8th Annual Dinner Videos Ready to View!

The MITSS 8th Annual Dinner and Fundraiser held this past November 12th was a smashing success due to the support and hard work of our sponsors, leadership committee, planning committee, board of directors, and volunteers. We have posted some exciting highlights to our You Tube Channel. Check out the links below:

Click here for general highlights;
Click here for the HOPE Award Presentation (part 1);
Click here for the HOPE Award Presentation (part 2);
Click here for Linda Kenney's Call to Action;
Click here for Sue Sheridan's wonderful Keynote Address (part 1);
Click here for Sue Sheridan's wonderful Keynote Address (part 2); and,
Click here for Sue Sheridan's wonderful Keynote Address (part 3).

We hope that you enjoy these clips. We'd also love to hear what you think -- your feedback is always appreciated.

Wishing everyone in the MITSS community a healthy, happy holiday season!!!

Engage with Grace -- Reprise

Last Thanksgiving weekend, many of us bloggers participated in the first documented "blog rally" to promote Engage With Grace -- a movement aimed at having all of us understand and communicate our end-of-life wishes.

It was a great success, with over 100 bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations -- our closest friends and family.

Our original mission -- to get more and more people talking about their end of life wishes -- hasn't changed. But it's been quite a year -- so we thought this holiday, we'd try something different.

A bit of levity.

At the heart of Engage With Grace are five questions designed to get the conversation started. We've included them at the end of this post. They're not easy questions, but they are important.
To help ease us into these tough questions, and in the spirit of the season, we thought we'd start with five parallel questions that ARE pretty easy to answer:

Silly? Maybe. But it underscores how having a template like this -- just five questions in plain, simple language -- can deflate some of the complexity, formality and even misnomers that have sometimes surrounded the end-of-life discussion.
So with that, we've included the five questions from Engage With Grace below. Think about them, document them, share them.

Over the past year there's been a lot of discussion around end of life. And we've been fortunate to hear a lot of the more uplifting stories, as folks have used these five questions to initiate the conversation.

One man shared how surprised he was to learn that his wife's preferences were not what he expected. Befitting this holiday, The One Slide now stands sentry on their fridge.

Wishing you and yours a holiday that's fulfilling in all the right ways.

(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. )

Check Out the MITSS White Paper on Clinician Support

We were very excited last week at our annual event to announce the release of "Disclosure and Apology ... What's Missing? Advancing Programs that Support Clinicians, " a comprehensive report highlighting current clinician support models in practice, and including a discussion of the legal barriers to support and how to overcome them as well as recommendations for future best practices. This report was formulated from a Clinician Support Forum that MITSS held last March that was sponsored by CRICO/RMF, the Massachusetts Medical Society, and Promutual Group.

Click here to download this important report.

And the Winners Are...

There was an unusual twist to the 2009 MITSS HOPE Award -- voting by an independent Selection Committee resulted in a tie! This year's winners were announced on Thursday, November 12th, at the MITSS 8th Annual Dinner and Fundraiser held at the Boston Marriott Copley Place.

This year's sponsor, rL Solutions' CEO and President, Sanjay Malaviya, presented the prestigious award to Patty Skolnik of Colorado Citizens for Accountability (CCA); and Sue Scott, Myra McCoig, and Laura Hirschinger of the forYOU Team from the University of Missouri Health System.

Ms. Skolnik was rewarded for her work in founding CCA after the tragic death of her son, Michael. CCA is a grassroots patient safety organization that has provided support and resources to thousands of individuals and families nationwide since 2005.

Ms. Scott, Ms. McCoig, and Ms. Hirschinger were recognized for their important work with the forYOU Team, a comprehensive approach for providing emotional peer support to clinicians, beginning immediately after critical events. Look for more information about these amazing winners and their programs in the Winter edition of the MITSS Newsletter coming in December.

It was a record year for submissions -- the depth and breadth of the work being done around the country that is aligned with our mission of Supporting Healing and Restoring Hope is astounding. We would not only like to congratulate our winners on their most deserving award, but we would like to honor everyone who submitted an entry. Keep up the important work!

You May Have Noticed...

...that this space has a bit more quiet than usual. That's because things have been quite busy of late. It's that time of year again -- fundraising season!

