Tuesday, December 30, 2008

Sharing the Load of a Nurse "Second Victim"

Rescuing the Healer After Trauma

December 2008’s RN Magazine’s cover story shares the University of Missouri Healthcare System’s journey toward better understanding and providing support for its nurses on the sharp end of a medical error or unexpected patient decline. (Click here to view the entire text of the article.)

As the authors point out, there were no nursing specific studies found in the literature regarding helpful interventions, so the UMHS began to compile their own data and gathered anecdotal information from their nursing staff through a series of interviews. Upon review of the findings, UMHS has now begun developing an institutional response to formalize three levels of support for its nurses: (1) peer/colleagues; (2) department leader; and, (3) other institutional resources. Ultimately, they came to the conclusion that a comprehensive response plan must be in place for staff who may be suffering as “second victims” either as a result of a medical error or an unexpected patient decline. Second victims need support in timely and predictable ways, and support systems (peers/colleagues as well as leadership) should be anchored throughout the institution. Supportive peers and department leaders must be properly trained, and staff members need to be made aware of the availability of support services before something happens.

The MITSS mission of Supporting Healing and Restoring Hope has always included the emotional impact on the clinician (in this case the nurse) involved in an adverse event. We have consistently recognized the immense psychological (and sometimes physical) suffering of the medical caregiver in these instances. Barriers to open and honest dialogue and providing the necessary supports have included fear of retribution, loss of employment, guilt, shame, and the list goes on. The culture of “sucking it up” and suffering in silence has been slow to change, but programs such as those at UMHS serve to give us hope.

MITSS will continue to advocate for institutions to develop formalized support programs for all of their clinicians. The UMHS program featured in the article appears to focus on the nursing staff, but we know that these events can negatively impact physicians, pharmacists, and other medical caregivers as well. We have been the sole voice calling for emotional support for everyone involved in an adverse event since our inception, and it is gratifying to see that our persistent calls for change are beginning to be heard.

Thursday, December 18, 2008

A No Cost Gift Idea with Lots of Benefits

Frank Federico, Executive Director, Strategic Partners at IHI and former MITSS Board Member, was kind enough to send along a wonderful and useful idea for holiday giving --

Medications are the most common intervention in health care. It is estimated that over half of older adults take 5 medications or more. In addition, many may be taking over-the-counter and/or herbal remedies. When these patients visit a hospital or their doctor’s office, it is difficult for them to remember all of their medications. The names of the medications do not make this task any easier.

Jennie Chin Hansen from AARP came up with a great idea. Encourage people to give their loved ones a list for Mother’s Day and Father’s Day. I am jumping ahead. Get started right now. For Christmas, why not ensure that each member of your family, immediate and extended, has an up-to date medication list. Imagine how much easier it will be for the patient to remember the medications he/she is taking, and for health care providers to review when providing care. And, promise to help keep that list up to date.

There are many formats to choose Check out http://www.macoalition.org/initiatives.shtml (Medication List) or visit the Institute for Healthcare Improvement (www.IHI.org ) for examples from participants in the 5 Million Lives Campaign (key word search: medication list).

By the way, if you or your loved ones do not take medications, how about a card that indicates that you do not take medications. In the event of an emergency, healthcare providers will not have to spend time trying to collect information about your medications.

Frank Federico
Executive Director, Strategic Partners

Saturday, December 13, 2008

MITSS and CarePages

In our most recent newsletter, you may have noticed that we had an announcement about MITSS and CarePages new partnership. We have done these to offer patients, families and clinicians a free, private web page to journal and share their experiences during a time when support maybe needed. At MITSS, we have come to appreciate the amazing healing power that comes with chronicling one's story. Setting up a CarePage is also a great way to share photos, news, and updates. A CarePage can be created and used at any stage of care, and it doesn’t have an end date. So,
visit www.carepages.com/mitss today and click on “Create” to start your own journal. In order to have the MITSS logo on your web page you must create through the above web page. Linda Kenney, the president of MITSS has created her own web page that chronicles her ankle replacement surgery and the subsequent infection. She will continue to update as she progresses and you can access her page by going to http://www.carepages.com/carepages/LindaKKenney .

If you know anyone that may benefit from using this tool, please pass it along.

Let us know what you think.

Wednesday, December 3, 2008

Arrogance and Etiquette

There were two interesting pieces in the New York Times this week on physician's attitudes and communication in the workplace, and the effects on quality of care.

"Arrogant, Abusive and Disruptive - and a Doctor" discusses how the intimidating and aggressive attitudes of some doctors lead to errors in care. Staff working with aggressive physicians feel they do not have the right to speak up about problems with care and may be shouted down if they do. The article also discusses institutional responses to the problem, including communication requirements in medical schools and increasing enforcement of hospital codes of conduct.

In a related column, "The Six Habits of Highly Respectful Physicians", Michael W. Kahn, a Boston area psychiatrist, advocates for basic etiquette training for physicians.

