Your Patient Safety Survival Guide Read online

  Your Patient Safety Survival Guide

  Your Patient Safety Survival Guide

  How to Protect Yourself and Others from Medical Errors

  Gretchen LeFever Watson

  ROWMAN & LITTLEFIELD

  Lanham • Boulder • New York • London

  Published by Rowman & Littlefield

  A wholly owned subsidiary of The Rowman & Littlefield Publishing Group, Inc.

  4501 Forbes Boulevard, Suite 200, Lanham, Maryland 20706

  www.rowman.com

  Unit A, Whitacre Mews, 26-34 Stannary Street, London SE11 4AB

  Copyright © 2017 by Gretchen LeFever Watson

  All rights reserved. No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without written permission from the publisher, except by a reviewer who may quote passages in a review.

  British Library Cataloguing in Publication Information Available

  Library of Congress Cataloging-in-Publication Data

  Names: Watson, Gretchen LeFever, 1960– author.

  Title: Patient safety survival guide : how to protect yourself and others from medical errors / Gretchen LeFever Watson.

  Description: Lanham : Rowman & Littlefield, [2017] | Includes bibliographical references and index.

  Identifiers: LCCN 2017001510 (print) | LCCN 2017003020 (ebook) | ISBN 9781538102091 (cloth : alk. paper) | ISBN 9781538102107 (electronic)

  Subjects: | MESH: Patient Safety | Medical Errors—prevention & control | Cross Infection—prevention & control

  Classification: LCC R729.8 (print) | LCC R729.8 (ebook) | NLM WX 185 | DDC 610.28/9—dc23

  LC record available at https://lccn.loc.gov/2017001510

  The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI/NISO Z39.48-1992.

  Printed in the United States of America

  For Paris Ann

  In memory of Dory, Gretchen Osgood, and Bud

  Because of Don

  Contents

  Contents

  Foreword

  Acknowledgments

  Introduction

  1 Help Me, Heal Me, Don’t Harm Me

  2 What Seems Too Simple toMatter Could Save Your Life

  3 Make It a Bad Day to Be a Bug

  4 Oops!

  5 Deadly Doses and Dangerous Drugs

  6 Beyond the Bedside

  7 Acceptance, Apology, and Forgiveness

  Notes

  Bibliography

  About the Author

  Foreword

  About a year ago, I ran into my friend Doug as he headed to visit his mother in the hospital. She was recovering from orthopedic surgery at a world-renowned academic medical center. Doug said Mom would be back on her feet in no time.

  Sadly, I could not encourage his confidence. My organization, The Leapfrog Group, issues letter grades rating hospitals on how safe they are for patients, an A, B, C, D, or F on how well they protect patients from errors, injuries, and infections. We tell the truth, even when the truth is uncomfortable.

  So I had to be honest with Doug. Despite its storied reputation, his mother’s hospital was far worse than average on preventable infections, surgical errors, and never events. We gave the hospital a “C” for safety, up from a “D” a year ago. Families should worry when loved ones are admitted to this hospital.

  Doug had a number of good questions. Why would an otherwise stellar hospital allow problems with preventable infections and mistakes? Is there something amiss with the surgeons, the nurses, somebody else? And most importantly, how could his family protect Mom?

  I launched into my two-minute elevator speech on patient safety. No, it’s not the individual physicians or nurses at fault, it’s the culture of the hospital that determines whether patients are safe or not. And even reputable hospitals can have a culture that doesn’t truly put patients first. This is why as many as one thousand patients a day die from preventable errors in the United States. And families can literally save patient lives; they should monitor all the medications and watch that caregivers follow the rules, like washing their hands before entering the patient’s room. Communities need to hold hospitals accountable.

  Doug is one among many people with concerns and questions, and the elevator speech only goes so far. So I was delighted to see my colleague Gretchen LeFever Watson writing this book as a resource for all of us to share. This is an accessible and definitive overview of the key issues in hospital safety, including what families, hospitals, clinicians, and communities can do to protect patients—and help solve this devastating problem.

  Gretchen brings an unusual breadth of knowledge and compassion to the subject, having fought for safety from many perspectives. She endured every mother’s worst nightmare, an error that nearly killed her four-year-old. She’s served in senior roles in health systems, as a community leader in a coalition addressing safety, and as an educator teaching safety to clinicians-to-be, helping the next generation understand how patient experience is shaped not only by their involvement as individual caregivers but also by the culture of the larger health system and community they are a part of.

  There is a great deal of important information in this book, useful for caregivers, leaders, patients, and advocates alike. But fundamentally Gretchen is an optimist with the soul of a healer, so the book is more inspiration than criticism. And more than anything else, improving safety requires such inspiration. Safety is about putting the patient first every minute of every day, washing hands every time, carefully honoring rules for inserting needles or administering medications, even when you are in a hurry or tired or in a bad mood. The patient is always first priority. It takes inspiration to never for even one minute forget why that matters and what’s at stake.

  Some hospitals with deep endowments and soaring reputations can fail to make the grade on safety. Conversely, some hospitals with mundane reputations, serving marginalized communities, achieve some of our highest ratings for safety. What makes the difference is not money or fame but the humble art of putting the patient first.