We hope that you will be able to join us next Thursday, November 12th, 2009, at the Boston Marriottt Copley Place for our Eighth Annual Dinner and Fundraiser. Cocktails and raffles begin at 5:30 pm, and the program starts promptly at 7 pm. It promises to be an extraordinary evening, and we hope that you will be there to celebrate and support MITSS!

If you cannot attend, but you would still like to help out, visit our online auction. Click here to view and bid on some terrific items. Start your holiday shopping now, but don't delay -- the online auction closes on Monday, November 9th!

The MITSS Online Auction is now open

LET THE BIDDING BEGIN! The MITSS 2009 Online Auction is now open. Don't be outbid -- win some terrific prizes, all for a great cause!!!


Click here to start your bidding. All the funds raised will assist MITSS to continue doing our work of "Supporting Healing. Restoring Hope." to patients, families and clinicians following adverse medical events.

Patient Safety Advocate Featured on Tonight's 20/20

Patient Safety Advocate, Alicia Cole, is featured on ABC's 20/20 tonight. Don't miss it -- she has an important story to tell:

Dear Fellow Advocates,

My story will be highlighted in the upcoming 20/20 show featuring the much anticipated new book 'SuperFreakonomics': Challenging Conventional Wisdom' There is a chapter in the book addressing hospital infections. Please be sure to watch if you can!

ABC 20/20
Friday, Oct 23, 2009 10:00 PM
Hand Washing Rate Low Among Doctors
Actress Nearly Died From 'Flesh-Eating Disease;'
'SuperFreakonomics' Authors Say Hospital Infections Are Preventable
When you are very sick, you go to the hospital to get better. But what if the hospital you choose actually makes you sicker, or even kills you?

Go to http://abcnews.go.com/2020 for a preview!

**I would love it if some of you would share your experiences in the comment section on the ABC website. People who come to the site and read the article need to know this is happening ALL OVER and everyone who gets an infection is not 'sick' - Many people are being infected following routine procedures due to carelessness.

Thank you very much....Alicia

LOOKING FOR YOUR INPUT

Our friends at IHI are looking for your input...

Don Berwick and Tom Nolan are asking for your input on how to design a low-cost, high-quality health care system for the future. To learn more, submit your ideas and stories, and engage in a conversation about health system transformation, click here.

The Healing Garden

Becky Martins from Voice4Patients sent along this note about an important project. The Healing Garden is a living memorial dedicated to those patients and their loved ones who have suffered a medical error.

I became a patient safety advocate following my father's preventable death in 2000 and founded Voice4Patients.com; a comprehensive web resource that provides patient safety information for consumers. Prior to that, I had been a long time advocate for end stage renal disease patients.

A number of years ago, there was a workgroup of consumers who had hoped to obtain the funding to buy land and have a memorial wall with the names of victims of medical error. As you can imagine, land in DC is expensive. Still, survivors wanted a way to honor their loved ones.

The living memorial garden has been created as a healing space to reflect upon and honor those whose journeys ended before we were ready to say our good-byes, as well for those who have experienced a medical trauma and live with the lingering emotional and physical effects. The garden includes a 40' diameter medicine wheel. There are four sections of flowers planted around the wheel in honor of the children, spouses, siblings and friends, and our elders. We had requests from those who work steadfastly everyday in the healthcare system, who also asked to be included to honor their commitment and dedication (and their hope and intention for a safer healthcare system). These champions are reflected in the walking path that leads into the garden area.

The healing space is located in midcoast Maine. There is no fee to have a flower planted, people only need to submit the information of who to plant the flower for and which section of the garden. Our family will be opening the garden to visitors in the Summer of 2010.

Thanks for posting the information,
Becky Martins

They will be planting bulbs this weekend. To make a donation or arrange for a flower to be planted, visit http://www.voice4patients.com/other_content/Living_Memorial%20Garden_Medical_Harm.pdf.

Transparency Forum -- Sept. 24th at Mt. Auburn

September Healthcare Transparency Forum – Honest Talk about Medical Mistakes

Lack of information about infections and errors in the nation’s healthcare industry are life threatening and costly secrets. There is a growing demand for honest and open public dialogue about keeping consumers safe. On Thursday, September 24th, 2009, at 7pm at Mt. Auburn Hospital, patients, consumers and health care providers will discuss the challenges of healthcare transparency in patient care.

