A Patient’s Guide: How To Stay Safe In a Hospital

 by Blair Hickman
ProPublica, Feb. 4, 2013
Propping up a patient’s hospital bed at a 30-degree angle can help prevent hospital-acquired pneumonia. Using alcohol wipes kills staph bugs, but you need bleach wipes to kill C. diff germs. High-protein snacks can help prevent bed sores.
However, most patients don’t know these things. And doctors and nurses can easily overlook these basic care practices.

Karen Curtiss makes it her mission to remind them. After her father and husband both experienced adverse events in the hospital, Curtiss says, she founded Campaign Zero to arm patients with the information they need for a safe stay. Her book, “Safe & Sound in the Hospital: Must-Have Checklists and Tools for Your Loved One’s Care,” collects scores of these simple actions and details that can make a big difference in a patient’s recovery.
Checklists have become more common for surgeons in the operating room. But according to Curtiss, she’s the only one producing checklists on hospital care for patients and families.
To make the checklists, Curtiss read everything she could get her hands on: nursing textbooks, information from the CDC, academic publications. She took her work to specialists and focus groups. And then distilled all of the information into something so simple a sixth-grader could read it.
We sat down with Curtiss, who is a member of ProPublica’s Patient Harm Community, to find out more about patient-centered checklists.

Why checklists?
Conventional wisdom says that when you go to the hospital, you take someone with you. However, nobody is prepared. There’s nothing in college that teaches you how to be an advocate. There’s nothing in your life experience. We have an army of people sitting bedside, who are ripe for education.
We put a checklist out on Campaign Zero, but I could tell from the traffic that people were finding it only after a problem had occurred. They were Googling bed sores and how to treat them, staph infections. People do not prepare to be sick. So I wrote the book.
I learned during my research that there are repeated problems that put people back into the hospital that nobody ever tells you about. For example, if you have congestive heart failure, you need to weigh yourself every single day. If you gain two pounds in a day, you have to get to a doctor right away.
But I don’t know how many people are told that. Even if you are told that when you’re discharged, many people are still on drugs and not thinking clearly. And it’s a hurried process. They need someone there with faculties intact to ask the questions, sweat the details, know what to look for and be encouraged to ask questions. The simple affirmation that it’s OK to ask questions makes people more comfortable.

Furthermore, we know checklists work. Atul Gawande, the author and surgeon, wrote in “The Checklist Manifesto” that the ideal checklist is no more than ten items.  And they are effective. It’s been proven with other checklist projects, some that are being rolled out throughout the country.

So I said OK, if checklists work for the medical community, then they can work for families. It’s a potential win-win.

A lot of people in ProPublica’s Patient Harm Community say that when they ask questions, providers push back. What would you say to them?
I relate to that so much. And it’s unfortunate, but it does happen.
First of all, before you choose a hospital, make sure to vet them. Some hospitals talk the talk, and others walk the walk. You can look at their Leapfrog score or their Consumer Reports rating, if you have access to it. [Editor’s Note: You can also check Medicare’s Hospital Compare.]
But that’s hindsight. If you have problems after you’ve committed to a hospital, you can always call the hospital advocate. You can call a Condition Help, also called a Condition H, if you feel like your loved one isn’t being heard, or cared for properly, and a team will respond. It’s also sometimes called a rapid response team – hospitals call it different things. But very few are transparent about the fact that you can do that.
I’ve heard of doctors quitting patients because they ask too many questions. Obviously, you find another doctor. You find another hospital. A recent study suggested 27 percent of doctors and nurses feel it’s inappropriate for patients to ask them to wash their hands. It’s because they feel chastised. Their egos are bruised.
So what should a patient do? Stick to your guns. Be humble, and play to those egos. “I know you’re the expert, but I want to protect you as much as my loved one.”
That’s why in my book I have pullout cards. Sometimes, it’s easier for people to read a note than hear people say it. That’s also why some of those cards are silly; humor can help break the ice.

A lot of items on the checklist seem to address communication.
Communication is the number one challenge. In the 1970s, there were two or three doctors involved in a patient’s care. Now, there are up to 15. That’s good news. But the bad news is how do they communicate? Care is much more fractured because it’s specialized.
I encourage people to be a part of the shift change, which is called the hand-off. That’s when they share notes with the doctors starting their shift. It’s a huge opportunity to spot inaccurate information, fill in gaps and raise questions. Ideally, the hand off should occur bedside. If they resist, you can always ask to go to where they’re doing it. It might be in a break room.

How are providers responding to the checklists?
We’ve had a lot of support. And not just from providers. Blue Shield of California is giving the book to patients at University of California, San Francisco, who are employed by the city and county of San Francisco. Community Trust Bank in Kentucky, which has 1,000 employees, is giving everyone who has a pre-planned admission a copy of the book.

I also collaborated with Mary Foley, who’s a prominent leader in nursing innovation and head of nursing research and innovation at the UCSF, to create a companion nursing workshop. Nurses on the front line probably haven’t had up-to-date education on the basics of patient safety because they’re really busy and went to nursing school a long time ago. Plus, people can walk in with these checklists, and one look from a nurse who isn’t on board can make them feel like they were thrown under the bus. The workshop is meant to help nurses understand how engaging families and supporting safe care practices can benefit them.

