I haven’t posted in quite awhile. Why? Because for the last 6 months I have devoted over 125 hours to creating a course that will provide you with the tools to fix our healthcare delivery system. Every system is designed to produce the results it achieves, and unfortunately at this time our healthcare systems are inadvertently designed to harm patients. You will learn how to apply the principles that high performing manufacturing systems to continually improve quality, you will learn how to apply the lessons you learned in team sports to becoming an integral member of your healthcare team. When patients become part of the healthcare team they are far more likely to receive higher quality, safer and more efficient care. You will learn how to recognize impending errors and dangerous conditions so that you can avoid harm. One of the most important lessons I will be teaching is how you can become an adaptive leader, a leader who can bring about change, and goodness knows our health systems need to undergo dramatic changes. And finally I will teach you how to organize others to achieve the goal of continually improving healthcare delivery. The course is free and it is offered through the University of Florida and Coursera. The Institute of Healthcare Improvement with the help of Michael Briddon has generously offered a number of teaching modules that have been incorporated into our course. Upon completing the course you can become part of the solutions. If everyone makes one or two small improvements every week or month our systems of healthcare delivery will steadily improve. WE ALL CAN MAKE A DIFFERENCE.
John and Julia Hallisy’s daughter Kate was first diagnosed with retinoblastoma of both eyes at the age of 5 months. She required 2 years of aggressive chemotherapy and radiation, as well as removal of her right eye. She appeared to be cancer free until age 8 when she developed severe pain in her right upper thigh. She quickly underwent a biopsy that confirmed the worst, she had a second tumor, osteosarcoma, a bone tumor that can on occasion accompany retinoblastoma.
Her surgeon planned to resect the tumor and leave sufficient bone to allow her to have a functioning leg. However, a preventable postoperative infection got in the way. Within 48 hours of her biopsy, Kate became hypotensive due to Staphyloccocus aureus sepsis resulting in respiratory and kidney failure. She underwent an incision and drainage of the infected biopsy site, received prolonged intravenous antibiotics, required ventilator support, and remained in the intensive care unit for 7 weeks. Painful bedsores also complicated her hospitalization.
The delay in treatment of her osteosarcoma resulted in continued growth of the tumor. As a consequence her leg had to be amputated above the knee two weeks after her discharge from the ICU. Kate’s parents were devastated, but John insisted, “We’re not going to mourn for her while she is still alive. We’ll have the rest of our lives for that. Our job is to make the most of every minute we do have.”
Kate’s last 19 months of life were extremely hard. Kate suffered from severe phantom limb pain, a well-known complication of amputation. The damage to her lungs during her septic episode reduced her ventilatory function to 70% of normal leaving her breathless when she tried to walk with her heavy prosthesis. She experienced severe post-traumatic stress from her intensive care experience frequently awaking after a nightmare or after wetting her bed. Through all her suffering Kate maintained a positive spirit and tried to look at the bright side of her predicament. After the loss of her leg she told her parents “You know, I will be able to walk again with a prosthetic leg. Some people lose both legs or a leg and an arm. I have it easier than they do.”
Julia and John will never forget their courageous and beautiful daughter. Following her daughter’s death Julia has been working as a patient advocate keeping Kate’s memory alive. Through her advocacy organization The Empowered Patient Coalition http://www.empoweredpatientcoalition.org she has reached out to other patients harmed by medical errors, and has documented over 500 hundred stories of pain and suffering.
Problem: Kate suffered a preventable Staphylococcus aureus infection following a “routine” biopsy that resulted in septic shock, respiratory and renal failure. The delays required to treat this infection prevented limb sparing surgery and necessitated an above the knee amputation.
Solution: It is likely that the skin overlying Kate’s biopsy site was not properly washed to remove surface Staphylococcus aureus. Prior to any invasive procedure the operative area should be thoroughly cleaned with Chlorhexidine. It is also possible that the biopsy instrument was contaminated with S. aureus and reliable procedures must be in place to assure that all surgical instruments are thoroughly heat sterilized.