Moderated by award winning television journalist and community leader, Liz Walker, the forum will feature health care professionals including Linda Kenney, MITSS Executive Director; Jim Conway, MITSS Board Member and SVP at IHI; Jeanette Clough, CEO from Mt. Auburn Hospital; Paul Levy, CEO of Beth Israel Deaconess Medical Center; and, Dr. Richard Miller, thoracic surgeon at Southcoast Hospitals Group.

The goal of the forum, which is part of a 4-part series called Better Living with Liz Walker airing on WCVB-TV, is “…to help create patient provider dialogues that inform and empower,” according to Walker.

We urge you and your colleagues to attend this important forum. If you would like more information, contact Winnie Tobin at (617) 232-0090 or e-mail to wtobin@mitss.org. We hope to see you there.

Boston "Champion in Health Care" in MITSS Midst

Congratulations to Deb Washington, MITSS’ Community Outreach Committee Co-Chair, for being named a Champion in Health Care by Boston Business Journal this month. Deb is the Director of Diversity in Patient Care Services at Massachusetts General Hospital and a founding member of the MITSS Community Outreach Committee. Her voice contributes depth and dimension to the committee and always addresses the needs of the underserved.

In March, Deb was also honored as the inaugural recipient of the Arnold Z. Rosoff Agent of Change Award by the Greater Boston Chamber of Commerce and the Ad Club of Boston. MITSS full heartedly agrees with the Boston Business Journal, the Greater Boston Chamber of Commerce and the Ad Club of Boston that Deb is an asset to the Boston community.

Congratulations Deb!

Click here for a link to the Boston Business Journal article:
www.boston.bizjournals.com/boston/stories/2009/08/10/focus9.html

Click here to see a clip of Deb talking on the new relationship of patient and healthcare providers on InsiderMedicine:
www.insidermedicine.com/archives/If_I_Knew_Then_-_Deborah_Washington_RN_MSN_Massachusetts_General_Hospital_on_Nursing_and_Patient_Care_2932.aspx

Click here to see a clip of Deb discussing diversity in healthcare on InsiderMedicine:
www.insidermedicine.com/archives/In_the_Spotlight_-_Deborah_Washington_RN_MSN_2180.aspx

Erin O'Donnell
Support Team Member

MITSS HOPE AWARD

MITSS is still taking nominations for the HOPE Award. For more information about how to nominate someone or yourself, please click here . Please take a few seconds and view a short video clip of Dr. Susan Abookire, one of the team members from Mount Auburn Hospital, who won last year's HOPE Award.

The Justin Micalizzi Memorial IHI Scholarship for 2009

Our friend and colleague, Dale Micalizzi, would like for us to pass on the following message about a wonderful opportunity:

Justin’s Hope Project & IHI are pleased to announce the Justin Micalizzi Memorial IHI Scholarship for health caregivers who are committed to serving vulnerable, underprivileged and underserved pediatric populations. The Scholarship covers the cost of Forum General Conference fees and includes a stipend for travel, lodging, or other conference costs. Please apply or pass on. I love to read the essays!

See Dale Ann Micalizzi on Facebook or visit http://www.ihi.org/IHI/Programs/ConferencesAndSeminars/21stAnnualNationalForumonQualityImprovementinHealthCare.htm?TabId=10 for more information.

Patient Safety Day -- July 25th

Our friend, John McCormack, passed this along...

PATIENT SAFETY DAY
National, World, Global Patient Safety Day
JULY 25th - CANDLELIGHT MOMENT OF SILENCE AND HOPE

Remembering patients and families who have lost their life (or quality of life) due to medical errors -
and in tribute to those who work to improve the safety and quality of healthcare for future patients."Together, lighting the path to safe healthcare - today and everyday:
safe, high quality healthcare is neither accidental nor static."

Time: Moment of Silence at Noon and 6 p.m. your timezone

There will be a meeting in Boston in front of the statehouse this Saturday, July 25th, at 11 am for a moment of silence remembering those who have been harmed by medical error.

rL Solutions to Sponsor 2nd Annual MITSS HOPE Award

MITSS is proud to announce that rL Solutions will sponsor its Second Annual HOPE Award. The HOPE Award was established in 2008 to recognize people -- patients, families, healthcare providers, hospitals (or teams or departments therein), academic institutions, community health centers, grass roots organizations, EAP programs, etc. -- who exemplify the mission of MITSS: Supporting Healing and Restoring Hope to patients, families, and clinicians impacted by adverse medical events. The winner will receive a $5,000 cash prize to continue their work.