We'd really like your thoughts on both of these pieces. Have you ever witnessed any kind of abusive behavior? Have you ever been on the receiving end of something like that? Do you think this type of behavior is commonplace, rare, or somewhere in between? Why? Do you think etiquette training for physicians would help?

Wednesday, November 26, 2008


We make choices throughout our lives - where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don't express our intent or tell our loved ones about it.

This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in a hospital. More than 80% of Californians say their loved ones know exactly or have a good idea of what their wishes would be if they were in a persistent coma, but only 50% say they've talked to them about their preferences. But our end of life experiences are about a lot more than statistics. They are about all of us. So the first thing we need to do is start talking.

Engage with Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences. And we are asking people to share this One Slide -- wherever and whenever they can -- at a presentation, at dinner, at their book club. Just One Slide, just five questions.

Lets start a global discussion that, until now, most of us haven't had.

Here is what we are asking you: Download The One Slide and share it at any opportunity --with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.

Let's start a viral movement driven by the change we as individuals can effect...and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them.

Just One Slide, just one goal. Think of the enormous difference we can make together. (To learn more please go to http://www.engagewithgrace.org/)

As a side note, the origins of this movement are chronicled in a very interesting article in today's Boston Globe. Check it out.

Thursday, November 20, 2008

Fox Guarding the Chicken Coop? In the Bag?

There was a story in last Friday’s Globe about Jason Fox, a young child who died at Children’s Hospital, and the investigation surrounding his death. Just looking at the picture of this beautiful baby boy, one can’t help but feel enormous sympathy for his grieving family. The loss of a child is an unimaginable tragedy.

There are serious allegations of withheld medical records, substandard care, and so on. We won't comment on the facts of the case as there is a great deal of investigation going on by a number of parties, and it is unclear from the article exactly what happened. What is clear, however, is that a family has been devastated. We know, too, that the clinicians (the doctors, nurses, and everyone else involved in Jason's care) must also be significantly affected by Jason's death.

Sometimes events like these can have a polarizing effect, and they serve to trigger strong emotions on all sides. This is especially evidenced in the online reader comments to the story. Unfortunately, we can still see an “us against them” mentality. At MITSS, we recognize that adverse events have significant consequences for ALL involved, and we advocate for patients/families, clinicians, and healthcare institutions to work together to find common ground and work toward effective solutions. After all, we are all human, and we all have a stake in safe, quality healthcare.

One reader comment stuck out for us especially, and we felt it important to comment. Sconiico writes…

Classic example of the fox guarding the chicken coop…

- heck, the lay group formed to help such victims (Medically induced trauma support services aka MITSS) has its office rent paid by Brigham & Womens Hospital. Everyone is in the bag!...

In the interests of complete transparency, we’d like to offer the following response:

As a small non-profit, MITSS relies on the generous donations (financial and in-kind) of organizations and individuals from both in and out of healthcare. Brigham and Women's Hospital has generously provided us with an in-kind donation of office space. They, like our other donors, support our mission and share our vision. However, we remain an autonomous organization governed by our own independent Board of Directors. We would invite anyone to contact us at (617) 232-0090 or visit our website at http://www.mitss.org/ and would welcome the opportunity to clear up any other misconceptions.

Appropriately, the theme of our annual event last week was Together, Moving Forward!, and that is our sincerest hope for the upcoming year.

Wednesday, November 5, 2008

Not Able to Attend Our 7th Annual Dinner and Fundraiser -- Not to Worry!

Our last blog post referred to how busy we've been getting ready for our Annual Dinner. I am happy to report that this year we are doing something different. We will be videotaping the keynote speakers for the purpose of streaming the video from our website. We hope that those who aren’t able to make our dinner will be able to enjoy the important highlights.

Our keynote speakers are both extremely dynamic change agents in Healthcare. Margaret Murphy from Ireland is a member of the WHO, World Alliance for Patient Safety, Patients for Patient Safety Steering Group. Margaret sees patients and families as a seriously under-used resource. Following the death of her son as a result of medical error, she became actively involved, sharing her family’s experience and engaging positively with healthcare systems and professionals. Her story is one of pain, needless suffering and death, and HOPE!

Paul F. Levy was appointed President and Chief Executive Officer of the Beth Israel Deaconess Medical Center in Boston in January 2002. He is the author of numerous articles in a variety of fields and co-author of Negotiating Environmental Agreements (Island Press, 1999). He is author of a blog entitled “Running a Hospital,” and in that regard is one of the very few hospital CEOs to share thoughts publicly about hospitals, medicine, and health care issues.

We will let you know as soon as we have these videos up and running from our site. As always, we will welcome your comments once you’ve had a chance to view.

Linda Kenney
Executive Director

Friday, October 17, 2008


You may have noticed that this space has been a bit quiet of late. It’s not for lack of things to talk about, issues to sound off on, or news to share. It’s that time of year again – fundraising season. Sometimes it feels like Santa’s Workshop as Christmas Eve nears – staff and volunteers are working furiously as our 7th Annual Dinner and Fundraiser, scheduled for November 6th, draws closer.

