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Showing posts with the label preventable error

Who is a Criminal - Parents or Providers?

Take a minute to read the articles linked to below then please share your thoughts: Is this a question of the conflict of the separation of church and state? What is the child died after they sought medical care as well? If a child dies in a parents arms who has not sought medical treatment, the parent is criminally liable and it is acceptable to put them in jail. In contrast: If a child dies in a medical setting from preventable errors after the parents have sought medical care of a trained health care provider, it is not acceptable to for the provider to be held criminally liable and serve jail time. What is the disconnect in public sentiment on what to do when an adults chosen course of treatment causes irrevocable harm to a child at the mercy of the adults surrounding him/her? How can this disconnect be repaired, or improved? These are not easy questions to consider; but consider them we must because people are "doing time" for what others have defined as "not doin...

A Healing Place

A Living Memorial Garden for the Victims and Survivors of Medical Harm was created in Maine by Becky Martins. Becky is one of the newest members of the board of CAPS (Consumers Advancing Patient Safety) and a member of the Worldwide Patient Safety Day Committee. When I first met Becky in Washington DC in 2007 she spoke of this garden. I wasn' t sure at the time if the soft-spoken yet determined demeanor was why I appreciated the concept so much, or if it was just because I personally needed a place to go that I "belonged". People who know about preventable medical errors experience string feelings of distrust, stupidity, trauma, devalued, annoyance, anger, denial, sadness, jealousy, and an earnest desire to save others from a similar fate. And as many different ways there are to get to be a member of this distasteful "club", there are that many ways to address the effects of it. All along I have sought peace. I realize now it is a fleeting state. When I d...

The Provider's Top Ten Tools for Safe Health Care Delivery

There has been a lot of direction from health care providers to patients in the past ten years since the release of the infamous Institute of Medicine report. I thought perhaps the providers and physicians could use some simple suggestions and requests from the patients to encourage safe care. What do you suggest for changes, deletions and additions? #1. Speak up! The most well-known and respected health care safety organizations ( AHRQ , IHI , TJC , NPSF , NQF , CAPS, WHO Alliance for Patient Safety) all agree that communication is the key element in successful outcomes. As a health care provider you are a key participant in the treatment team. If you see or hear that care being provided to a patient falls below the current standards, is at risk, risky, or questionable your willingness to speak up may have a direct impact on the outcome of care. #2. Maintain Accurate Medication & Treatment Records! As a health care provider, you must take responsibility for drafting and maintainin...

Still Missing

The porch light is left on all night every night. There are seven Christmas gifts that have not been opened. His clothes are laundered, folded and tucked away neatly in a Rubbermaid container in the attic. His hospital beanie cap sits on my bureau. His portrait - dated by seven and a half years hands with his siblings which were all taken within a few months of today. He is here. But he is still missing. I have spent seven and a half years figuring out what happened to my son and then what I would do to be able to live with it. I am still figuring out. His body lays 8 feet or 9 feet under a small black marble slab with his name on it. The 32 plus x-rays taken in a day of his life probably are much more similar to him now than the photo sitting on my nightstand. Certainly the sternum wires are in tact. I am drawn to the cold, the wind, the snow. The sudden hush that blankest the bustling suburbia invites me to take a discreet and peaceful journey. I want to go back. Back to court. B...

Restorative Conferencing in Health Care

"Now the doctor, by virtue of accepting science so totally, creates a total imbalance, forgetting the art of healing, forgetting the art of engagement, forgetting the art of listening, forgetting the art of caring and ceasing to invest time with the patient. So I believe medicine has lost its human face.” ~ Dr. Bernard Lown Doctors do not like to be shamed or blamed. Neither do nurses. Nor surgeons. As a matter of fact, any query from a patient to the healthcare provider is received as critique of job performance. Much of this is a result of the disconnect between physicians and their patients. Physician, by the way, is the term I prefer to use over “doctor” since learning the definition variations: per Merriam Webster dictionary a physician “heals” and a doctor “has been awarded a medical license” (Webster, 2005). This is a worthwhile difference to note when seeking quality medical care. Dr. Bernard Lown described in his book, “The Lost Art of Healing” his inspirat...

Physician Learning Styles that Promote Healing

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...