medical reason.  I have been with patients at discharge when they were handed a prescription for pain pills with no discussion about the potential dangers of becoming addicted.  The patient is taking the medication and becomes addicted.  Now they are back in the hospital looking for more. It’s a big circle of blame the patient.

When I hear about high school education teaching young people about becoming addicted to drugs, I am confident that no one thinks it can happen to them.  (I know I don’t believe I would become addicted even though I was addicted to cigarettes and swore I could quit for years before I was able to).

What we can be teaching young people, as I have been doing, is about medication “errors” - mistakes in medication such as look-alike sound alike drugs – nail glue vs eye drops, Clearasil looks like teeth whitener, and generic vs. name brand and yes, pain pills available that you may not need.

In the news I hear over and over someone mention that they started on the road to addiction after root canal, surgery or a broken bone.  It’s never discussed further. Education must start BEFORE the prescription is written.  Or yes, they will be back.


It looks like I have some new material for the Family Centered Patient Advocacy Training coming in October.

Monday, June 5, 2017

Lavern's Law

Changes Needed


Imagine having terrible pain in your leg and going to the doctor who tells you to take some medication and get some rest.  When that doesn’t work you go to physical therapy and then a new medication and more rest.  You follow these instructions and feel worse in the months that follow.  Finally, you wait for another appointment with a doctor a friend recommends who recommends another doctor who sends you to a specialist. 

It takes a few months to get that appointment, work through insurance and finally, a full 18 months following the original misdiagnosis, you get the correct diagnosis that the cancer in your leg has spread throughout your body.  You begin months of treatment concentrating only on saving yourself but it’s too late.  Eight months after the correct diagnosis you find that the treatment, as well as the original diagnosis has been all wrong. Now,  three years after the incorrect diagnosis, you succumb to the cancer leaving your three children under ten years old with no mother.


Your grieving family doesn’t want to sue but they want answers.  No one answers their questions. The doctors or medical practice.  Not even the hospital who cared for you at the very end.  No one responds to phone calls or to letters requesting a meeting.  Now, you need to search for a lawyer and can’t find one.  Read why here:  


Have a comment?  Want to get involved?  Send your messages to info@pulsecenterforpatientsafety.org

Wednesday, May 24, 2017

Transparency?

Punish or Fix America’s Healthcare Facilities

A nurse who is involved in patient safety commented on Facebook that a local hospital is “closing their OB/GYN services. They are a remote town, downeast just over the border.”
She went on to explain “This closure puts pregnant women in danger. I hope the people downeast fight this one tooth and nail.”  

I felt the need to comment on that post and ask: Isn’t this what people who lose loved ones from a medical error want? If they were injured because of the care they received, don’t they want to see regulatory agencies close the doors?  Could it be that a wrong medication, an infection, or a baby born with disabilities was the start of that facility closing the doors to the thousands of patients they serve?

I get it. When my son died I wanted the doctors fired, the hospitals closed and the investigation (if there ever was one) made public.  Now, many years later, I want clinicians, hospitals, nursing homes and rehabs to do better, not close down. I don’t want to see jobs lost and people die from no available care.

The agencies that review patients’ charts, investigate complaints and inspect facilities are not the reason for the problems.  The problems come from the people who are overworked and making mistakes.  Still, are they to blame?  Isn’t it the system (run by people) really to blame?

I know many people want the oversight agencies that inspect, review and fine facilities to make their records public.  I could understand a government-run agency such as our state Department of Health doing that.  After all, it is government-run and I want to know what my government is doing for me.  As for other agencies that may be involved in fixing the problem, why do we need to know the details of the problems when — I hope — we just want them fixed?  If there are fewer infections at one hospital, does that mean another, best-graded hospital has no infections?  I can’t believe that the public thinks that if a hospital was found to be spotless, a nurse can’t injure a patient with the wrong medication.  What about a nursing home that shows no bedsores and reports of low infection rates; does that mean there aren’t patient falls each year with broken bones?

Why is there such insistence that organizations that inspect, survey or grade hospitals report their findings?  Why aren’t hospitals and nursing homes themselves required to report to the public directly?  Three days since our last injury from a fall!  Two days since our last surgical site infection!  Only three wrong site surgeries this year!  Just two deaths from medication errors this year!