It’s never easy to ask for money, but the services that MITSS is able to offer and the number of people that we are able to help are entirely dependent on our doing just that. Times are difficult for everyone this year, but every little bit helps, and we really need your support.

Join us for our 7th Annual Dinner on Thursday, November 6th, 2008, at the Renaissance Boston Waterfront Hotel, from 5:30 to 10 pm. It’s going to be a great event as we feature Paul Levy, President and CEO of the Beth Israel Deaconess Medical Center, and Margaret Murphy, a member of the WHO’s World Alliance for Patient Safety and a mother whose son died due to a medical error, as our keynote speakers. The incomparable Billy Costa of NECN and KISS 108 will be our emcee and preside over a fabulous live auction. For tickets, call Winnie Tobin at (617) 232-0090, e-mail at wtobin@mitss.org, or click here.

Another way to help MITSS is to participate in our 2008 Online Auction. We are going live on Monday, October 20th and will be taking bids through November 3rd. Click here to preview the fantastic items that our wonderful Planning Committee has assembled. Check back often as our catalog will be updated when donations come in. Win an exciting prize while supporting the work of MITSS!!!

We hope to see you on November 6th. Best of luck with your auction bids!

Friday, October 3, 2008


This year, as part of the MITSS Annual Fundraiser, we have put together an exciting Online Auction. Anyone can participate!!! Preview our Online Auction at cMarket by clicking here! From now until October 20th, check out our fabulous auction prizes.

The actual bidding will go Live on October 20th and be open through November 3rd. We will be adding new items to our catalog, so check back often to see what’s new. Feel free to place a Watch on your favorites so that you’ll know as soon as the bidding begins.

We need your help! By supporting our Annual Dinner and Online Auction, you will be helping to fund the vital work that we do.

Tuesday, September 30, 2008


There was a study published last week in the Archives of Internal Medicine that indicated many doctors don’t demonstrate empathy even when their patients seem to ask for it. This particular study examined a number of encounters where patients were being treated for lung cancer, and the physicians were either oncologists or surgeons. The researchers concluded that doctors were able to express empathy only about 10 percent of the time. Physicians appeared more comfortable discussing medical concerns and shifted the conversation away from emotional issues, including fears and anxieties about death and dying.

It would seem that discussing things like death and dying would be difficult for anyone, but studies have indicated that patients who are shown empathy are more likely to be satisfied with their care and have better knowledge about their condition. Still, empathy is not something one can learn – as they say, you either have it or you don’t. Some people, including doctors, are just better at it than others.

This whole discussion led us to thinking – what about the physicians who need to disclose and apologize following an adverse event? How difficult, in those cases, must it be to empathize with the patient and/or family member? Would an ordinarily compassionate and empathetic clinician be less so because of other complicating factors? We have identified a number of barriers to honest and compassionate communication with patients following an adverse, and possibly preventable, event. These would include the clinician’s shame, humiliation, and feelings of incompetence as well as the culture of fear surrounding the medical-legal issues. Quite simply, these discussions can be extremely uncomfortable to have.

A full disclosure and empathetic apology can be charged with extraordinary emotion, for both the patient and the physician. We would favor a “team” approach – oftentimes the expertise of someone from Social Work, Patient/Family Services, or Chaplaincy is needed. Also, the clinician directly involved may not possess the requisite communication skills. In any case, institutions need to adopt communication policies that encompass these difficult situations. They need to have clear processes and procedures in place that are understood by all providers throughout the organization. Most importantly, hospitals need to train staff, develop tools that can be accessed by anyone at anytime, and have a system of support in place for patients and families as well as clinicians.

Wednesday, September 24, 2008


Given Linda's experience over the past year with MRSA (which has been chronicled in this blog) in addition to the fact that my 3 year old niece was just diagnosed, I wondered whether or not I was beginning to get "germ phobic."

There was an interesting piece in the NY Times Well Blog yesterday that deals with the issue of wearing scrubs in public places. This is something which I had never given a thought to before -- I've seen medical people wearing scrubs at the supermarket, at the dry cleaners, in the dentist's office, and all those other places that we "regular" people frequent in our daily lives. (I was probably even a little impressed up until now -- especially if they had a stethoscope hung around their neck.) Now, I'm thinking "Typhoid Mary" and looking for the quickest exit!

Seriously, though, this brings up an important point. As a clinician, do you have occasion to wear your scrubs in public? Are you alarmed when you see someone else wearing their scrubs out and about? If you're not, should you be? Is this much ado about nothing, or might there be some legitimate concern here?

Winnie Tobin

Thursday, September 11, 2008


Linda Kenney's surgery went smoothly yesterday afternoon, and she is resting comfortably this morning in her hospital room. Thank you to everyone for their best wishes and prayers!

