restorARTively

It is hard to maintain a restorative mindset when preventable death and pain keeps rearing its ugly head in pediatrics. This morning I learned of the death of a 40 day old baby who had been diagnosed with a treatable CHD (congenital heart defect ) - but the parents had never been told of the diagnosis. So the patent ductus arteriosus killed the child. I shed a tear and screamed in my heart. The parent should have been told. Of course, there is no guarantee as to the outcome - but what would have been guaranteed is that the family would have been a part of the treatment team. If tragedy still struck, there would have been a community of support built already the parent and the medical team. This brings me back to why I am here to begin with. Why James died. Why I ended up enduring the additional trauma of civil litigation. Why the book is titled, "Split the Baby ". Such a phrase can evoke disturbing imagery. Trust me. What James looked like after the medical interventions was...

Politicians are struggling with bipartisanship and meaningful transdisciplinary conversations over health care insurance. Debate has begun to shift to one of the major factors of steep costs in health care - medical malpractice. Most of the media focus has been on "tort reform" which is symptomatic of the problem, not the problem itself. Pennsylvania Patient Safety Authority board member and lawyer, Cliff Reiders, wrote in the summer of 2009 how the tort reforms made into Pennsylvania law in 2002 have significantly reduced the number of medical malpractice claims while at the same time the reports of medical errors in Pennsylvania hospitals have increased . These numbers are significant to Philadelphia and its surrounding area as it houses at least 6 major hospitals and health systems - most internationally recognized as leaders in innovative medicine. Though the worst medical cases may end up in Philadelphia's hospitals, there are many simple patient cases that fall...

Consider the true impact of medical malpractice. How does it affect patients, caregivers, siblings, parents, etc? What is the impact on society at large? What happens when you lose trust in a doctor? Or your local hospital? Or are a provider and you lose trust in a patient? What is available to help heal the iatrogenic injured bodies and souls? How much of a burden does medical malpractice put on our social services industries? Where do clinicians go to get help? Is there a place for patients and their families to reach out? Can patients and clinicians impacted help each other? In working one on one with both parties, each will move forward. What seems more challenging is meaningful healing that brings a sense of understanding and being understood. Absent understanding to bring peace, both impacted parties are stuck in a pattern of anger, grief and denial. Each party leans on whatever they can find available to fill the void left by anger and isolation. Alcohol, prescription drugs, fo...

Malpractice Confidentiality Clauses Could Put Others At Risk - Milwaukee News Story - WISN Milwaukee I posted this article on my Facebook page and it produced numerous comments. More than a comment box is necessary to explain my stance on transparency in health care. The underlying principles that guide work in restorative justice/practices under which I work towards education and communication in health care include accountability, respect, honesty, and community (all stakeholders included). These principles acknowledge the human condition/need to be a positive contributor within a community of caring. A group of individuals and institutions engaged in the delivery of or receipt of care to the sick and dying could be defined as a "community of caring." Anything that restricts the employ of accountability, respect, honesty, and community in health care impedes the restoration of health and healing (even in circumstances where dying occurs because there is healing to st...

DECLINING MEDICAL MALPRACTICE CLAIMS, INCREASING MEDICAL ERRORS A simple analysis by the Committee for Justice for All in Kingston, Pennsylvania compared public information available on medical malpractice claims as opposed to medical errors. The data consists of Mcare Fund payouts, commercial insurance claims and Pennsylvania Patient Safety Authority data. The Mcare Fund is a creature of the Pennsylvania Insurance Department and supplies half the medical malpractice insurance coverage that doctors and hospitals are required to carry as a result of medical errors that cause harm to patients. The data shows the number of case filings according to the Administrative Office of the Pennsylvania Courts as of April 2009. In the year 2000 the number of case filings throughout the entire Commonwealth of Pennsylvania was 2,632. That already small number fell every year for which statistics have been kept down to 1,602 in 2008. Considering the number of hospital admissions in Pennsylvania, that ...

A few recent developments have set me off balance: The WSJ OpEd piece, a collection of health risk managers, and a group of fellow heart moms who successfully diminished the impact of my son's loss and the work I did in seven years to understand his death and offer compassion to his medical providers. I am reminded that the health care system has known about the life-threatening issues within its profession for well over ten years. They know them so well the common comparison is made to air travel. The amount of deaths each year to preventable medical errors is equal to a jumbo jet crashing every day leaving no survivors. This brought memory of the words of Susan Cohen. Her daughter, Theo, was one of the passengers killed on Pan Am Flight 103 in 1998. "There was the grief group therapist who told me she was worried about my anger, that I should open my heart. .... It was an open, bleeding wound......I didn't need anyone telling me there was something wrong with my enorm...

Anger moves things. T his Opinion Editorial from today's Wall Street Journal really ticked me off. Taking advantage of his advanced education and the weight the general public will give it, this author is putting forth decades old myths about medical malpractice. I have spent the past seven years digging against the strength of a huge institution to find out what happened to my son and then gathering the personal strength to share what I have learned so others (including the providers) do not suffer needlessly. In Pennsylvania alone, which put in place its own tort reform in March 2002, there were approximately 350,000 reported sentinel events to the state's Patient Safety Authority for 2007. For the same time period there were only about 1300-1400 medical malpractice cases on the judicial dockets. That is one-half of one-percent. And, of those few cases that will go to jury trial , the vast majority will be found for the defense. I am proud to be an American. There are multitu...

I presented my son's one way ticket to heaven and my subsequent journey to hell and back via health care with a small group of health risk managers this morning. The informal restorative practices that I implemented on my own after nothing else worked can serve as an example of what patients and providers can do for themselves. It is possible for them to talk even after errors and mistakes. Hopefully, our story can make a difference for another patient & provider in conflict. Most of the audience understood the importance of proactive restorative circles in health care. The idea of reactive restoration was more of a challenge. One mentioned they had to tell patients we cant talk to you while we are investigating these care concerns. I asked "What will it take for you to include the patient and family in the investigation?" I asked, "Why don't you tell the patient, 'we are investigating what happened and would like your input?'" The most revealin...