Judy’s terrible experience began with a routine meniscus repair in January, 2007, performed by a respected orthopedic surgeon at a world renowned hospital. She scheduled the surgery early in the year so that she would have time to recover for Spring outdoor activities. As she pointed out “It could have waited–this was certainly not an emergency.” Unbeknownst to her the hospital where the procedure would be performed was experiencing a sudden increase in the number of infections following arthroscopic surgery. She later learned there was a problem with the equipment sterilizer. And much to her dismay she also subsequently learned that the surgeons and other hospital personnel were aware of the problem, but chose to continue to perform anthroscopies despite an increased risk for infection. As Judy noted “In signing the forms authorizing the surgery, I basically consented to a risk without knowing the full extent of that risk.”
Two weeks later she was readmitted with joint infection caused by Staphylococcus aureus, an often aggressive organism that can quickly cause serious tissue damage. as well as sepsis. During the surgery to clean out her knee she suffered an aspiration pneumonia requiring intubation (tube in her trachea) and mechanical respiratory support. She awoke to find her hands and arms tied down with a tube in her throat. This experience haunts her to this day. The pulmonary specialist who cared for her apologized for “everything we did to you.” She was discharged from the hospital with an intravenous line for the delivery of vancomycin that she received for 6 weeks. The good news is the vancomycin eliminated the infection; however, the bad news is she suffered a known complication of vancomycin – tinnitus or ringing of ears. She continues to experience this “high-pitched machine like noise from which there is no escape.”
As Judy notes “I walked into that hospital a perfectly healthy person with a minor problem; and have suffered the consequences of really bad medical decisions, errors, and practices for the rest of my life. That all of these mistakes were preventable haunts me.”
Problem: The hospital failed to discontinue surgery in the face of an outbreak of Staph infections.
Solution: We in health care can learn from Toyota. At their manufacturing plants all frontline assembly workers have a rope called the andon cord that they can pull if they detect a defect in the car they are working on. The assembly line stops until the cause of the defect is clarified and corrected. Health care providers need to apply the same approach. When an error is detected, in this case a defect in the sterilization of surgical instruments, elective surgery should be discontinued until the cause of the defect is clarified and corrected. If this had happened in Judy’s case she would not have suffered a post-operative infection, pneumonia and permanent ringing in her ears.
We have a supermarket chain in Florida called Publix. George Jenkins founded this remarkable company in 1930 at Winter Park, Florida. The success of his company has always been based on customer service. As he told his employees at the end of each orientation, “If there is ever a customer you can’t handle, give them my phone number, because I will.”
Publix has a guarantee posted in every store that reads:
“Publix guarantees that we will never knowingly disappoint you. If for any reason your purchase does not give you complete satisfaction, the full purchase price will be cheerfully refunded immediately upon request. We have always believed that no sale is complete until the meal is eaten and enjoyed.”
Publix has been rated by Fortune Magazine as one of the top ten best companies to work for (2005–2008) and is one of Forbes Magazine’s top ten largest private companies (2009). Publix consistently scores higher than any other supermarket for customer satisfaction based on the national American Customer Satisfaction Index survey (1995–2010). (See Critically Ill: A 5-point plan to cure health care delivery)
Publix attributes its success to a continual focus on its customers. The key question arises, if Publix supermarkets can guarantee their food after it leaves the store shouldn’t our health care systems be willing to guarantee the care they provide to their patients after they leave the hospital or clinic? Stories like those of Jess, Carla, Marty, Veronica, and Georjean, would never have to be told. Imagine if each time a medical error occurred, the caregiver and health system immediately informed the patient, deeply and sincerely apologized, explained how the health system was taking steps to prevent the same error from harming others, and then fairly compensated the patient. Patients injured by medical errors would no longer feel as though they were being ostracized. They would no longer lose their trust in our medical system. They would no longer be suffering the financial hardship brought on by their injuries. After all, these injuries were not the fault of the patient. Why have the very institutions whose charge is to help those in need turned their backs on the patients who morally and ethically most deserve their help? When our health systems and caregivers make mistakes, shouldn’t they do everything in their power to help those they have injured?
