A teaching moment...

On April 1, 2012, twelve-year-old Rory Staunton died of septic shock bought on by a bacterial infection he received after diving for a basketball in his school’s gym. Prior to his death, Rory had experienced a high fever, vomiting, and pain in his leg. After visiting his family pediatrician, he was sent to NYU Langone Medical Center, a premier medical facility in New York, to be treated for what physicians thought was “a sick stomach and dehydration” (Dwyer, 2012). At NYU Langone, he was given medication and sent home. Two days later, Rory would be gone.

While in the hospital, Rory had undergone lab tests and his results came in after his discharge. The lab results showed signs of an infection, but the Staunton family was never notified of this. Rory’s family pediatrician also wrote in her notes that the patient had “mottling [skin which] could mean that vessels in his skin were constricting from low blood pressure” (Dwyer, 2012). The hospital records “do not reflect any communication with” the family pediatrician or her findings about Rory’s skin (Dwyer, 2012).

In response to the death, NYU Langone has recently implemented a new patient discharge procedure. In the new procedure, “emergency physicians and nurses would be ‘immediately notified of certain lab results suggestive of serious infection’” which Rory’s lab results showed (Dwyer, 2012). NYU Langone’s new checklist will also ensure that “a doctor and nurse have conducted “a final review of all critical lab results and patient vital signs” before a patient leaves” (Dwyer, 2012). The hospital further elaborated that “in the unlikely occurrence that a clinically relevant test is only available after the patient is discharged from the E.D., the patient will be called, and the information will be shared with referring physician” (Dwyer, 2012).

While it is good that the hospital is making strides to improve procedures after such poor quality, such things should be preventable. The main issue is the lack of communication between the pediatrician and the ER doctors. The pediatrician should have ensured that the family had the information to give to the ER doctors if there was not a way to send it electronically. Yet the biggest error in this case is no one informing the family about the abnormal lab test results. While it is unknown what procedure NYU Langone had prior to this, such a simple act of communication could have prevented an untimely death.

Providing quality care depends wholly on receiving quality information. Providers who do not have all pertinent information cannot effectively treat patients. Simple acts such as appropriate communication and dialogue can save lives. This summer, I had two courses in which group work was required. In both groups, communication was critical to get information and provide quality work. If such a basic skill is stressed in school, why is it not practiced in hospitals? Why were Rory’s medical records not sent to NYU Langone? And most importantly, why was the family not notified of abnormal lab test results?

While it is easy to point fingers, we must not forget that ineffective processes can cause as much harm as human error. This case should have administrators thinking about the quality of the processes that are in place for labs to communicate to physicians thorough the hospital. A quality program where systems are integrated and communicating to one another can increase patient safety and quality of care provided. While it is unfortunate that a young child had to lose his life, this story can certainly be a teaching moment for all healthcare providers. And while it is important that processes are improved, they must be continuously updated to reflect changes and prevent possible issues.

Dwyer, J. (2012, July 11). The New York Times. Retrieved July 20, 2012, from www.nytimes.com: http://www.nytimes.com/2012/07/12/nyregion/in-rory-stauntons-fight-for-his-life-signs-that-went-unheeded.html?pagewanted=all

The Patient's Perspective in Adverse Events

Adverse events, while unintentional still cause hundreds of thousands of injuries, illnesses, and even deaths annually in the United States (Attarian, 2008). Adverse events for the most part are caused by human error or systematic error that causes human error (Attarian, 2008). Evidence-based medicine (EBM) exists to help prevent these issue yet they still occur. So why do we still rely on EBM? Should we not ask patients as they are the recipients of medicine and they can first feel adverse affects?

