Susan Sheridan, 50, of Idaho, learned about health-care system failures the hard way. Her son, Cal, was diagnosed late with a case of severe jaundice 14 years ago.  He suffered permanent brain damage. Her husband, Patrick, died from cancer because a pathology report that identified malignant cells never made it to his physician. “The document got filed without his doctor knowing,” she said.

Sheridan had considered herself savvy in the world of health care. But she found even an intelligent consumer can miss important information. At the end of his life, Patrick’s words drove her to be a crusader. “He said, ‘Whatever you do, don’t give up on patient safety.’”

Sheridan, president of Consumers Advancing Patient Safety and now a single mother of two, worked with other mothers of children with kernicterus, a toxic form of severe jaundice, to push federal agencies and the medical establishment to adopt new standards for jaundice management, and to make mothers aware of the dangers of untreated jaundice.

Since her husband’s diagnosis in 1999, she has worked with the same federal health agencies, hospitals, and doctors to make sure all patients get copies of critical medical tests. “It can save lives,” she said.

Take proactive steps

Women 50 and over tend to take more medications than younger women or may suffer from chronic conditions, which puts them at greater risk of health-care error. But they can take steps to make their hospital visit a positive experience. 

“The most important message is to be an assertive consumer and shopper and carry that attitude into the hospital.”  said John Connolly, Ed.D., CEO of Castle Connolly Ltd. of New York, a health research and information company. “You should not be afraid to ask questions, to challenge, and if necessary to be assertive.  It’s your health.  It’s your life.”

For the last decade, the American Hospital Association (AHA) maintains, its 5,000 member hospitals and health-care organizations have been working to improve patient safety. “Hospitals have taken dramatic steps in improving patient safety through electronic health record systems, ‘sign-your-surgery site’ programs [in which doctors actually initial a surgical site before performing surgery], bans on the use of confusing abbreviations, bar-code systems for medications, read-back of verbal orders, and other advancements,” the association said in a statement.

“We also work very closely with groups like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which accredits about 80% of the nation’s hospitals. They have developed national patient safety goals for improving the safety of patient care in health-care organizations,” the statement continued.

Fatal hospital errors

The movement in patient safety generally is considered to have begun in 1999, following a groundbreaking Institute of Medicine (IOM) study, To Err is Human: Building a Safer Health System, that estimated patient deaths due to hospital error at up to 98,000 a year. The IOM is a non-profit organization that provides advice to medical decision-makers and the public.

“I think the number is closer to 200,000, and it is probably low,” said Martin Hatlie, CEO, Coalition for Quality and Patient Safety of Chicagoland.  The organization is a clearing house on the best practices in health facilities and advocates for the best patient care possible. He based his figure on a 2004 Healthgrades (the leading independent healthcare ratings organization) study based on billing practices. “Don’t expect the healthcare system to be safe, he added. “Healthcare is the most complex human activity on the face of the planet.  It’s prone to failure.”

Public opinion polls have been harsh on the medical system. A 2004 Harris/Wall Street Journal poll showed 39% of Americans were “extremely” worried about medication errors.  Thirty-seven percent were extremely worried about diagnostic errors. 

Primary-care doctors, specialists, technicians, and nurses all have to coordinate in communicating critical and sensitive information, Hattie explained. Dozens of healthcare workers may be involved in one person’s hospital stay. Then the critical patient information has to be conveyed from one shift change to another.

Aside from coordination and teamwork, the risk of infection and falls are high on the list of potential patient dangers. Cases of MRSA (Methicillin-Resistant Staphylococcus Aureus), a deadly antibiotic resistant bacteria, and Clostridium difficile or C. difficile-associated disease, an infection that can lead to diarrhea, blood poisoning, or death, increased dramatically between 2000 and 2005, according to the Agency for Heathcare Research and Quality (AHRQ) of the U.S. Department of Health and Human Services. The federal government recently issued grants to researchers to study the causes to those infections and the best way to combat the problem.

Now, with the threat of H1N1 (swine flu), even more emphasis is on infection prevention, the health experts added.

Do your research

Connolly recommended that if you are going into a hospital for any length of time that you spend some time researching the facility. Twenty-five states have laws mandating record keeping on hospital infection rates, according to RID: The Committee to Reduce Infection Deaths, a non-profit group. State public health departments keep those rates on their web sites as well.

In addition, RID offers specific tips on what to do in the hospital to reduce a patient’s risk of infection:

• Ask all hospital staff who enter your room to clean their hands.
• Ask that clippers be used to shave surgical areas. Razors can leave cuts that can become infected.
• If a “central line” catheter (one that leads to the chest cavity or the heart) is required, ask for an anti-infection product.
• Make sure the stethoscope is wiped with alcohol before it touches your body.

Both the Centers for Disease Control (CDC) and AHRQ also offer extended assessments and guidelines on how to be safe in the hospital.

Get help from loved ones

If you go into a facility for an emergency procedure, ask a loved one or family member to be your eyes and ears and your advocate, experts recommend.  If you’re able, be sure to ask questions and be aware of  each person who is treating you, why they are in the room, and what their role is in your treatment. If you can’t do it, ask your friend or loved one to do it for you.

When medication is brought into the room by a nurse or technician, find out the name of the medication, why you are receiving it, and what dose you are being given. If necessary, ask for access to your hospital computerized records, Hatlie recommended.

When Hatlie’s 82-year-old mother was treated for ovarian cancer in Minnesota in 2009, he learned firsthand how important it is to be aware of medications. He and his three brothers were at their mother’s bedside while she recovered from surgery.  

A lawyer by training and well-versed in what can go wrong at a hospital, Hatlie said he missed a medication error during his mom’s hospital stay–but his mom didn’t. She looked at the medication cup and noticed the dosage of one of her meds was a lot larger than the day before, Hatlie explained. She was given three times the dose of a recommended medication.  The sons checked the hospital’s computer record, which confirmed the larger dosage.

“We trusted the computer; we thought the computer was right,” Hatlie said.  However, they continued to investigate, and confirmed the dosage was wrong. “My mom was right,” he said.

In a situation like that, when you are given conflicting critical information, be vigilant and find a person in authority, be it a shift supervisor or doctor or specialist in charge, Hatlie explained.       

Even little things should be brought to the staff’s attention,  he added, noting that in the Airline industry, if one minor indicator fails, the plane sits on the tarmac.  Such thinking should be standard in health care, he said.

“We are just beginning to grow that consciousness.  Don’t be afraid to bring up the little things,” Hatlie concluded.

— Mary Voelker
 

Resources:

• Agency for Healthcare Research and Quality: http://www.ahrq.gov/,
• American Hospital Association: http://www.aha.org/
• Centers for Disease Control: http://www.cdc.gov/
• Coalition for Quality and Patient Safety of Chicagoland: http://www.chicagopatientsafety.org/
• Dr. John Connolly, Castle Connolly Ltd.: http://www.castleconnolly.com/
• Healthgrades: http://www.healthgrades.com
• Institute of Medicine: http://www.iom.edu/
• The Joint Commission on Accreditation of Healthcare Organizations: http://www.jointcommission.org/
• RID: The Committee to Reduce Infection Deaths: http://www.hospitalinfection.org/,
• Susan Sheridan, Consumers Advancing Patient Safety: http://www.patientsafety.org
• U.S. Department of Health and Human Services: http://www.hhs.gov/