Transcript Fatal Care
Telling Their Stories Sanjaya Kumar, M.D., M.Sc., MPH Karin Janine Berntsen, RN, BSN THE QUALITY COLLOQUIUM - August 22, 2007 Vision & Objectives: • • Move the healthcare consumer beyond the statistics associated with medical errors. Who are the people behind the numbers? • What are their stories? • • • How do errors impact lives of those affected and those that are involved? Bringing the consumers to the forefront so they can relate to the impact of medical errors on the personal lives of people. Move the consumer into action. FATAL CARE Rationale for “Fatal Care” • Consumer naivety • Medical overconfidence • Assumptions can be deadly. • Good, non-fiction, literary work exists that is beginning to bridge the gap between the consumer and caregiver. • Internal Bleeding - Wachter, Shojania • Through the Patient’s Eyes - Gerteis, Edgman-Levitan, Daley, Delbanco • The Patient’s Guide to Preventing Medical Errors Berntsen • How Doctors Think - Groopman • These works mostly emphasize the numbers and statistics. • FATAL CARE is personal - you, your child, your spouse, your neighbor, your friend, your mother... • FATAL CARE - The next step to drive change in how the consumer interacts in their healthcare to help prevent medical errors. FATAL CARE: “Novel” Type NonFiction Stories The Janson Directive Coma The Scorpio Illusion Shock Critical The Bancroft Strategy Robin Cook Robert Ludlum New York Times bestsellers On Parrish Island, off the coast of Virginia, lies a psychiatric facility. Far from prying eyes, it is a government - run hospital for former intelligence employees in possession of highly classified information. Former Consular Operations agent Hal Ambler is one of these patients whose mind is filled with secrets of state - and is considered such a security risk that he is kept heavily medicated and closely watched. But there’s one critical difference between Ambler and the other patients - Ambler isn’t crazy. Now he must find a way to escape the facility, find out who put him there, and uncover the truth of who he was…and why someone is willing to risk everything to see him dead. Each chapter tells a different story of a family impacted by a preventable medical error. • • • • • • • • • • • • Three Little Angels: Indiana Babies - Heparin Overdose Even the Tough Can Fall: Charlie Weis - Surgical Complication Never Routine: Lewis Blackman - Failure to Rescue Reading Between the Lines: Trisha Torrey - Misdiagnosis Critically Wounded: Diana Brookins - Bloodstream Infection Wrong Turn: Benjamin Houghton - Wrong Side Surgery You Can Have My House: Johanna Daly - Surgical Site Infection The Mission: Taylor McCormack - Delay in Treatment Picking up the Pieces: Diane Ford - PCA Pump Failure They Are Not Listening: Ken Simon - Wrong Diagnosis Coming Together: Linda Kenney - Medical Trauma One of Their Own: Liz Augusta - Near Miss THREE LITTLE ANGELS Heather heard muffled yelling and crying from inside the door, but she couldn’t make out what they were saying. She felt a gnawing, sick feeling in the pit of her stomach, like something bad was about to happen and her body knew it before her head…Now Heather heard her mother yelling. “What do you mean? What’s wrong with Thursday Dawn? What’s wrong with the baby?” Joanna’s voice became increasingly shrill and hysterical. “Accident, Hep-a-rin, what did you do to her?” 11% Percentage of medication errors involving dangerous high-alert medications, such as heparin, morphine, insulin, potassium chloride and chemotherapy agents. NEVER ROUTINE By Sunday afternoon, Lewis’ abdomen hurt worse than ever. His belly grew rigid and distended. His eyes had a sunken, hollow look. Alarmed by his condition, Helen knew Lewis needed to see a doctor right away. She repeatedly pushed the call button, but they had stopped answering the call light in room 749… NEVER ROUTINE …As morning broke, the awful pain in Lewis’ abdomen abruptly stopped. When the nurse heard this news, she took it as a positive sign and said, “Oh, good.” But to Helen it seemed strange, like the eerie calm in the eye of a hurricane, where things are temporarily quiet before even greater trouble lands onshore. 75% Percentage of U.S. hospitals who still have not implemented a Rapid Response Team (RRT). Following Each Story… Sections that provide insight and help for the consumer. Fatal points describe breakdowns in the process that can lead to patient harm. Critical Safeguards describe steps that a patient and family can take to help avoid a medical error. Safety Keys are brief snapshots of patient resources and tips. • A balance of positive and negative outcomes: • Fatal Care had a potential to be a “downer”. • Limited fatal outcomes, included near misses. • Altered positive and negative outcome stories. • Unfortunately, it could have been Fatal Care Children. • Limited children to three stories. • Geographic locations: • Medical errors happen in every area, city, country and in-between. • Contacts came from all over the world limited to U.S. for this book. • New York City, LA, South Carolina, Everett Washington, Chicago area, Portland, Boston • All size and types of hospitals: • Medical errors happen in every size hospital: • Teaching/University • Community based hospitals • Specialty hospitals • Outpatient centers • Cross section of type of errors. • • • Generally healthy people that received care or treatment for an illness or injury. For this book, we did not select chronic illness or complex, multiple diagnosis case scenarios. Targeting the general healthcare consumer who could relate to, or experience a common medical error. • Queries for the Stories: • Fatal Care Website http://www.fatalcare.com/ • PULSE http://www.pulseamerica.org/ • Previous contacts from: • • • Public news stories Mothers Against Medical Errors • • The Patient’s Guide to Preventing Medical Errors [email protected] National Patient Safety Foundation • [email protected] • • Medication errors Infections • • • • • • • SSI Device related infections Misdiagnosis Surgical complications Delays Wrong site surgery Near Miss • Methodology: • The key method was personal interviews. • Written accounts • Published stories • Professional education • Stories: • Some are in litigation. • Some had completed litigation/settlement. • Others did not have litigation.