Nominations are due by September 14, 2009, and the award will be presented at the MITSS 8th Annual Dinner and Fundraiser to be held at the Boston Marriott Copley Place on Thursday, November 12th, 2009.

For more information about the award, or to nominate someone, visit us at http://www.mitss.org/; call Winnie Tobin at (617) 232-0090 or e-mail wtobin@mitss.org; or, mail us at MITSS, 830 Boylston Street, Suite 206, Boston, MA, 02467.

About rL Solutions:

rL Solutions provides proven risk management, patient feedback, claims and infection control software to help healthcare organizations improve patient safety and healthcare quality. rL Solutions brings together innovative technologies, stellar client service, and a broad ecosystem of partners to give its 500 clients a complete safety and quality solution. With products that are easy to use and easy to implement, rL Solutions is a world leader in the healthcare market. For more information, visit http://www.rl-solutions.com/.

Progress Slow in Stopping Hospital Harm

MITSS Executive Director, Linda Kenney, is featured on a Channel 5 (WCVB Boston) news story on hospital errors. Included is the compelling story of a nurse harmed at the hospital where she works.

Check out the video at -- http://www.thebostonchannel.com/video/19984320/index.html

Tune In to Rhode Island Public Radio

Rhode Island Public Radio's Megan Hall produced a wonderful piece on the emotional impact of adverse events. It highlights the work that MITSS is doing with patients and families. It also discusses plans to bring clinician support to Rhode Island hospitals. Tune-in to the link below!

http://www.wrni.org/content/first-do-no-harm-part-3

Raising Joy in the Healthcare Workforce

Our Friends at IHI are producing a new free audio broadcast series. We thought an upcoming program would be of particular interest to clinicians -- Raising Joy in the Health Care Workforce is scheduled for Thursday, July 9, from 2:00 – 3:00 PM Eastern Time.

Join WIHI host, Madge Kaplan, and experts Joanne Watson and Katie Bell, for a lively discussion of new research findings and new strategies being deployed to build stronger connections between clinical outcomes, patient-centered care, and engaged frontline employees. Come listen, share your knowledge, and ask questions on IHI’s brand new audio “talk show” - the first of its kind devoted to capturing the best ideas for reforming the health care system through system redesign.

At MITSS, we believe that there is a direct connection between engaged, SUPPORTED staff and the quality of patient care. Check out the audiocast and let us know what you think. To register, visit
http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/WIHI.htm.


About WIHI: WIHI is a new free audio/web broadcast from the Institute for Healthcare Improvement that combines the best of improvement ideas with global experts, a seasoned host, and hundreds of engaged participants. The 60-minute program is offered live every other week and by download whenever it's convenient for you to listen. Produced and hosted by Madge Kaplan, WIHI is your opportunity to meet up with colleagues who want to improve patient care and shape a true health reform agenda.

Patient-Centered Care -- Reality or Fantasy?

There was an interesting piece in last week’s Well Blog of the New York Times. In “Letting Patients Call the Shots,” Dr. Pauline Chen talks with Dr. Don Berwick about his definition of patient-centered care. Many clinicians believe their care is “patient-centered,” but is it really? Are Dr. Berwick’s ideas too radical? Is patient-centered care a really good idea, but just not practical or realistic? Would a true commitment to patient-centered care transform the American healthcare system? What can patients do now to improve their healthcare? The questions seem endless. We’d like to hear what you think.

Impact of Medical Error Survey

Impact of Medical Error Survey

You are invited to take part in a research project investigating the impact of medical error on the family members of the patient. Your participation will be a valuable contribution to patient safety research, and I strongly encourage you to participate if you qualify. If not, please pass it along to others that may be interested in the study.

The invitation that follows is offered by Sherry Worsham, a graduate student at Harvard University. MITSS has agreed to forward this research opportunity to you. We believe this study will be useful for many of us who are doing this work.

Thank you for your time.

Linda K. Kenney

President/Executive Director

You are invited to take part in a research project investigating the effect of medical error on the family members of the patient.

This invitation is offered by Sherry Worsham, a graduate student at Harvard University. The MITSS organization has agreed to forward this research opportunity to you.

Your participation in this study is completely voluntary. If you choose to participate, you will respond to questions about the medical error experience of a family member.