  The good news about Doug’s mom: over the past year her hospital finally embraced that humble art, and just last month Leapfrog upgraded their Hospital Safety Grade to an “A.” The bad news for Doug’s mom: this happened too late for her. She suffered surgical errors and painful infections, causing debilitation for her and the family over many hard months.

  Someday all hospitals will earn an A, and our families will not have to endure unnecessary suffering like Doug’s family did. This book will guide us there, and inspire us to persevere.

  Leah Binder, President & CEO

  The Leapfrog Group

  November 29, 2016

  Acknowledgments

  The message of this book represents a culmination of a long series of professional and personal experiences, beginning with a year abroad as a US Junior Ambassador of Goodwill through the Rotary Exchange Program. As a seventeen-year-old with no prior exposure to German, I learned to speak the language proficiently and see the world differently—ever after appreciating that “languaging” affects perceptions and behavior.

  In terms of early influences for this book, I’d like to thank Professor Fredric Sugarman for raising the bar on my career aspirations and encouraging me years ago to apply to Boston University (BU), where I learned to think criticall
y and recognized that great scholars are willing to mentor ordinary students and citizens who strive to bring their lofty ideas into meaningful practice, as the late professors Philip Kubzansky and Sigmund Koch did for me. BU is also where my friend Jonathan Knee introduced me to ideas of the likes of Alasdair MacIntyre (then visiting professor at BU), whose philosophical writings from decades ago still inform the field of patient safety and medical malpractice. And BU is where Professor Emeritus Frances Grossman and her graduate students—especially Suad Noah and William Pollock—brought research and the field of clinical psychology to life for me.

  My graduate school selection was based purely on the amount of financial support offered, but it turned out that attending the University of Illinois at Chicago (UIC) was a great choice. The program honored the Boulder scientist–practitioner model of clinical psychology, and my dissertation advisor, Brian Vaughn, encouraged his students to pursue high-quality projects that could be completed in a feasible amount of time—getting us out of the program faster than its then eight-year average. Because my UIC funding required that I simultaneously pursue clinical psychology (study of abnormal development) with developmental psychology (study of normal development), the program molded me as an academic boundary spanner—something that has always served my career well. My postdoctoral training at Georgetown University Medical Center reinforced the value of the Boulder Model and cross-disciplinary investigations.

  My first professional job was with the Naval Hospital in San Diego, where I learned how much one’s social community could affect one’s quality of life. Professionally, I grew up fastest at Eastern Virginia Medical School (EVMS). It was at EVMS where Larry Pickering, MD, encouraged me—at the time a shy and timid full-time clinical faculty member—to pursue a research project that mattered to me, which, in turn, altered the course of my career. It was also there where Ardythe Morrow, PhD, mentored me in epidemiology research, public health practice, and academic publishing. I am also grateful to Children’s Hospital of The King’s Daughters, an EVMS affiliate, for having provided funding and support for me to lead the formation of a school health coalition—a 10-year endeavor that shaped my appreciation for the need to more directly involve the public in the fight against common medical mistakes.

  I am not able to name Sentara Healthcare patients, executives, employees, and affiliates who inspired me to write this book. You know who you are.

  I might never have had the idea of writing a book if I had not met psychiatrist Sally Satel. Sally arranged for me to spend parts of several summers working out of the American Enterprise Institute and introduced me to Jo Ann Miller—an accomplished editor and champion of aspiring authors. Upon learning about my desire to write a patient safety book, Jo Ann offered sound advice on preparing a winning proposal and encouraged me to obtain a position with relevance to the field on a national level. The situation did not allow Jo Ann to edit the manuscript for this book; however, a national platform opportunity did materialize. I took it, which, indeed, turned out to be important for writing this book.

  While working with and for Mike Summers, provost at Tidewater Community College in Virginia Beach, to create a workforce to support the rapid adoption of electronic health record systems across the country, he patiently allowed me to focus on how the project could impact patient safety. Two people who were especially important in this regard are Leah Binder, President & CEO of The Leapfrog Group, and Dr. David Classen, a physician, technology innovator, and academician with a passion to improve patient safety. Leah and David, as well as partners and staff at Pascal Metrics, graciously shared their time and expertise and encouraged me to continue to pursue my ideas about improving the human side of safety. Gratitude also goes to patient safety experts who answered my calls and emails without knowing me, including Drs. Atul Gawande, Albert Wu, Vikki Entwistle, Kathleen Leonhardt, and John Clarke.

  The most significant contributor to this book is Andrea Powell Arcona, PhD. Andrea was my first clinical practicum student who grew to become a cherished colleague and friend. We collaborated for over twenty years, and Andrea spent many hours discussing this book and helped shape its premise and cowrote an earlier version of chapter 3. Perhaps had it not been for her booming clinical practice and wonderfully busy family life, this book would have been better through her ongoing contributions.

