Wednesday, March 23, 2016

Hospital Safety

You go to for an appointment, see the nurse first to go over medications, get weighed, maybe get some tests, and the results, finally see the doctor and then there's a follow up where you start all over again and maybe throw in a medical misadventure or two. Repeat over and over again. At each stage of your visits, you get weighed, vital signed, medication list reviewed, and talk to numerous people, repeating the same information ad naseum.

Most of the time every thing goes okay. Sometimes it doesn't. And who's fault is it? The question should be asked. And also how is it going to be fixed. This is the main concern. How will the hospital fix this so it doesn't happen again? As patients, usually we will never know. We just assume someone at the hospital will say 'we need to fix this'.

But now at Brigham & Women's Hospital in Boston, they had decided in the interest of full transparency, they provide a blog on their Safety Matters. Previously a PDF, it became a blog last year and now is available online to all. It discusses a recent safety issue and then reviews what is being done to correct the situation. In January's issue, for example, a patient was given the wrong dose of a medication. It goes through what happened, how did it go wrong and how it was fixed.

What I find most interesting is that it shows the entire process, how it works, and what went wrong. What surprised me is that how many times the patient gave the information and it was never verified. What would it take for just one person to verify the information? Seriously.

I know sometimes when I go to for an appointment, I feel I get rushed by the nurses and not as much care is given to review information - when the nurse asks me what I weigh instead of weighing me on the scale next to her or when they never even look at my amended medication list.

I do know that now that I have read several issues of Safety Matters, I will start doing more of my part to make sure I bring all my information with me to visits. And no I will not switch to BWH just because of their blog.

1 comment:

Anonymous said...

I suppose my most recent adventure was not a safety issue, unless mental health is a safety issue. I had been having severe hip pain, and the x-ray was ambiguous so I asked my oncologist for a bone scan. Went in, had it, onc's office called on a Friday morning saying everything was fine. I decided to look at the report in my on-line medical records Friday afternoon. When I pulled it up, it said "secondary lesions to bone." Of course my oncologist's office closes at noon on Friday. I called my surgeon in a panic. By the time I got to her office, my blood pressure was 151/110. She pulled up the record and said 'when did you find out you were metastatic? Who diagnosed this, and why didn't I know?' My response was no one ever told me that. She called a radiologist whom I trust and he read the scan and said it was simply osteoarthritis. Despite this being reassuring, I had a very bad weekend. Monday morning I marched into my oncologist's office brandishing the report, and said (paraphrasing) 'what the hell is this?' Onc called that afternoon and said 'you're going to think this is a really lame explanation' and proceeded to tell me that a clerk had inserted that as the diagnostic insurance code for the scan because she knew that the insurance company would accept the code. WTF???
That notation is still on that report, although it has been removed from all the other hospital records. Sometimes the things they do are simply unacceptable. At least it didn't turn out I was metastatic and the only thing that was harmed was my sanity.