Wednesday, September 10, 2008


As many of you know, Linda Kenney, MITSS Executive Director, has a very long history of surgeries on her ankles. Well, she is headed to the hospital today for yet another unexpected surgery. If all goes according to plan, she will be in the hospital for about 3 days with two weeks on crutches after that. She is, of course, very optimistic about her recuperation period and determined not to let this take too much time out of her busy schedule.

Join us in wishing Linda a safe and uneventful surgery as well as a speedy recovery!

Thursday, September 4, 2008


As the Quaid family tragedy illustrates (see post below), prescription drug mix-ups can have devastating consequences. Some drug names in particular are quite similar to others and can lead to confusion for both patients and prescribers. Bad handwriting, smudged ink, or a data entry mistake can change the name of one drug to something altogether different. The results can be dangerous and sometimes lethal. At least 1.5 million Americans are estimated to be harmed each year from medication errors, with name mix-ups accounting for a quarter of them.

The Boston Globe reported in a story on Tuesday that a web-based tool (http://www.usp.org/) is now available to consumers and doctors to check whether they are using or prescribing error-prone drugs and the names they might be confused with. Coming some time this fall from the Institute for Safe Medication Pratices and iGuard (an online health service) is a more patient-oriented website that will send users e-mail alerts about drug-name confusion.

The Food and Drug Administration is also piloting a program that would hold the drug manufacturers more responsible to guard against name confusion. The hope is to avoid confusing drug names before the product gets to market.

Monday, August 25, 2008

The Quaid Family Tragedy

Many of you may have watched 60 Minutes last night. It was a repeat of a story first aired last spring and chronicled the harrowing experience of the Quaid Family (click here for video). Dennis Quaid, the actor, and his wife's newborn twins were accidentally overdosed on Heparin in a California hospital. The babies survived the ordeal, but the Quaids are speaking out about preventable medical errors.

MITSS posted to the 60 Minutes blog last spring, and we'd like to reaffirm our response to the story here:

Our thoughts and prayers go out to the Quaid family. Medical errors and bad outcomes are a huge problem in healthcare demanding urgent attention by hospitals, physicians, nurses, pharmacists, insurers, regulatory agencies, patients and their families, and everyone else involved. We must all work together to come up with effective solutions -- there is far too much at stake. In the interests of balance and fairness, 60 Minutes should have included the many organizations involved in heroic efforts all over the country in terms of prevention. Still, little attention has been paid to the devastating emotional toll taken on patients, family members, and care providers. We are a non-profit organization dedicated to supporting everyone impacted by a bad medical outcome. Even in the safest of systems, things can and do go wrong. Errors occur at a huge financial cost to the system, but let's not ignore the human cost on both sides of the equation.

It wasn't clear from the piece, but it didn't appear that Dennis, his wife, or any of the clinicians were offered any emotional support following the event. The event must have profoundly impacted the pharmacists, nurses, and physicians involved. Emotional support needs to be "hard wired" into the system when anything goes wrong, for care providers as well as patients and their families. It's simply the right thing to do.

Monday, August 11, 2008


We highly recommend a new book, The Best Practice, written by former Boston Globe journalist Charles Kenney. The book tells the story of some of the pioneers of the health care quality movement, from Don Berwick to Lucian Leape, who are finding ways to eliminate preventable medical errors and transforming American medicine in the process.

As an added bonus for MITSS, the Institute for Healthcare Improvement (IHI) has generously arranged for 10% of purchases made through a special Amazon.com link to be donated to MITSS. To purchase a copy of The Best Practice through this special arrangement, click here.

Friday, August 8, 2008

Where can you find MITSS this week? The Boston Herald!

This article in the Boston Herald from Sunday 8/3/08 features MITSS founder and Executive Director, Linda Kenney, and one of MITSS’ esteemed board members, Jim Conway. They were asked to comment on the progress and trajectory of apology and disclosure in medicine. Although we are always pleased when this topic is highlighted, it is likely that the column inches allotted were not enough to do it justice. So, we would like to put the question to you: How do you see the progress and direction of apology and disclosure in healthcare? How does it impact you personally?

Wednesday, July 16, 2008

Physician Frustrated in Efforts to Prescribe Critically Necessary Medications

In today's post, our guest blogger, a local primary care physician, sounds off on a bureaucratic nightmare and the potential harm to patients:

I am a primary care physician and have been practicing in Cambridge for nineteen years. There are many challenges and frustrations for physicians attempting to provide the best possible and safest office based care to patients. However, never before have I felt more outraged by the unnecessary potential and actual harm and suffering some of my patients have had to endure with the introduction of many of the individual insurance programs that were created by the relatively new Medicare Part D program. Some of these programs are completely unscrupulous in their limitations to essential medication.

