THE QUALITY COLLOQUIUM - August 22, 2007THE QUALITY COLLOQUIUM - August 22, 2007

Telling Their StoriesTelling Their StoriesSanjaya Kumar, M.D., M.Sc., MPHSanjaya Kumar, M.D., M.Sc., MPH

Karin Janine Berntsen, RN, BSNKarin Janine Berntsen, RN, BSN

Telling Their StoriesTelling Their StoriesSanjaya Kumar, M.D., M.Sc., MPHSanjaya Kumar, M.D., M.Sc., MPH

Karin Janine Berntsen, RN, BSNKarin Janine Berntsen, RN, BSN

Vision & Objectives:Vision & Objectives:• Move the healthcare consumer beyond the Move the healthcare consumer beyond the

statistics associated with medical errors.statistics associated with medical errors.• Who are the people behind the numbers?Who are the people behind the numbers?

• What are their stories?What are their stories?• How do errors impact lives of those affected and those that How do errors impact lives of those affected and those that

are involved?are involved?

• Bringing the consumers to the forefront so they Bringing the consumers to the forefront so they can relate to the impact of medical errors on the can relate to the impact of medical errors on the personal lives of people.personal lives of people.

• Move the consumer into action.Move the consumer into action.

FATAL CAREFATAL CARE

Rationale for “Fatal Care”Rationale for “Fatal Care”

• Consumer naivetyConsumer naivety

• Medical overconfidenceMedical overconfidence• Assumptions can be deadly.Assumptions can be deadly.

Rationale for “Fatal Care”Rationale for “Fatal Care”

• Consumer naivetyConsumer naivety

• Medical overconfidenceMedical overconfidence• Assumptions can be deadly.Assumptions can be deadly.

• Good, non-fiction, literary work exists that is beginning Good, non-fiction, literary work exists that is beginning to bridge the gap between the consumer and caregiver.to bridge the gap between the consumer and caregiver.• Internal Bleeding Internal Bleeding - - Wachter, ShojaniaWachter, Shojania• Through the Patient’s Eyes -Through the Patient’s Eyes - GerteisGerteis,, Edgman-Levitan, Edgman-Levitan,

Daley, DelbancoDaley, Delbanco• The Patient’s Guide to Preventing Medical ErrorsThe Patient’s Guide to Preventing Medical Errors - -

BerntsenBerntsen• How Doctors Think How Doctors Think -- GroopmanGroopman

• These works mostly emphasize the numbers and statistics.These works mostly emphasize the numbers and statistics.• FATAL CARE is personal - you, your child, your spouse, FATAL CARE is personal - you, your child, your spouse,

your neighbor, your friend, your mother...your neighbor, your friend, your mother...• FATAL CARE - The next step to drive change in how the FATAL CARE - The next step to drive change in how the

consumer interacts in their healthcare to help prevent consumer interacts in their healthcare to help prevent medical errors.medical errors.

• Good, non-fiction, literary work exists that is beginning Good, non-fiction, literary work exists that is beginning to bridge the gap between the consumer and caregiver.to bridge the gap between the consumer and caregiver.• Internal Bleeding Internal Bleeding - - Wachter, ShojaniaWachter, Shojania• Through the Patient’s Eyes -Through the Patient’s Eyes - GerteisGerteis,, Edgman-Levitan, Edgman-Levitan,

Daley, DelbancoDaley, Delbanco• The Patient’s Guide to Preventing Medical ErrorsThe Patient’s Guide to Preventing Medical Errors - -

BerntsenBerntsen• How Doctors Think How Doctors Think -- GroopmanGroopman

• These works mostly emphasize the numbers and statistics.These works mostly emphasize the numbers and statistics.• FATAL CARE is personal - you, your child, your spouse, FATAL CARE is personal - you, your child, your spouse,

your neighbor, your friend, your mother...your neighbor, your friend, your mother...• FATAL CARE - The next step to drive change in how the FATAL CARE - The next step to drive change in how the

consumer interacts in their healthcare to help prevent consumer interacts in their healthcare to help prevent medical errors.medical errors.

Robert LudlumRobert LudlumRobert LudlumRobert Ludlum

ComaComaComaComa

The ScorpioThe Scorpio IllusionIllusionThe ScorpioThe Scorpio IllusionIllusion

New York Times New York Times bestsellersbestsellersNew York Times New York Times bestsellersbestsellers

The Janson The Janson DirectiveDirectiveThe Janson The Janson DirectiveDirective

CriticalCriticalCriticalCritical

FATAL CARE: “Novel” Type Non-FATAL CARE: “Novel” Type Non-Fiction StoriesFiction StoriesFATAL CARE: “Novel” Type Non-FATAL CARE: “Novel” Type Non-Fiction StoriesFiction Stories

Robin CookRobin CookRobin CookRobin Cook

ShockShockShockShock

The The Bancroft Bancroft StrategyStrategy

The The Bancroft Bancroft StrategyStrategy

On Parrish Island, off the coast of Virginia, lies a psychiatric On Parrish Island, off the coast of Virginia, lies a psychiatric facility. Far from prying eyes, it is a government - run hospital facility. Far from prying eyes, it is a government - run hospital for former intelligence employees in possession of highly for former intelligence employees in possession of highly classified information. classified information.

Former Consular Operations agent Hal Ambler is one of these Former Consular Operations agent Hal Ambler is one of these patients whose mind is filled with secrets of state - and is patients whose mind is filled with secrets of state - and is considered such a security risk that he is kept heavily medicated considered such a security risk that he is kept heavily medicated and closely watched. But there’s one critical difference between and closely watched. But there’s one critical difference between Ambler and the other patients - Ambler isn’t crazy. Ambler and the other patients - Ambler isn’t crazy.

