A Patient’s Thoughts on a System’s Response Helen Haskell Mothers Against Medical Error Columbia, South Carolina Whose Medical Error?

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Presentation transcript:

A Patient’s Thoughts on a System’s Response Helen Haskell Mothers Against Medical Error Columbia, South Carolina Whose Medical Error?

Lewis Wardlaw Blackman

Synopsis of a Medical Error Lewis, a healthy 120-pound boy, is prescribed a five-day adult course of the NSAID ketorolac tromethamine following surgery. Adequate fluid levels are not maintained. Three days after surgery, Lewis begins complaining of severe, unremitting epigastric pain. Nurses and residents fail to act upon increasing signs of instability. Parents’ request for an attending physician is not honored. Four days post-op, following 30 hours of deteriorating vital signs, including four hours of completely undetectable blood pressure, Lewis dies. He has not seen an attending physician for over two days. Autopsy shows a giant duodenal ulcer and 2.8 liters of blood and gastric secretions in the peritoneal cavity.

AFTER OUR CHILD DIED What we expected from the hospital  Alarm;  Remorse;  Compassion and support;  Urgent investigation;  Urgent change.

How Does Full Disclosure Help Patients?  It relieves guilt and fear.  It restores trust.  It allows them to believe that their healthcare providers care about them.  It reassures them that they do not have to face a dark future alone.

How Does Full Disclosure Help Providers? It allows them to maintain their compassion and integrity and to fulfill their mission as caregivers.

What we wanted  The option to meet with those involved in our child’s death;  The chance to tell investigators what we had seen;  The chance to have input into change.

Questions Would the residents have felt less abandoned if they had the opportunity to meet with Lewis’s parents? Did investigators’ desire to spare the residents’ feelings prevent the residents from learning from their mistakes? What lessons did they then learn instead?

Patients’ Emotional Needs after a Medical Injury Acknowledgment of the significance of the loss; Learning and change; Accountability.

Root Causes of Errors Production pressure Inadequate training Poor care coordination Unsupervised trainees

What do patients expect? Expertise Vigilance A plan A backup plan A system that delivers what it promises