Imagine if the hospital, nursing home other healthcare facilities started to share their data with those of us who pay for their service?  Who would really come out on top?

##

Ilene Corina is the President of Pulse Center for Patient Safety Education & Advocacy a community based patient safety organization located in New York. 

Contact Ilene Corina: icorina@pulsecenterforpatientsafety.org or (516) 579-4711

Saturday, April 15, 2017

Hospital Report Cards Out Again

Long Island Hospitals’ Grades in Latest Patient Safety

If you are wondering whether I have an opinion about the recent release of safety report cards on Long Island hospitals,  I do. 

Hospitals may do better or worse on such evaluations, (and many LI hospitals didn’t fare very well) but in the end it’s mostly down to individuals.

Another tool for rating your hospital is welcome, but what can we actually do with this information?  We can’t really do much to change the hospitals, so for the past 20 years I have been swimming upstream to change us — the patients and our families who support us.  Patient safety is a lonely commitment.  It’s not warm and fuzzy like toys for kids or snuggling with pets.  It’s not helping those already struggling with a disease that is no one’s “fault.”  Patient safety is about preventing harm when simply using the healthcare system.  It’s not unlike wearing a seatbelt even though it won’t be your fault if a car hits you. It’s about protecting yourself from the other driver who might fall asleep at the wheel – not illegal, just an accident.

Let’s think about measurement of hospital safety. Does this mean you won’t be injured at one of the best hospitals? Maybe not. Hopefully you won’t be injured at any of them, but there are never any guarantees. No matter how good a hospital’s patient safety culture may be, there will always be a risk from individuals who are casual in their adherence to the hospital’s error-prevention practices.

Think about the patients at these hospitals: some are at greater risk of adverse outcomes than others.  Are the hospitals with the best “report cards” serving a high percentage of immigrants who don’t speak English and maybe have not seen a doctor in five, ten or 20 years?  Are they serving a person who weighs 400 pounds, is an alcoholic and doesn’t see a doctor for his high blood pressure?  Are the patients at these hospitals young girls giving birth with no prenatal care? Maybe, maybe not . . . . but patients’ backgrounds and histories affect their outcomes.

Are the hospitals with lower ratings seeing the gunshot victims, dealing with angry and unruly families, or patients with no health insurance? Again, it’s a possible factor.

We don’t want to blame the hospital, if it has a culture of safety. I have had a number of experiences suggesting that even in such hospitals there are individuals at the bedside who just don’t get it. Where is this reported?

When a surgeon was asked, “Can you please wash your hands before examining the surgery site?” the surgeon responded dismissively, “I did wash and I showered today too”.  I know that this facility takes hand washing very seriously.  Yet an individual employee had no problem not supporting the patient’s right to safe care.

I asked a nursing assistant and nurse to please be sure a patient’s tray table was close by, so she wouldn’t fall trying to get it.  Whenever I visited, it was again out of reach.  The family noticed that she was not eating: that was the reason.

A doctor came in through the swinging doors leading from outside with his coat still on and a stethoscope around his neck, walked over to the (bleeding) patient I was with, and attempted to examine him.  I stopped him and asked the patient to refuse care until the doctor washed.  When the doctor refused I went to the desk in the emergency room and asked for a different doctor. The staff knew of this doctor’s attitude and accommodated us. This could have happened even at the hospitals receiving top safety grades.

When I asked a nurse to state whom a medication was for before putting it in a patient’s IV, the nurse’s reply was “It’s for her. Did you think it was for you?”  Then the nurse called the same patient by the wrong name. It could happen in nearly any hospital.

Hospital report cards are one way of knowing more about the inner workings of what happens on a larger scale.  There are also the NY State Department of Health and the Joint Commission keeping watch on safety for us – but if each one of us took responsibility for the patient’s safety — our own, our families’ and our friends’ — maybe we could help Long Island’s three million residents get the best care possible.








Tuesday, January 31, 2017

Politics and Patient Advocacy

What does today’s politics have to do with being a patient advocate?