Now he must find a way to escape the facility, find out who put 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 him there, and uncover the truth of who he was…and why someone is willing to risk everything to see him dead.someone is willing to risk everything to see him dead.

Each chapter tells a different story of a family impacted Each chapter tells a different story of a family impacted by a preventable medical error.by a preventable medical error.

• Three Little Angels: Indiana Babies - Heparin OverdoseThree Little Angels: Indiana Babies - Heparin Overdose• Even the Tough Can Fall: Charlie Weis - Surgical Complication Even the Tough Can Fall: Charlie Weis - Surgical Complication

• Never Routine: Lewis Blackman - Failure to Rescue Never Routine: Lewis Blackman - Failure to Rescue • Reading Between the Lines: Trisha Torrey - Misdiagnosis Reading Between the Lines: Trisha Torrey - Misdiagnosis • Critically Wounded: Diana Brookins - Bloodstream Infection Critically Wounded: Diana Brookins - Bloodstream Infection • Wrong Turn: Benjamin Houghton - Wrong Side Surgery Wrong Turn: Benjamin Houghton - Wrong Side Surgery

• You Can Have My House: Johanna Daly - Surgical Site Infection You Can Have My House: Johanna Daly - Surgical Site Infection

• The Mission: Taylor McCormack - Delay in Treatment The Mission: Taylor McCormack - Delay in Treatment • Picking up the Pieces: Diane Ford - PCA Pump Failure Picking up the Pieces: Diane Ford - PCA Pump Failure • They Are Not Listening: Ken Simon - Wrong Diagnosis They Are Not Listening: Ken Simon - Wrong Diagnosis • Coming Together: Linda Kenney - Medical Trauma Coming Together: Linda Kenney - Medical Trauma • One of Their Own: Liz Augusta - Near MissOne of Their Own: Liz Augusta - Near Miss

11% Percentage of medication errors involving dangerous high-alert medications, such as heparin, morphine, insulin, potassium chloride and chemotherapy agents.

THREE LITTLE ANGELSTHREE LITTLE ANGELSTHREE LITTLE ANGELSTHREE 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?”

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…

NEVER ROUTINENEVER 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).

Following Each Following Each Story…Story…

Sections that provide Sections that provide insight and help for the insight and help for the

consumer.consumer.

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

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

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

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

• A balance of positive and negative outcomes:A balance of positive and negative outcomes:• Fatal Care had a potential to be a “downer”.Fatal Care had a potential to be a “downer”.

• Limited fatal outcomes, included near Limited fatal outcomes, included near misses.misses.

• Altered positive and negative outcome Altered positive and negative outcome stories.stories.

• Unfortunately, it could have been Unfortunately, it could have been Fatal Care Fatal Care Children.Children.

• Limited children to three stories.Limited children to three stories.

• Geographic locations:Geographic locations:• Medical errors happen in every area, city, Medical errors happen in every area, city,

country and in-between.country and in-between.• Contacts came from all over the world - Contacts came from all over the world -

limited to U.S. for this book.limited to U.S. for this book.• New York City, LA, South Carolina, New York City, LA, South Carolina,

Everett Washington, Chicago area, Everett Washington, Chicago area, Portland, BostonPortland, Boston

• All size and types of hospitals:All size and types of hospitals:• Medical errors happen in every size Medical errors happen in every size

hospital:hospital:• Teaching/UniversityTeaching/University• Community based hospitalsCommunity based hospitals• Specialty hospitals Specialty hospitals • Outpatient centersOutpatient centers

• All size and types of hospitals:All size and types of hospitals:• Medical errors happen in every size Medical errors happen in every size

hospital:hospital:• Teaching/UniversityTeaching/University• Community based hospitalsCommunity based hospitals• Specialty hospitals Specialty hospitals • Outpatient centersOutpatient centers

• Cross section of type of errors.Cross section of type of errors.• Generally healthy people that received care or Generally healthy people that received care or

treatment for an illness or injury.treatment for an illness or injury.• For this book, we did not select chronic illness or For this book, we did not select chronic illness or

complex, multiple diagnosis case scenarios.complex, multiple diagnosis case scenarios.

• Targeting the general healthcare consumer Targeting the general healthcare consumer who could relate to, or experience a common who could relate to, or experience a common medical error.medical error.

• Queries for the Stories:Queries for the Stories:• Fatal Care Website Fatal Care Website http://www.fatalcare.comhttp://www.fatalcare.com// • PULSEPULSE http://www.pulseamerica.org/• Previous contacts from:Previous contacts from:

• The Patient’s Guide to Preventing Medical ErrorsThe Patient’s Guide to Preventing Medical Errors

• Public news storiesPublic news stories• Mothers Against Medical ErrorsMothers Against Medical Errors

• Mamemoms@aol.com

• National Patient Safety Foundation National Patient Safety Foundation • PATIENTSAFETY-L@LISTSERV.NPSF.ORG

• Medication errorsMedication errors• InfectionsInfections

• SSISSI• Device related infectionsDevice related infections

• MisdiagnosisMisdiagnosis• Surgical complicationsSurgical complications• DelaysDelays• Wrong site surgeryWrong site surgery• Near MissNear Miss

• Methodology:Methodology:• The key method was personal The key method was personal

interviews.interviews.• Written accountsWritten accounts• Published storiesPublished stories• Professional educationProfessional education

• Stories:Stories:• Some are in litigation.Some are in litigation.• Some had completed Some had completed

litigation/settlement.litigation/settlement.• Others did not have litigation.Others did not have litigation.