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THE QUALITY COLLOQUIUM - August 22, 2007

Telling Their Stories Sanjaya Kumar, M.D., M.Sc., MPH Karin Janine Berntsen, RN, BSN. THE QUALITY COLLOQUIUM - August 22, 2007. FATAL CARE. Vision & Objectives: Move the healthcare consumer beyond the statistics associated with medical errors. Who are the people behind the numbers?

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THE QUALITY COLLOQUIUM - August 22, 2007

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  1. Telling Their Stories Sanjaya Kumar, M.D., M.Sc., MPH Karin Janine Berntsen, RN, BSN THE QUALITY COLLOQUIUM - August 22, 2007

  2. FATAL CARE Vision & Objectives: Move the healthcare consumer beyond the statistics associated with medical errors. Who are the people behind the numbers? What are their stories? How do errors impact lives of those affected and those that are involved? Bringing the consumers to the forefront so they can relate to the impact of medical errors on the personal lives of people. Move the consumer into action.

  3. Rationale for “Fatal Care” • Consumer naivety • Medical overconfidence • Assumptions can be deadly. FATAL CARE

  4. Good, non-fiction, literary work exists that is beginning to bridge the gap between the consumer and caregiver. • Internal Bleeding - Wachter, Shojania • Through the Patient’s Eyes -Gerteis,Edgman-Levitan, Daley, Delbanco • The Patient’s Guide to Preventing Medical Errors -Berntsen • How Doctors Think -Groopman • These works mostly emphasize the numbers and statistics. • FATAL CARE is personal - you, your child, your spouse, your neighbor, your friend, your mother... • FATAL CARE - The next step to drive change in how the consumer interacts in their healthcare to help prevent medical errors.

  5. FATAL CARE: “Novel” Type Non-Fiction Stories The Janson Directive Coma The Scorpio Illusion Shock Critical The Bancroft Strategy Robin Cook Robert Ludlum New York Times bestsellers

  6. The Ambler WarningLudlum On Parrish Island, off the coast of Virginia, lies a psychiatric facility. Far from prying eyes, it is a government - run hospital for former intelligence employees in possession of highly classified information. Former Consular Operations agent Hal Ambler is one of these patients whose mind is filled with secrets of state - and is considered such a security risk that he is kept heavily medicated and closely watched. But there’s one critical difference between Ambler and the other patients - Ambler isn’t crazy. Now he must find a way to escape the facility, find out who put him there, and uncover the truth of who he was…and why someone is willing to risk everything to see him dead.

  7. FATAL CARE Each chapter tells a different story of a family impacted by a preventable medical error. Three Little Angels: Indiana Babies - Heparin Overdose Even the Tough Can Fall: Charlie Weis - Surgical Complication Never Routine: Lewis Blackman - Failure to Rescue Reading Between the Lines: Trisha Torrey - Misdiagnosis Critically Wounded: Diana Brookins - Bloodstream Infection Wrong Turn: Benjamin Houghton - Wrong Side Surgery You Can Have My House: Johanna Daly - Surgical Site Infection The Mission: Taylor McCormack - Delay in Treatment Picking up the Pieces: Diane Ford - PCA Pump Failure They Are Not Listening: Ken Simon - Wrong Diagnosis Coming Together: Linda Kenney - Medical Trauma One of Their Own: Liz Augusta - Near Miss

  8. FATAL CARE THREE LITTLE ANGELS Heather heard muffled yelling and crying from inside the door, but she couldn’t make out what they were saying. She felt a gnawing, sick feeling in the pit of her stomach, like something bad was about to happen and her body knew it before her head…Now Heather heard her mother yelling. “What do you mean? What’s wrong with Thursday Dawn? What’s wrong with the baby?” Joanna’s voice became increasingly shrill and hysterical. “Accident, Hep-a-rin, what did you do to her?” 11%Percentage of medication errors involving dangerous high-alert medications, such as heparin, morphine, insulin, potassium chloride and chemotherapy agents.

  9. FATAL CARE NEVER ROUTINE By Sunday afternoon, Lewis’ abdomen hurt worse than ever. His belly grew rigid and distended. His eyes had a sunken, hollow look. Alarmed by his condition, Helen knew Lewis needed to see a doctor right away. She repeatedly pushed the call button, but they had stopped answering the call light in room 749…

  10. NEVER ROUTINE …As morning broke, the awful pain in Lewis’ abdomen abruptly stopped. When the nurse heard this news, she took it as a positive sign and said, “Oh, good.” But to Helen it seemed strange, like the eerie calm in the eye of a hurricane, where things are temporarily quiet before even greater trouble lands onshore. 75% Percentage of U.S. hospitals who still have not implemented a Rapid Response Team (RRT).

  11. FATAL CARE Following Each Story…Sections that provide insight and help for the consumer.

  12. FATAL CARE Fatal points describe breakdowns in the process that can lead to patient harm.

  13. FATAL CARE Critical Safeguards describe steps that a patient and family can take to help avoid a medical error.

  14. FATAL CARE • Safety Keys are brief snapshots of patient resources and tips.

  15. FATAL CARE - Story Selections

  16. FATAL CARE • A balance of positive and negative outcomes: • Fatal Care had a potential to be a “downer”. • Limited fatal outcomes, included near misses. • Altered positive and negative outcome stories. • Unfortunately, it could have been Fatal Care Children. • Limited children to three stories.

  17. FATAL CARE • Geographic locations: • Medical errors happen in every area, city, country and in-between. • Contacts came from all over the world - limited to U.S. for this book. • New York City, LA, South Carolina, Everett Washington, Chicago area, Portland, Boston

  18. FATAL CARE • All size and types of hospitals: • Medical errors happen in every size hospital: • Teaching/University • Community based hospitals • Specialty hospitals • Outpatient centers

  19. FATAL CARE • Cross section of type of errors. • Generally healthy people that received care or treatment for an illness or injury. • For this book, we did not select chronic illness or complex, multiple diagnosis case scenarios. • Targeting the general healthcare consumer who could relate to, or experience a common medical error.

  20. FATAL CARE • Queries for the Stories: • Fatal Care Website http://www.fatalcare.com/ • PULSEhttp://www.pulseamerica.org/ • Previous contacts from: • The Patient’s Guide to Preventing Medical Errors • Public news stories • Mothers Against Medical Errors • Mamemoms@aol.com • National Patient Safety Foundation • PATIENTSAFETY-L@LISTSERV.NPSF.ORG

  21. FATAL CARE • Medication errors • Infections • SSI • Device related infections • Misdiagnosis • Surgical complications • Delays • Wrong site surgery • Near Miss

  22. FATAL CARE • Methodology: • The key method was personal interviews. • Written accounts • Published stories • Professional education

  23. FATAL CARE • Stories: • Some are in litigation. • Some had completed litigation/settlement. • Others did not have litigation.

  24. FATAL CARE - it’s about the people

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