The Pennsylvania Patient Safety Authority has recently released its Annual report for 2008. The Authority begins by stating that it is “just at the beginning of a journey and we have a long way to go.” The Authority was been at work on this for the past five years; the Institute of Medicine watershed report, “To Err is Human” is ten years old. It has been a decade. In that decade approximately 933514 lives have been lost to preventable medical errors in the US healthcare system. This excusatory beginning to the report is indicative of the entire report. The overall tone of the language used within the report increasingly diminishes the importance and relevance of any patient death or injury. "But” or “that is only..." was used repeatedly in the report. One death is one too many. All this language succeeds in is to stunt any natural response a healthcare provider may be feeling about the loss of one his/her patients. Deep within he report, you will find meaningful data on wh...

Recent posts reflect my continuing struggle to reconcile the way in which my son died, the means by which I learned what happened, and the conflicting desire to create a Restorative Culture in healthcare. Perhaps this is a function of the holidays. For bereaved parents, each holiday, anniversary, birthday, life milestone is merely a time stamp of how much continues to be lost. At the start of the new year, unexpected conversations and experiences gave me courage to speak of a part of James' loss I rarely discuss. After he suffered severe insult to his brainstem and his cortex, I had to limit my thought processes, expectations, dreams and hopes for James. At this point in his life, I was the parent of a severely disabled child. And I wanted him. I wanted the medical equipment, the doctors, the appointments, the frustration, the years of wondering "would it be better if he had..." I have the advantage of knowing it would not have been better if he had died. It would have b...

I went to a movie this evening. As busy as I am there was little time to research which to attend beyond finding one at the most convenient theater at the most convenient time. Believe it or not, I have still not learned that convenience is not the best way to make decisions. The Curious Case of Benjamin Buttons is my inspiration for tonight's post. The civil trial in Delaware Superior court of Mannix v. Nemours, et al ended on a cold, wet, gray Fall day in October 2005. It was much like any other Fall day for most. People were busy looking for umbrellas and the right combination of clothing to stay warm, dry, and appealing for whatever their station in life may have been. For my husband and I it was the day of the verdict. It was the Friday before Columbus Day and for those of the Jewish faith it was also amidst Rosh Hashanah. Maybe it if hadn't been the Jewish holiday our key witness would have ben able to testify in court instead via video. If Pennsylvania hadn't changed...

At the outset of my Fall Research and Statistics in Retsortaive Practices coursework, the intelligence of my trust in the physician-defendant in my son’s case (with whom I began a unique post-verdict dialogue) came into doubt by national leaders in patient safety, as well as by a couple trusted peers and confidants. It was the first time I had ever thought to question the doctor’s “story” and his explanations of his actions and decisions that fateful October evening. Just weeks previous I shared a piece of our post-verdict reconciliation to an international audience of healthcare leaders at Harvard University (Krukenkamp & Mannix, 2008). Afterwards, a few questioned the validity of my words, my story as well as who the mysterious doc must be since I did not reveal his name. I have never revealed the name since the doctor expressed an interest in remaining a quiet supporter of my attempts to reconcile the patient – physician relationship post-adverse event. However, for those tru...

This is copywrighted material. No reproduction in whole or in part may be reprinted without express, written permission from the author. Introduction In a response to medical malpractice crisis in 2001, the Pennsylvania Patient Safety Authority was created through legislation as a result of these concerns there is new data to study. There are 300,000 to 400,000 “sentinel event” (an outcome of treatment that is unexpected and has left the patient preventably injured or deceased) reports in the state each year (Pennsylvania Patient Safety Authority, 2007). It is widely accepted amongst stakeholders there is underreporting and misunderstanding as to what classifies as a reportable “sentinel event”. Hospital acquired infection, wrong site surgery, ventilator-induced pneumothorax are a few examples that have been identified by government agencies (Agency or Healthcare Research and Quality) as preventable and sentinel events. It appears much concern is driven by medical malpract...

"So this is Christmas And what have you done Another year over And a new one just begun And so this is Christmas I hope you have fun The near and the dear one The old and the young " ~John Lennon, Happy Christmas The second Sunday of December has been tagged by grieving parents as the one to remember our lost children. We light a candle at 7 PM. I am not certain how long this has been an event; but this is my eighth year performing the ritual. I am not sure who decided to make it December; but I haven't been able to sing Silent Night without crying for eight Christmases. I don't think many others remember my son throughout the year; but this day gives me permission to remind them its a gift when they say his name, "James". I don't know exactly how many children have died from preventable medical errors; but there are as many as 277 patients a day that die from preventable medical error. I can't imagine how Pennsylvania physicians manage to pay their ...

Learning comes from listening. “You have one mouth and two ears,” is a Maori (New Zealand) saying my peers shared during a Restorative Practices graduate course. I keep that in mind while adding - I have two eyes and one dominant hand. After six weeks of graduate level study, I feel most aware of many inadequacies, shortcomings and talents not fully saddled. The discussion of concepts, ideas and life experiences shared by my classmates was a key component in my overall learning experience. Who'd of thought a young, handsome, intelligent man would be the one in a mixed group to refuse to reveal his age? As I excitedly turned 40 this month, this young man, Joe, a new classmate in grad school, was holding back. He had good reason. He learned the hard way early that when people know his age, automatically a certain set of expectations and judgments are cast upon him, his abilities and his intentions. Who wants to be placed in such an unforgiving box? I try to follow a similar ...