In our Family Centered Patient Advocacy Training which is based on being a Patient Safety Advocate for friends, family or becoming a professional, we stress the importance of being a good listener and being objective.  This past election year and the past weeks have become a great test for these skills.

As I listen to the news, I hear opposing comments and ideas. Depending on what channel I watch there can be very strong opinions one way or another. One reporter or speaker won’t make me change my mind, won’t make me feel differently, but it gives me the skills to try to understand that what is being said is  important to the people saying it and the people supporting them.

I am glad that there are people speaking out on their beliefs.  That is important to our country.  It has never been OK to call names and poke fun of people’s looks or behavior when that is not the focus of the issues.  It loses credibility when I hear about the way a person dresses, walks or laughs and that becomes part of the discussion.

Being a patient’s advocate means being able to focus on facts and what really matters to the patient. Being objective which may mean putting your own feelings aside to listen and then allow a patient to make their own decisions, even if it’s not what you would want for yourself - or them. 

If you are a friend or family member acting as an advocate for a loved one who wants to have surgery but you don't think its a good idea, it means listening carefully and trying to understand what they want and why they want it that way. If you can’t get past your own needs then you may not be the best advocate.  Find an advocate that can be objective and right for the whole family. 

As I watch what looks like a civil war starting on our own soil, I want to get some good out of this.  It may be to just practice my listening.

Wednesday, January 4, 2017

When One Door Closes

A Letter to My Doctor
Today I sent the following letter to a doctor.  I hope others are encouraged to share why they leave a practice before they go.


Dear Dr. XXXXXXXX


I am requesting that my medical records be forwarded to XXXXXXXXXXXXXXXXX

I will not be able to use your services any longer.  Please allow me to explain why.
First, I should explain how I chose you as a physician — and possibly a surgeon — that I would use.  I put a call out to friends and family for a recommendation.  Your name came up.  Even though our state physician profile lists you as having made five malpractice payments in the past six years, three payments above average, I did recognize that your membership of five prestigious organizations such as the American Medical Association, the Medical Society of State of NY and the Nassau County Medical Society might mean patient safety was important to you. 

I thought it would be important to share with you why I am leaving and can’t recommend your practice.

      1.  I found it offensive and disturbing that my reason for seeing you was discussed at the front desk.  I knew why other patients were there because it is asked when signing in, and written down where the next person can see; also, the receptionist confirmed aloud what my appointment was about.  Although this is not a HIPAA violation it would be a breach of privacy were there someone present from my circle of friends or family with whom I didn’t want to share my business. Imagine if a gynecologist’s receptionist asked whether a patient was there for a pap test or a yeast infection, or to see if she were pregnant.  These discussions belong inside your office.

     2. Although your x-ray technician was very nice, he seemed rushed and impatient with other staff.  He told your PA that he was waiting for me for a half hour.  I was not even there for 10 minutes.  He also did not describe what was happening to me, what he would do, or why he would do it.  He said almost nothing to me.  A brief explanation of what would be happening while he was working – thus taking no extra time — would have been helpful, especially if I were someone feeling scared or alone. It also would have made a great impact on my experience.

     3. I don’t appreciate being called “Doll” after every sentence by a staff person who is half my age (or any staff person).  If she couldn’t remember my name, there are safer ways of confirming she has the correct person.

     4. An unknown, elderly woman in a wheelchair was wheeled into my room while I was waiting for you.  I had to stop the staff person from bringing her in.  He apologized and said he had the wrong room.  This gives the impression that your office is in some disarray and there are on-going problems.

     5. On my first visit with you, you were obviously very sick with a serious head cold and let me know that.  I understand that it is not easy to take off from work, yet you never washed your hands and even after blowing your nose you went back onto the computer in your room without cleaning your hands.  Then, you left the room touching the door knob.
   
 Dr. XXX, this letter is not being sent as an official complaint to the Office of Professional Medical Conduct, but instead offers an opportunity to review practices that can be viewed as potential hazards to your reputation, your staff, and most importantly your patients. It is very difficult for me to write this letter but I think it is very important that these issues of respect, courtesy and safety are addressed.

Thank you for your time.

Sincerely,
Ilene Corina, Patient Safety Advocate

CC:
American Medical Association
Medical Society of State of NY
Nassau County Medical Society