  Some critical influences on my thoughts about patient safety have been more obtuse. My sister Cynthia spent most of her Boston College freshman year in Brigham and Women’s Hospital, where I visited her almost every day. The Bernard Lown Cardiovascular Group, whose patient care philosophy was revolutionary at the time, treated her. Because of their approach, Cynthia is alive and healthy today, and I was exposed as a young adult to what was the best hospital care America had (and might still have) to offer. Every step of the way, Cynthia’s care was guided both by science and compassion and delivered in a manner that instilled hope while adhering to the notion of “nothing about me without me.” Learning decades later that one of her cardiologists formed the Lown Institute to protect patients from unnecessary diagnosis, treatment, and harm has again been comforting—this time it affirmed the direction of many of my past and present professional pursuits.

  On a more pragmatic level, my mother managed to always ask how the book was coming along without a whiff of that dreaded maternal tone of “Is-your-room-clean-yet?”

  A former colleague and a few friends rallied around me for a moment of good cheer as I embarked on what seemed like the daunting task of writing a book: Sid and Wendy Vaughn, Mo and Mona Ghobriel, and Rick and Kathy Fee. Having celebrated that start of the process with them kept me from giving in to any thought about quitting.

  A number of colleagues and friends stood by me through various highs and lows that formed the background of experiences that led up to publishing this book; I know I would not have survived with my spirit equally intact without their support, including my kindred spirit Mary Hull, Mary Wong, Thursday Groups of Encinitas, Steve and Melanie Smith, Trisa Thompson, Brenda Gruber, Joe and Nancy Francis, Lynn Zoll, Linda Owen, Irv Wells, Linda Frantz, Carla Galanides, Marlyn Fabrizio, Michele Bordelon, Kim Hron-Stewart, Keila Dawson, Bob Frenck, Glen Snyders, Jeanne Lenzer, Sue Parry, Lou Lloyd-Zannini, Fred Ernst, Bob Whitaker, Jonathan Leo, Shannon Brownlee, Aubrey Blumsohn, Nancy Oliverie, Kevin Martingayle, Joe Bouchard, Eileen Chiccotelli, Roy and Vivienne Phelps, Jeff Hammaker, Bob and Carol Bibbs, Larry and Betsy Leonard, Don and Susan Bradway, Lorraine Jordana, Julie Seipel, Katie Taylor, Sel and Liz Harris, Dan Evans and other dear KGPC family and friends. There were also my PEO Sisters, two aunts who included me in their nightly novenas, a family priest, six Lake Woebegon–like siblings, fun-loving aunts and uncles, cousins, academic mentors and collaborators Drs. David Antonuccio (who I consider a treasured friend and extraordinary clinical psychologist and defender of academic integrity), David Healy, Linda Perloff, Gershon Berkson, Christopher Keyes, Arnold Sameroff, Ron Seifer, Leslie Feil, and Margo Villers, and a few anonymous guardians who provided unsolicited financial support at a critical life juncture.

  Suzanne Staszak-Silva, executive editor at Rowman & Littlefield, has earned my eternal gratitude for taking a chance on me as a first-time book author. This book would not have been possible without the ever-ready staff, particularly Kathryn Knigge and Elaine McGarraugh.

  While working on the book, my windsurfing friend Pam Levy introduced me to Vin Altruda, former president of Borders Group, who, in turn, introduced me to other publishing pros, including Jill Tewsley and Mary Jo Zazueta—working without an agent, their just-in-time guidance and services were invaluable. The same is true of my author friend and fellow psychologist Lindsay Gibson. I’d also like to thank Lynn Garson (attorney and author of Southern Vapors) for always being at the ready with publishing advice and support. If outside graphic designers were allowed, the kind, competent, and creative Kami Hines of Hines Designs stood ready to assist with the book jacket design.
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  My heartfelt appreciation goes to my daughter, Paris Ann, for surviving, for tolerating years of ridiculously long conversations about my work, and for reading most of this manuscript before I sent it to the publisher. Of course, I am forever grateful to my husband, Don, for enduring all the hours I spent holed up in my study and for keeping me grounded during the writing process. Without his patience, support, and pragmatic wisdom, I might not have finished this book.

  Introduction

  Healthcare is a dangerous business. Every day, over one thousand hospital patients in the United States die and many more are needlessly harmed by the care they receive. When I was a young mother listening to doctors at a military hospital apologize for nearly killing my four-year-old daughter, I had no idea how often human error jeopardized our health and safety. And it wasn’t until fifteen years later, after being hired to serve as the director of patient safety and performance excellence for a large healthcare system, that I realized our country was in the midst of a patient safety crisis.

  Since taking that first patient safety job, I have learned much about the science and practice of safety in hospitals and nursing homes; as well as in nuclear power plants, shipbuilding and ship-repair facilities, and motor repair shops. One thing is clear: every industry is doing a better job with safety than the healthcare industry, but none is working harder to improve it.

  The public first got a glimpse into the world of patient safety in 1999, when the Institute of Medicine (IOM) published the now seminal report titled To Err Is Human. Until then, healthcare had never systematically tallied and publicly reported how often care that is supposed to help and heal patients actually harms them. The report claimed that nearly one hundred thousand US hospital patients died each year as a result of medical mistakes. This finding shocked people inside and outside of the industry.