Here is one example:
One 63 year old man who has multiple medical problems including diabetes, hypertension, heart disease and decreased kidney function has been fairly stable in recent years, but close to needing dialysis in spite of our best efforts to hold that off with medications. There are many clinical guidelines and studies that support the use of one of his medications (losartan, of the class of medications called “ARB’s) to protect his kidneys and stave off dialysis in the situation he is in (He is unable to tolerate first line medications called “ACE I”). He had been on this pill along with many others for many years. When his insurance was switched to Health Net Orange, one of the 15 or so Medicare part D programs approved to practice in the state, they denied him use of this medication or any alternative in the class. They offered no explanation except to say that it is not formulary. After reapplying a couple of more times and being rejected I called the company myself, hoping to reach a medical reviewer, even the Medical director to explain my rationale for the necessity of this medication. After literally 2 hours of calling, getting put on hold and being transferred, this physician had only spoken to various clerks, and gotten no useful advice. Further calls by the office manager were equally unfruitful. Finally the only way the medication was approved was when I referenced in my clinical notes that I felt that this medication was necessary to prevent complete renal failure which would lead to lifelong dialysis, stroke or heart attack, and that in spite of my best efforts to get the medication approved, his insurer would not do so. I further went on to say in the record that I felt the insurance company should have some responsibility if one of these untoward events occurred while off his medication! I have never written anything referencing any insurance company in a record in my entire career, and might have considered it unprofessional before this, but my patient’s health was at stake and I couldn’t think of any other way to try to get the medication approved.

I sent a copy of this note to the insurance company with the fourth medication request and after about 6 person-hours over a 3 week period of time trying to get this medication approved, it was miraculously approved the very next morning until the year 2039!!

It infuriates me to see patients put at unnecessary risk like this, and it is exhausting the precious resources of primary care practices. Think of the cost of this occurring dozens or hundreds of times per year probably in every office in the state and the harm that undoubtedly has come to easily thousands of patients per year! This is not the only insurance carrier that commits this disservice; but some the Medicare part D carriers are very much more inclined to this sort of practice than the HMO’s and traditional carriers in the area and even much more so than Medicaid and the newcomer Commonwealth Care, in my experience. I write this to help give a voice to practitioners struggling to do their best for their patients in this arena and to let patients know about this threat to the safety of patients that is very real and has disempowered practitioners to get their patients medications they need. I am looking for ideas how to find ways to make these carriers more accountable to patients in the basic area of necessary medications.

Tuesday, July 15, 2008


Over the past six years on behalf of MITSS, I have had the great fortune of travelling the country and abroad. I have spoken at conferences and forums, large and small, speaking with patients, family members, and clinicians. It seems that everyone has a story. Each time I speak with a clinician who has been affected by a medically induced trauma, I not only relate on a truly personal level, but it has served to strengthen my commitment and resolve to change the systems which fail each of us every day.

There can be nothing more powerful than a personal story, and we have encouraged anyone affected by an adverse event to share their experience with us on our website. While it seems that I hear from healthcare providers in equal numbers, they don’t appear as willing to share their stories. There has been a very moving entry recently added, and we invite you to take a look at our clinician story page. Also, if you’d like to share your own story, please feel free. The submission is anonymous, and confidentiality is assured. By sharing your personal and professional experience, you may be helping a colleague out there to feel less isolated and alone. We hope to hear from you.


Saturday, July 5, 2008

Communication Loop Following Adverse Events

Below is a Post I wrote last week but we held off posting it....

All the literature out there tell us that patients and families want several things following bad outcomes and medical errors:

1. They want the truth and in a timely manner.

2. They want either an apology or an acknowledgement.

3. They want to know what the organization is going to do to prevent another occurrence.

4. They want support.

a. emotional support
b. financial support when appropriate

My observation, though, is that many hospitals still struggle with looping back to the patient and family with the information about what happened and how. But, more importantly, they neglect to relay to patients and families the changes to be made moving forward to prevent reoccurrence.

There isn't a mechanism to loop back to staff to give them the same information. I can see why this would be difficult given all the different departments and staff involved. But, I think it just as important that we be transparent with the staff as well. It would also diminish assumptions and rumors among staff.

Does anyone have ideas for how this can be done effectively and routinely?

Does anyone have any suggestions on how we can start doing this better?

...this post seems fitting given the news last week of a Boston Hospital that had done a wrong site surgery. They disclosed to the patient who is recovering at home. But, the President/CEO and the VP of Quality and Safety sent an internal email (click here for full text) letting the staff know about what they described as a horrific incident. I was truly impressed!

Linda Kenney

Monday, June 30, 2008


MITSS Support Team Member and Doctoral Student in Psychology, Erin O'Donnell, shares some reflections regarding her godson's hospitalization. Erin chronicles a very common problem with seemingly routine healthcare communication -- one that needs to be addressed in our quest for true patient-centered care:

On Wednesday morning, my 4 month old godson received a heart transplant in another state. Naturally, this is a big moment and gift beyond words. There is so much that can be said about the magic and miracle of organ donation; the amazing donor families, the science and the great treatment teams. However, I would like to comment on the something else.