In the opinion of this writer, EBM should be the primary determinant of adverse events. While it is a tragedy that patients are harmed due to medical error, the proportion is relatively small in comparison to the amount of patients. Placing that amount of pressure on patients is unfair. The purpose of healthcare providers is to take care of patients. They are trained and educated for that task. Experience helps hone these skills and improve the care patients receive. Patients are already nervous about other health issues and worrying about dying due to medical error can create a hyper-vigilant state to the point of paranoia. Furthermore, with the influx of medical information available on the internet, patients may wrongly perceive symptoms or develop hypochondriac tendencies. In addition, not all patients will be able to perceive adverse events (Ransome, Joshi, Nash, & Ransome, 2011, p. 244). For example, patients in surgery my not immediately feel the left over cotton ball in their body until much later.

This topic is the responsibility of medical providers. Facilities know the causes of human errors, such as fatigue, failure to follow procedure or incorrect information. These need to be addressed to prevent adverse events from re-occurring. In this way, facilities can help ensure the safety of both patients and employees. If a tired nurse is making mistakes, instead of blaming the nurse, allow him to rest before continuing work and prevent self-injury and injury to others.

Adverse events are preventable and facilities need to ensure they are doing all possible measures to prevent them from happening.

Attarian, D. E. (2008, May). www.aaos.org. (S. T. Canale, Ed.) Retrieved June 19, 2012, from American Academy of Orthopaedic Surgeons: http://www.aaos.org/news/aaosnow/may08/managing6.asp

Ransom, E. R., Joshi, M. S., Nash, D. B., & Ransom, S. B. (2011). The healthcare quality book: Vision, strategy and tools (2nd ed.). Chicago: Health Administration Press.

Quality and Cultural Competency

I recently read a pretty interesting article about quality, the CAHPS® (The Consumer Assessment of Healthcare Providers and Systems) questionnaire and other quality surveys. If you are interested in reading it, I will provide the citation information and if you are student, I am sure you can search your school library’s article database for a copy. However, I digress.

The article was about the quality surveys and questionnaires that facilities use and how they are not providing an accurate view of quality. Why is this important? Well, someone will write a general survey or questionnaire. However, different races/ethnicities will have different notions of what healthcare quality is and if they received it or not. For example, I, a black female, have different experiences than you. Even if you are a black female, you still have had a very different life experience from me. You are from a specific culture and have different influences on your expectations and opinions on what is quality care from a provider.

So how can health administrators get an accurate view of quality from surveys and questionnaires? The article state “with the exception of whites, participants across all of the [minority] groups noted the importance of cultural competency in facilitating communication” (Bagchi, af Ursin, & Leonard, 2012). And of course, everyone has their own ideas of what constitutes as cultural competency (Bagchi, af Ursin, & Leonard, 2012). So what is an administrator to do when a frustrated physician has a Haitian patient that describes their ailments with sounds? (My Haitian grandmother does it all the time). Should we just have a file of all different groups served for providers to reference?

This article is something for administrators to think about. For facilities that serve diverse populations, cultural competency and excellent communication is imperative. Patients need to be able to feel comfortable and respected to give providers with accurate medical information. Yes, I know, it is a two-way street but I believe that providers ear more responsibility. And while the facility may have a diverse staff, not everyone will be covered. So, what can we do?

Bagchi, A. D., af Ursin, R., & Leonard, A. (2012). Assessing cultural perspectives on healthcare quality. Journal of Immigrant Minority Health, 14, 175-182.

What Does “Quality” Mean to You?

I must say, some things you never really think about until asked. This is certainly one of them. Quality…what a question! To me, quality means that an individual took time and effort to present a thoughtful and conscious service and/or product. Quality is the proof that care went into making something possible and that the process was as important as the finished product or service. The process showed knowledge on the subject matter, dedication to higher goals and selflessness. After all, when providing quality, we do not all get thanked. While we cannot always have physical proof of quality, I think that we can all see it when it is present and when it is not. In healthcare, this is especially true. Often, people can walk into a facility and feel quality in the atmosphere. And when at an appointment with a healthcare provider, we feel quality. In the way that staffers makes us comfortable, ease our fears, provide knowledge and offer realistic and applicable solutions to improve our health and well-being. Quality is felt and when it is good, not only do patients feel good, but the facility can benefit from positive word of mouth. While it may not come standard at all times, quality does make a difference.