In December of 2008 Georjean had robotic assisted laparascopic surgery to remove her kidney that contained a large tumor. The good news was that the tumor proved be noninvasive papillary transitional carcinoma and had not spread to her lymph nodes or to any other adjacent tissues. She was cured. The bad news was that immediately following the surgery she began experiencing severe abdominal pain. The physicians and nurses minimized her complaints. However, on the second day after her surgery Georjean became hypotensive (her blood pressure dropped). She looked into her husbands eyes and told him she was going to die. He called for help and the surgeons rushed her to operating room where they discovered her bowel had been nicked during her prior surgery and over a billion bacteria had leaked out of her bowel into her peritoneum and into her blood stream. Her severe abdominal pain and septic shock had been caused by what is called secondary peritonitis, a very dangerous and potentially fatal infection. The large collections of pus and bacteria were washed out, and drainage tubes were placed throughout her abdomen,
Her infection was complicated by respiratory failure requiring that she be intubated (a tube placed in her airway), supported by a mechanical respirator, and moved to the intensive care unit where she remained for 20 days. Soon after being moved to a regular floor she was discharged to her home with multiple drains, only to return 6 days later because of additional undrained abdominal abscesses. A total of 8 abscesses required drainage, and one was infected with a fungus in addition to bacteria requiring strong anti-fungal therapy in addition to intravenous antibiotics. After multiple procedures and prolonged antibiotic treatment requiring over 2 months in the hospital, she was again discharged to her home in mid-March. Here she required a special vacuum dressing and continued dressing changes for open wounds that finally healed 6 ½ months after her original surgery. As she became more active she developed large hernias in both inguinal areas (lower abdominal areas) as well as a large midline hernia.
Her surgeon elected to delay repair because of all her recent suffering. Unfortunately because of her illness she had lost her job, and soon lost her health insurance coverage. Now she could not longer afford to visit her surgeon and could not personally pay to have her hernias repaired, and by the time she was able to get Medicare coverage her surgeon was fearful of operating. He warned that surgery on her extensively scarred bowel could cause further bowel damage. Because of her poor bowel function Georjean eats a very limited diet and has to wear a special binder to reduce her hernias. Many physicians have discharged her from their care because “You ask too many questions.” Now she asks no questions and agrees with whatever the doctor says, but she wishes they would help her to fully regain her health.
Problem – Georjean underwent resection of her kidney using a laparascope. Laparascopes minimize the size of the incision and usually allow the patient to recover more quickly. However laparoscopy is technically more challenging and makes visualization during surgery more difficult. As a consequence the surgeon accidentally cut into her bowel causing severe peritonitis and septic shock.
Possible solution – Physicians who have not undergone extensive simulation training in laparoscopic surgery should utilize open abominal exploration to reduce the risk of a complication.
Problem – The nurses and physicians minimized Georjean’s complaints about abdominal pain. They thought she was a troublemaker,
Solution – Doctors and nurses should carefully listen to their patients’ complaints and order the appropriate tests to exclude a serious cause. In Georjean’s case she should have undergone surgical exploration and drainage within the first 24 hours. This would have reduced the severity of her infection, and probably preventing her from developing respiratory failure, as well as reduced the number and severity of her abdominal abscesses.
Problem – Georjean lost her job and her health insurance as a consequence of a surgical error.
Solution – Shouldn’t the health system and physician who made this mistake have assisted Georjean both medically and financially, rather than dropping her from their care? Is this how you would want to be treated? Anyone in her shoes would agree that hospitals and caregivers need a new approach to caring for patients who are injured by a medical or surgical error. Potential solutions will be discussed in my next post.
Carla was 50 years old at the time. She had difficulty with her left knee and consulted an orthopedic surgeon who recommended a total knee replacement. She failed to seek a second opinion. She subsequently learned that a total knee was unnecessary. Unbeknownst to her, the surgeon placed a non-FDA approved prosthesis, and according to a second orthopedist who she subsequently consulted he misaligned the prosthesis.