Today, my friend, my godson’s mom, called me and said, “People say stupid things sometimes.” She went on to tell me about how the person she thinks was the anesthesiologist (the doctor didn’t adequately identify her role) introduced her name to my friend when entering her son’s room in the Cardiac Intensive Care Unit. The doctor then began talking to the other surgeon in the room as if my friend, the mother, were not in the room. This conversation included saying, “Most transplant babies are off the ventilator after 2 days.” Everyone in the room knew that this was 4 days after the transplant. It was an insensitive comment to make in front of the mother in that manner. The part that my friend found most rude was that the comment could wait until they left the room, since it was information all parties present already knew. When I expressed my irritation with the fact that the treatment team was talking as if she weren’t in the room, instead of integrating her into the team, my friend said that such discussions happen ALL THE TIME! How many times in our lives do people talk about us or our loved ones in front of us and pretend as if we don’t exist in the room? Is this a strange phenomenon that has become commonplace in the healthcare setting? How should a patient or family member confront such behavior without being seen as a problem patient? How did this kind of behavior originate in the first place? I wonder if it started as some sort of communication shortcut.

I do not believe either of the providers in the room were intentionally insensitive nor do I believe that they are callous people. This is a more widespread problem. It seems there are great barriers to overcome when discussing the importance of integrating the patient and family in their own treatment decisions, particularly when there are still providers that “forget” that they even exist at all.

Erin O'Donnell
MITSS Support Team Member

Wednesday, June 25, 2008


It sometimes goes unnoticed that pharmacists can have a significant stake in patient care. They may find themselves involved in organizational, hierarchical, or ethical dilemmas. A Boston area pharmacist writes of a recent experience. He poses some important questions to the healthcare community:

I recently had a patient who was an 86 year-old female. She was designated for hemodialysis and as part of the process was prescribed a ceftriaxone by the Renal Physician prior to the treatment. When processing this order in the pharmacy, I noticed that a warning in the computer system indicated she was allergic to piperacillin. These 2 antibiotics are sometimes cross sensitive, and there was potential to cause harm to the patient. I called the Nurse who was taking care of the patient on the floor and asked if she knew what type of reaction she had.

I learned that she had a rash, and as such a reaction is immunologically mediated, my concern that ceftriaxone could cause harm to the patient was elevated. I asked if it was a whole body rash. However, the Nurse did not have enough information to affirm it. I then paged the MD and asked about the potential for cross sensitivity and perhaps to use another agent. The MD said that the cross sensitivity is about 10%, and he was aware of the issue. I knew that the cross sensitivity issue was not true as there is no evidence to support this and to develop a study to determine rates of cross sensitivity are generally seen as unethical. In addition not being an ID Pharmacist, I would not have a recommendation for another agent that would cover the strains of bacteria that the MD wanted to cover. I approved the order.

The next day I came in to a note that the ICU needed to have Diphenhydramine restocked. I saw that a patient (the same 86 year-old female) was in the ICU with a standing order of Diphenhydramine 50 mg every 6 hours. When I called the ICU, I asked them why the patient was receiving the medication, and they indicated that the patient had a whole body rash. I asked, “What was the causative agent?” The Nurse indicated that all they knew was that the patient was transferred from the floor during the night. The Nurse also indicated that they would need a dopamine drip to maintain the patient’s blood pressure during the dialysis session that would be going on during the morning.

I called to the floor, and they could not explain why the patient had been transferred to the ICU. A little later, I received a call from the ICU to say that the dopamine was not working for the patient and asking if we could bring a phenylephrine drip to the ICU. I said I would have one sent, but that we needed an order so we could dispense it. I took the phenylephrine to the unit and spoke to the Nurse who was helping the Dialysis Nurse set up the patient for treatment. She still did not have the order, and she told me to talk to the Renal MD who was sitting at the ICU desk.

When I asked the MD to write the order for the patient, he did not respond to me. He did not even look up, even though he was less than 10 feet away from where I was having the conversation with the Nurse. I asked him again, and he got up from the chair, walked to his left and retrieved an order sheet. He wrote the order, handed it to me, and still did not look up. I gave the infusion to the Nurse and went back to the Pharmacy.

I still do not have an answer about what happened, but I have a couple of questions.

Did I go the extra mile?

Why is there this inability for health professionals to talk openly about these events?

Friday, June 20, 2008


Yesterday's Globe reported that the Massachusetts state government (both as an insurer and purchaser of health care) as well as Blue Cross and Blue Shield of Massachusetts have announced that that they will no longer pay for 28 types of medical errors defined as "Never Events" by the National Quality Forum. For a list of these types of events, click here.

This past November, the Massachusetts Hospital Association announced that all of its members had adopted a policy of not charging patients or insurers for nine of these types of events.

There are clearly significant details to be worked out, but we support any efforts on the part of the state and federal government, healthcare community, professional associations, and insurers to shift the focus to quality healthcare for the citizens of Massachusetts.