What would you say is the one most important thing someone can do?
I have two: Ask people to wash their hands. The greatest hazard in hospitals is infection, and the number one thing you can do to prevent infections is hand washing. Don’t let people give you flack about it.

The second thing is to take notes. Take notes to ask questions and be organized. When the doctors and nurses come in, if you’re prepared with your questions in notes, then you use your time wisely.
Also note when medications are given, when tests are ordered and the test results. You could have tests ordered at 9 a.m., and the results might be critical for next steps. If they don’t come until 9 p.m., that’s a problem. And a detail like that can get lost.
People respect stuff that’s written down. And if the doctors and nurses know you’re on it, they will be more accountable. It’s very subtle, but it takes the drama and emotion out of it, and makes the experience more businesslike.

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Why Patients Don’t Report Medical Errors

Are we talking only about Medicare in USA ? Seems to be genocide.

iStockphoto

by Marshall Allen
ProPublica, Sept. 25, 2012,

 

 

I was recently browsing through the nearly 200 stories we’ve compiled with our Patient Harm Questionnaire, when I was reminded again of a troubling truth. Many of the people who suffer harm while undergoing medical care do not file formal complaints with regulators. The reasons are numerous: They’re often traumatized, disabled, unaware they’ve been a victim of a medical error or  don’t understand the bureaucracy.

That’s a problem for those individual patients and for the rest of us. There are many places to complain: a state licensing agency; a professional licensing board that monitors doctors or nurses; the Joint Commission, which accredits hospitals or a Medicare Quality Improvement Organization. But if there are no complaints, there are no independent investigations, and that means no outside accountability for providers who may have made mistakes, and no public inspection reports that documents the case -- assuming an agency makes reports public, which is not always the case. It’s a collective problem because patient safety flaws that remain hidden, if they are not corrected, may be repeated.

We have staggering estimates of the number of people harmed while undergoing medical treatment. A review of medical records by the U.S. Health and Human Services Department’s inspector general found that in a single month one in seven Medicare patients was harmed in the hospital, or roughly 134,000 people. “An estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths,” the IG found, “which projects to 15,000 patients in a single month.”

But there’s no central system in place to tally and track these events. There’s no way to know when and where patients are being harmed or to tell if the problem is worse in one place than another.

It’s not like keeping track of patient harm is a new idea. More than a decade ago the Institute of Medicine’s landmark “To Err Is Human” report called for a national system to capture cases of serious harm to patients or death. The report said accurate reporting provides accountability and knowledge that leads to learning. That’s information that could save lives.

“You really can’t improve what you don’t measure,” said Dr. Julia Hallisy, president of the Empowered Patient Coalition. “How do you know where to focus your improvement efforts if you haven’t measured what’s happening in the first place?”

Efforts at the state level appear to be falling short, according to federal inspectors. In many states, hospital are required by law to file a report every time a patient suffers unexpected harm -- often called  “sentinel” or “adverse” events. But a July report by the HHS inspector general’s office found that only 12 percent of harmful events identified by the office even met state requirements for reporting them. Compounding the problem: Hospitals themselves only reported 1 percent of the harmful events.

We found something similar when I was a reporter in Las Vegas. We used hospital billing records to identify 3,689 cases of patient harm at the city’s hospitals in a two-year period. Each of those cases would fit the state’s definition of a “sentinel event,” meaning the hospitals were required by law to report them. Yet in the same time period they reported to the state only 402 sentinel events.

The federal Agency for Healthcare Research and Quality is now accepting public comment about a proposed program to encourage consumers to complain about harm suffered while undergoing medical care. The goals include collecting information in a common format, developing prototype methods for gathering information on the phone and Internet and creating a follow-up questionnaire for medical providers. Patients will be asked what happened, who was involved and for permission to follow up with the providers involved in the event.

I recently referred the 1,000 members of the ProPublica Patient Harm Facebook Group to a story about the proposal in The New York Times. Many members of the group have suffered harm firsthand and filed complaints, so the article created lively discussion:

• Robin Karr said that based on her experience, she’s skeptical about reporting harm directly to the government “but not without hope” about the proposed program.
• Debra Van Putten said she knows many people who have filed complaints about harm they suffered, but little came of their efforts. Patients want more than mere acknowledgement, she said. They want accountability for whoever is responsible.
• Martha Deed said there are so many barriers to a patient reporting harm -- emotional trauma and physical disabilities, feeling intimidated by providers, social pressure not to complain -- that a passive questionnaire is unlikely to elicit responses. Instead, the patient harm information should be gathered in a way that’s standardized, she said, like the national survey that’s administered to recently discharged hospital patients that has results publicly reported on Hospital Compare.

That’s food for thought for those developing the program. Official public comment is due Nov. 9 and can be sent to Doris Lefkowitz, the AHRQ reports clearance officer: doris.lefkowitz@AHRQ.hhs.gov.

We’d also love to hear your comments. How do those of you who work in the medical field feel about this type of reporting system? Patients, what do you think about it? And what would you recommend as characteristics that would be essential to such a program?

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