Following the placement of her total knee she experienced continual severe pain requiring strong narcotic pain medications, oxycodone and oxycontin. These medicines precipitated a severe depression and a suicidal attempt. She was unable to work and suffered financial hardship.
6 months after placement of the first prosthesis she had to undergo a second major operation to replace the prosthesis. Her pain continued and she sought legal recourse, however given her fragile mental state she was unable to tolerate the emotional stress of litigation and withdrew her claim.
After a 1 1/2 years she discontinued her pain medications and thanks to her deep abiding faith she was able to overcome her disability and pain. She transformed herself from a victim to a survivor, and now is a successful realtor.
As her father had warned her as a child “Life is not always fair.”
But shouldn’t Carla have received financial assistance during this difficult period of pain and mental anguish? Her injury was not her fault, and I suspect the surgeon installed this new prosthesis expecting a superior result. Unfortunately his lack of familiarity with the prosthesis led to misalignment and Carla’s poor outcome. What would have happened if he had acknowledged his mistake, sincerely apologized, explained his plans to prevent this outcome from happening to other patients and contacted his insurance company to fairly compensate Carla during the period she was unable to work? Carla would have felt validated and in all likelihood would have recovered more quickly. She and her physician could have maintained a positive relationship, and Carla’s distrust of the healthcare system would have been alleviated.
Oregon now is considering a legislative act entitled: RESOLUTION OF ADVERSE HEALTH CARE INCIDENTS that will encourage this much more effective approach to patient injury. Our legal system has failed in making injured patients whole, <25% of those with preventable medical injuries receive a legal settlement and when they do 2/3rds of the award goes to their lawyers. Litigation creates an adversarial relationship between caregivers and patients and prevents both groups from communicating. This lack of communication makes emotional closure nearly impossible and stokes the fire of destructive anger. Patients need to devote their emotional energy to recovery rather than toward blame and anger. Bills like the one in Oregon have the potential to help transform victims of medical errors into survivors.
All through high school and college I played three sports. My senior year at college I earned letters in Football, Wrestling and Lacrosse. You may think, “Was this guy crazy? How did he have time to study?” I was born with a great deal of energy and when I wasn’t working out, I felt as though something was missing. Throughout medical school I continued vigorous exercise, playing rugby and then settled on rowing as my lifetime sport.
I began my rowing career the year of my medical internship at Boston City Hospital, and rowed that year in the Head of the Charles. I will never forget getting ready for the race. I was so nervous I leaned out to place my oar and fell into the water. Needless to say I was a little embarrassed. I rowed the race in wet cloths. Fortunately it was a warm day.
For the past 20 years prior to my injury, I rowed nearly every morning. I drove to Lake Santa Fe at 6 AM to enjoy the glassy waters, the herons, egrets, and osprey. The rhythmic rowing on this idyllic lake created a meditative state and served as a spiritual beginning to every day.
Now my day begins by grabbing my walker and hopping to the living room where I place a sleeve over my residual leg. I measure the diameters of the leg each day to document the degree of swelling and decide how many socks I will need to add to be sure the socket fits properly. I then lubricate the seal of the sleeve and slip into my prosthesis. Will it fit properly today? Will it be painful when I bare weight? I never know. There are good days and there are bad days. I practice walking. I try to stop from dragging my left hip backwards, and try to keep my hips even as I walk with my crutches. On good days I can use a cane. I always feel a little anxious about falling.
Two months ago I returned to the lake for the first time since my injury. As my brother, Steve, and I arrived near the shore, all the memories of rowing on the lake came rushing back. With tears in my eyes I walked toward the water. The toe of my prosthesis caught in the grass, and I suddenly tumbled. I pulled my lower back muscles trying to catch my fall. I never made it to the water. My back pain forced me to turn back. My brother had to carry me under my arms to the car, and we headed home. I had back spasms for two days, and I haven’t gone back to the lake since that sad day.
How has your life changed since your medical or surgical injury?
(For the description of Dr. Fred’s preventable hospital injury hit “About Dr. Fred”)