Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY September 2015 Webinar

Welcome Lisa Morrise, Program Coordinator, Consumers Advancing Patient Safety 2

Learning Objectives Create awareness about the emotional impact that medical errors and adverse medical events have on patients/families and clinicians/providers. Describe what patients and families want following medical errors and adverse medical events that cause harm. Explore the presence or absence of support services that exist in respective institutions Identify and discuss the barriers that prevent utilization of these supports 3

Agenda 1.Helen Haskell – An Overview of the book Case Studies in Patient Safety. 2.Linda Kenney – Share, briefly, the story from the book, “The Silence of the Hospital,” including the lingering medical consequences of this and later operations 3.Linda Kenney – Development and Mission of MITSS – Purpose: To create awareness, promote open and honest communication, and to provide services to patients, families, and clinicians affected by medically induced trauma. – Vision: Our vision is for all those involved in a medically induced trauma to have access to support services. We envision a more compassionate, people-centered healthcare system. 4.Linda Kenney and Frederick (Rick) van Pelt, MD, – Optimum Supports for Physicians and Patients 5.Helen Haskell, Linda Kenney and Rick van Pelt, MD – Questions / Discussion 4

Case Studies in Patient Safety 5

The Patient Story Patient stories in the book highlight real issues in Patient Safety. Many patients have taken their stories and developed effective advocacy that benefits patients and providers as well as supports Patient Safety efforts. Introduction of Linda Kenney 6

November 18, 1999

We all have stories…

Emotional impact Constant Questions Follow up with Orthopedic surgeon Calling the hospital First Six Months 9

Transparent communication in real time An Apology or an acknowledgement Organizational response to prevent recurrence Support (unique for each individual) What Patients and Families Want Following Adverse Medical Events

2002 – Medically Induced Trauma Support Services (MITSS), Inc. Mission: To Support Healing and Restore Hope to patients, families, and clinicians following adverse medical events. Creation of MITSS

A non-profit organization founded in June 2002 by a patient who experienced an adverse event. Local (headquartered in Chestnut Hill, MA), national, and international reach. About MITSS

Medically induced trauma is the emotional toll that results when something goes wrong during medical and/or surgical care. It may or may not be due to an error, but is an undesirable outcome due to some aspect of diagnosis or treatment. Most importantly, these events can significantly affect the emotional well being of the patient, family member(s), and/or clinician involved. MI What is medically induced trauma?

Found out my ankle shifted and couldn’t get the ankle replacement without another surgery – Had surgery to realign my ankle 2007 – Rt Ankle replacement – 3 weeks later ended up with a SSI (Surgical Site Infection) – MRSA 3 months in bed with open wound and a PICC line Skin graft surgery to close wound On PO Antibiotics on and off for 18 months Another surgery to remove hardware that was infected. Another PICC line for 6 months 2011 – surgical site hernia repair(where the chest tubes where placed) 2014 – Removal of ankle replacement (because of breakdown) to do a Total Ankle Fusion 2014 – 2015 constant pain in swelling in ankle 2015 – Surgery to fix the non union of the ankle fusion 2015 – Emergent Hernia repair 2015 – Need to get a custom foot brace for right ankle Ongoing Medical Issues…

Rick van Pelt, MD, MBA

Discussion a.What barriers do you feel exist to providing full disclosure following medical error? b.How do full disclosure programs overcome the barriers to transparency that exist on both sides? c.What could be done to alleviate the adverse effects of providers who are involved in medical error? Is having an employee support program enough? d.Other questions? 19

News October 22 – Ilene Corina – Turning Personal Tragedy into Advocacy – Meeting the Needs of Vulnerable Populations On the CAPS Website (patientsafety.org) – Find links to prior events – Information about the IOM Diagnostic Errors report Please take the survey for patient advocates and HENS: