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Patient Safety Week – Medical Mistakes Happen

Hey everyone — it’s Patient Safety Week!

If you aren’t in health care, you may be wondering what “patient safety” even means. I know I got images of metal detectors screening for weapons, alarmed doors on the maternity floor to detect when a baby is carried off without authorization, and “wet floor” signs.

If only it were as simple as that.

In health care, patient safety means preventing medical errors. And medical errors are a real problem.

Around 100,000 people per year are harmed or killed by medical mistakes. (See the Institute of Medicine’s report in 1999, “To Err Is Human“)

Just let that sink in for moment.

It’s the equivalent of a jumbo jet crashing and killing every passenger on board… Every. Single. Day.

I hope it stuns you as it does me. But many hospitals prefer to stick their heads in the proverbial sand and pretend they don’t make medical mistakes…until their dirty laundry gets dragged into the light by a highly-publicized medical mistake at their facility.

I am fortunate. The hospital where I work and to which I take my kids hasn’t had a highly-publicized mistake…yet. And they are working very hard to eliminate serious safety events. They talk about it from the CEO’s office to the board of trustees to the nursing units to the ORs. They show the number of days between “serious safety events” (the worst kind) on our intranet site for all 12,000 employees to see. They commission teams to investigate the mistakes that do happen and other teams to design systems to fix the problems they find. And they have been very successful. Just a few years ago, we had over 30 of the most serious kind of medical mistakes per year. This past year, we had less than 10.

But we still had them. And every child hurt is a tragedy. It’s inexplicably painful for the families and for the caregivers, all of whom carry grief and guilt over the incident for their entire lives.

Patient Safety Week is a national effort to get hospitals to voluntarily pull their heads out of the sand, take a hard honest look at their performance, and take some action to make health care at their facility safer.

Today, I attended a regional health care conference where I heard Sorrel King speak. She’s the mother of four children but lost her youngest, little Josie, in a medical mistake at Johns Hopkins. She and her husband were able to rise above the pain and anger to look at how they could partner with Johns Hopkins to make things safer. They began the Josie King Foundation to help hospitals, health care providers, patients, and families work together to eliminate medical mistakes.

One statement she made yesterday really struck me: “The thing I can hardly believe, even today, is that my daughter died because of a breakdown in communication. That is something we can fix now. We don’t have to wait, like we’re waiting for the cure to cancer and AIDS and diabetes. We can improve communication NOW.”

She’s right. Every difficulty we’ve had (fortunately, we haven’t had many) have centered around communication. You can’t be a consumer of health care for as many years as we have without experiencing mistakes. But what I have seen is that usually at least one person sees that the mistake is happening or about to happen. The make-or-break moment occurs when that person decide to say something or not, and if they do speak up, if the rest of the team listens.

The worst one for us (so far, and hopefully ever) happened five months before Ellie died. She was given too many drugs that did the same thing, just in different ways, so all three were working on the same thing at the same time resulting in massive overkill.

I knew something was wrong, so I asked her nurse. The nurse gave me an explanation that I listened to, for awhile. But the situation didn’t resolve, so an hour later, I asked again. The nurse looked again, gave me the same explanation, but I was still convinced something was wrong. He offered to call the fellow (a physician completing additional specialized training) to look at her and talk to me.

The fellow came in, looked her over, and basically gave me the same explanation I’d heard before.

I asked a few more questions, because I was still really concerned. But I’m not a doctor. These people are super-smart and super-experienced and to be completely honest, I wanted to believe that they were right. I also didn’t want to piss them off… after all, with two kids with complex medical problems, I was likely to run into this fellow again. I didn’t want to be “that problem parent.”

I will regret that for the rest of my life.

So we took Ellie home even though the situation still hadn’t resolved. That night, I got out all those meds, called again to verify one of them because it didn’t look the same, got the same fellow, and could tell that he was annoyed. I went ahead and gave them all.

The next morning, not only was she not ok, but I could see something really bad was happening. But I would not call that fellow back. I thought he’d just tune me out again. I called a few other people, but none grasped the big picture (she was always a complicated patient) and understood what was happening.

We finally got to the bottom of it the next morning (two entire days later) when I was finally able to talk to her specialist. The one who knew her, knew me, listened to what I said, and took me seriously. The one we’d worked with for 8 years. He finally heard me, put the pieces together, discontinued all those meds, and tried to reassure me about the bad stuff I was seeing.

But the damage was done, and it took months to clear up. I could still see traces of it the day before she died.

This stuff is real, folks. We have to pull our heads out of the sand, listen to one another, and be vigilant. We have to teach physicians communication skills (both speaking clearly AND listening carefully) from the get-go. We have to empower patients and families to take action and find someone who will listen when they have a concern about a mistake being made.

I plan to share some of the things I’ve learned as a parent of patients to help keep them safe in the hospital. I’d love for you to share too. Let’s work together to make sure medical mistakes don’t happen to our loved ones.

Did you know how frequently mistakes happen in medicine? Has anyone ever made a mistake with your care, your child’s, or another loved one? What do you do to keep this from happening?

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