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
Monday, June 30, 2008
Wednesday, June 25, 2008
DID I GO THE EXTRA MILE?
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?
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
A STEP IN THE RIGHT DIRECTION
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.
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
A CMO's PERSPECTIVE ON DISCLOSURE, APOLOGY AND SUPPORT
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
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
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