Thursday, June 5, 2008


Dr. Anthony Whittemore, CMO of Brigham & Women's Hospital in Boston, has been a strong and early supporter of the MITSS mission. When asked about his recent observations and experiences, Dr. Whittemore writes...

During the past few years, medicine as practiced in hospitals has undergone a very significant transition in handling adverse events from a very protective, defensive posture designed to mitigate litigation to a more transparent, non-punitive environment which openly deals with adverse events. Although we have certainly worked to minimize the occurrence of such events, poor outcomes as well as medical errors, the IOM report of 1998 "To Err is Human" certainly catalyzed the process.

Openly admitting that an error has occurred is a difficult task for some moreso than others, and requires support systems that enable clinicians to comfortably discuss the events with patients and their families and to deal with their impact on themselves. As a result, institutions have adopted policies that guide the process of apology and full disclosure and provide support for staff and patients as they deal with the aftermath of a poor outcome or medical error. The net result is a far more comfortable environment, an environment that will never be entirely free from errors, complications and unanticipated outcomes from interventions, but one which openly seeks to improve by learning from each adverse event.

Andy Whittemore, M.D.
Chief Medical Officer, Brigham & Women's Hospital
Professor of Surgery, Harvard Medical School

Wednesday, May 28, 2008

What Do I Tell My Doctor?

We received an interesting comment to another post on the MITSS Patient and Family Blog yesterday. This person asked such pertinent questions and brought up such rarely discussed issues that we thought we would repost it here.

Anonymous writes...

I really appreciate this blog.

My medical injury occurred almost 15 years ago, at a time when these issues simply were not acknowledged. Ever. I think it's only to our benefit that it's now being talked about.

If I could ask a question: What, if anything, should a patient tell subsequent physicians?

Medical injury has a way of casting a long shadow over future medical encounters, especially if it's handled badly. I became very avoidant after my injury. On my rare visits to the doctor, I'm usually tense and unhappy and on the verge of an anxiety meltdown. My current doctor doesn't know what happened to me and I think he's both puzzled and annoyed that the relationship isn't more productive. Weirdly enough, I actually really like him, but I don't know how much I should tell him. What if he doesn't get it? What if he trivializes it? What if he blames me for everything? What if he decides he doesn't want me as his patient anymore?

I know, I know; the distrust is talking here. But it's not that easy to switch it off. Also, telling the truth would entail saying some negative things about some of his colleagues, and I'm really uncomfortable going there. Does he have a right to know? Would it help provide safer care? Or would it be better not to burden him with all the baggage I've been carrying around?

I've never seen this addressed in any of my (admittedly obsessive) readings on the subject. So if you're ever looking for a future blog topic, maybe you could address it. Thank you for listening.

What do you think? The writer raises some very legitimate concerns. Does anyone have any suggestions or comments?

Tuesday, May 27, 2008


Last Thursday, along with MITSS Board Chair, Karen Moore, I had the opportunity of meeting with the Caritas Quality Committee at Caritas Holy Name Hospital in Methuen, MA. The Quality Committee is made up of key leaders from all of the Caritas Hospitals. It was a great discussion on the changes in culture over the last several years, especially in the area of disclosure and apology. The conversation was truly focused on the support following adverse medical events (which we all know is MITSS’s passion!). A courageous CEO from one of the hospitals admitted that although we are doing a better job with disclosure and apology, we really aren’t doing well with supporting the staff. It became so clear to me in that moment – of course, we aren’t doing a good job with support. We didn’t know what we didn’t know, and, until recently, there really wasn’t much out there about the emotional impact on clinicians. But, now that we know, shouldn’t we have systems in place that can provide support that is timely and accessible for both clinicians and patients and their families?

Friday, May 16, 2008


Beth Conlin, MITSS Volunteer; Linda Kenney, Executive Director; and, Erin O’Donnell, Support Team Member, pose for a photo at the MITSS Booth at the National Patient Safety Foundation’s Annual Congress in Nashville, Tennessee (May 13th through the 16th, 2008).

They promise to be blogging about their experiences in Nashville once they get home to Boston and settled. Look for their reports next week!!!

Friday, May 9, 2008

Is This the Tipping Point?

There is so much I want to share about my interactions with so many people in and out of healthcare on this blog…I will try to keep it to one observation at a time!

During the past five years or so, I have been extremely privileged to speak at conferences all over the country. After most presentations, there is a question and answer period (which is always painful to me personally). I wait and pray there will be someone brave enough to ask a question. The moments usually drag on…and, at last, there will be a question. Usually that question is simple – no controversy. But, what never ceases to amaze me is that after these presentations, there is a line a people waiting to ask questions or tell me their personal stories that they weren’t comfortable enough to share publicly. The personal stories were usually from clinicians who had been at the sharp end of an adverse event and got no support whatsoever. They still felt horrible about what had happened.

In the last six months to a year, though, there has been a bit of a shift. The painful stories clinicians have are now being shared publicly, and they are no longer waiting to line up after my talk. It’s clear there has been a shift -- no longer are clinicians willing to suffer in silence about how these adverse medical events affect them. Is the phrase “this is the price of practicing medicine (or doing business)” still applicable, or are we reaching the “Tipping Point”?

Tuesday, May 6, 2008


National Nurses Week is May 6th through the 12th, and today is National Nurses Day. MITSS would like to salute the dedicated nursing professionals across the country who come to work every day committed to providing the very best of patient care.

During those times when things don’t go quite as expected, MITSS continues to be a safe place where nurses can come for support. If you’re a nurse dealing with the emotional fallout from a bad medical outcome, give us a call (1-888-36MITSS). Also, we would encourage any nurse to join in the discussion on this blog for clinicians as nurses are most oftentimes the frontline caregivers, and, from that perspective, your input is invaluable.

Happy National Nurses’ Day!

Friday, May 2, 2008


From time to time, we will be featuring guest bloggers – doctors, nurses, pharmacists, and other healthcare providers who have graciously agreed to share their stories and insights in the hopes of supporting one another.

Dr. John Fromson, Chairman of the Department of Psychiatry at MetroWest Medical Center and also a MITSS Board member, writes…

Not long ago, while attending a medical society continuing medical education conference, a resident physician in internal medicine, who I had known as a student, asked if she could have a confidential talk with me. Initially, I assumed this was for a "curbside" consultation about a patient she had taken care of who was having some sort of psychiatric problem. It soon became apparent that the problem was not that of a patient, but of an entire culture of medicine that was in desperate need of repair. Here's what happened. The resident had mistakenly ordered and was administered the incorrect dose of insulin for a diabetic patient. The dose was double what it should have been for this particular type of relatively short acting drug that helps to control blood sugar levels in patients with diabetes. Minutes later, after having had a chance to review her orders, the resident realized what had happened. Instead of letting a medical colleague, nurse, or hospital pharmacist know about this medication error, she kept it a secret. Concerned about the patient, but not telling him what had happened, she supervised and encouraged him to drink and eat foods that contained high levels of sugar so his blood sugar levels would not drop dangerously low. She also checked in with him every few minutes and monitored his vital signs until the insulin's effects wore off and she was sure he was no longer in physical danger.

Having had some exposure to patient safety education, the resident physician intellectually knew that a very faulty system contributed to this medication error. She was able to rationalize that if a root cause analysis had been performed by the patient safety officer at the hospital, multiple causes or failures in the drug delivery system would have been identified and corrected, preventing this type of error from happening again. Specifically, the nurse who took the order for the insulin should have questioned the unusual dose, so too should have the pharmacist who sent the drug from the pharmacy to the patient's unit, as well as the nurse who administered the drug to the patient. But emotionally, the resident could not forgive herself for not letting the patient and other health care professionals know what had happened. When asked why she could not share this information, even if it meant preventing future reoccurrences, she replied, "Fear, fear that I would be punished, perhaps lose my job, and perhaps lose everything I had spent years working toward, my professional career." She had witnessed public retaliatory, blaming, and shaming behavior on the part of the senior medical leadership toward another resident who had made a drug dose miscalculation that was reported by nursing staff. She feared experiencing similar humiliation and the subsequent bout of depression that her colleague experienced. While the resident was relieved that her patient fortunately was not injured during this event, it became apparent that she was still experiencing severe emotional distress, in fact she was profoundly depressed. The fear of being blamed turned out to be just as debilitating as actually being publicly blamed. Caregivers can bear the emotional scars of an adverse medical event even when their patients may escape injury. The culture of medicine must change from one of shame and blame to a culture of safety.

John A. Fromson, M.D.


One of our favorite blogs at MITSS is Paul Levy’s Running a Hospital. In the interests of sharing another great resource (as well as giving ourselves a shameless plug), check out today’s post at www.runningahospital.blogspot.com.

Monday, April 28, 2008


Since our inception back in 2002, the MITSS mission has been to “Support Healing and Restore Hope” to patients, families, and clinicians who have been impacted by medical errors and adverse medical events. MITSS has always recognized that when things go wrong in healthcare, the clinician (doctor, nurse, pharmacist, or other healthcare providers) can be dealt an equally devastating emotional blow. As we know, these events can be very difficult to talk about, and there is little out there in the way of support services.

Our goal for the MITSS Clinicians’ Blog is to provide a forum for healthcare providers to speak openly about the emotional impact of adverse events as well as exchange useful information and resources with your colleagues. We hope that you will be willing to share your experiences as we look toward fostering a community of support among medical caregivers.

With that said, though, we admit to a sense of uncertainty about where this blog is going to take us. Please join us in a lively and respectful discussion as we create a space to have this kind of dialogue!

With warm regards,
Linda Kenney
By posting comments to this blog you agree to refrain from posting any content that names an individual medical institution or care provider.