To be eligible to take part in the study, you must be 18 years of age or older and have a family member that experienced a medical error between the dates of January 1, 1999, and January 1, 2009.Only one member of each family in which a family member has experienced medical error should complete this study. If you are the victim of a medical error please select one family member to complete the survey.

If you completed the questions earlier or are not interested in research participation, please ignore this invitation; however, you are encouraged to forward this invitation to others that might be interested in this study.

To find more information and to tak part in this study, please click on this link: Impact of Medical Error Enter the password: CAT (all caps!)

Thank you,

Sherry Worsham

Email: sworsham@fas.harvard.edu

It's Wasn't Personal

“It wasn’t personal… Nobody intended to harm you… It was a systems error…”

These are the phrases that are often said to patients and family members following a medical error. The reasons behind them are good ones—very rarely are adverse events caused by willful acts of harm from an individual. The vast majority of errors can be traced to problems with the systems of health care, and the “tradition” of assigning blame and punishing individuals does nothing to address the real problems.

But sometimes this line of thinking is taken too far and leads to the discounting of the patient and family experience:

“It wasn’t personal… Physically you are healed, so why can’t you get over it… Nobody intended to harm you, so you shouldn’t feel so betrayed… Don’t take it so personally…”

But for patients and families who are victims of medical errors, it is personal. It is incredibly personal. The damage to the patient’s body is personal. The damage to the patient’s ability to trust is personal. The physical and emotional trauma is personal.

We don’t want to blame the individuals, but how do patients get the acknowledgement and support they need from a “system”? Where is the balance between these two seemingly conflicting ideas? It lies in the recognition that there is a difference between “taking blame” and “taking responsibility”.

There is a popular word used in business—“BLAMEstorming”. When something goes wrong, everyone involved gets together to supposedly brainstorm a solution. But the discussion quickly devolves into figuring out who is to blame, usually the person lowest in the hierarchy (and not present to defend themselves.) That person is punished and everything then continues as before with no changes made to identify or correct what really caused the problem. This activity is about as counter-productive in business as it is in health care.

“Taking responsibility” is completely different. It is the ability to say, “I recognize that there is a problem, and I will make sure it is addressed appropriately, whether or not it was my fault.” It requires a willingness to make it personal—a willingness to connect on a personal level with someone who has been harmed. So, why is this important? After all, it was a systems error, it wasn’t personal.

When patients decide to have a medical procedure, they don’t approach an empty hospital building and say, “That building looks trustworthy; I will have my procedure there.” Patients generally meet with a clinician and decide to trust that person. The trust is personal, so when something goes wrong the feeling of betrayal is also personal. In order for the patient to heal emotionally, the betrayal of trust needs to be addressed on a personal level.

What do patients and family members need to heal? It is specific to that individual but some general needs are: An apology for the harm caused; investigation of the error; disclosure about what happened to cause the error; corrective steps to prevent the error in the future; and support for the patients and family members harmed by the error. The person who takes responsibility for providing these also needs guidance on what these actions entail and how to provide them, or there is a risk they will become checkboxes on a form:

Apology – “The hospital is sorry you think there was an error.”

Investigation – “What makes you think an error occurred? Who did you talk to? Why didn’t you do this…?”

Disclosure – “Nobody remembers what happened, so we can’t tell you anything about it.”

Corrective Action – “Next time you should make sure your history is properly documented in your chart.”

Support – “You can’t seem to get over this; you should go see a psychiatrist.” It is no surprise that the patient or family member feels worse after this exchange and the person assigned by the institution comes to the conclusion that “Disclosure and Apology” doesn’t work.

Again, it comes back to the personal connection. The conversation may be awkward. The patient or family may be angry. They may need to have several discussions over what seems like a long period of time, even years. They may be better one day, and worse the next. This is the nature of trauma response; it doesn’t follow an order or timeline. If the person taking responsibility can think about what they would want if they were harmed, and approach the situation with compassion, the healing process can start even without them knowing all the information or the perfect words to say.

The person taking responsibility should also not be expected to provide all the assistance the patient or family may need, as it may include professional emotional or physical treatment. The goal is for the affected person to feel supported—not abandoned—by the system that caused the harm. By working together for healing, patients, families and clinicians can get away from the adversarial tradition of blame and punishment, keep their personal connection, and even together help repair the “systems” that contribute to adverse events and medical errors.

Megan McIntyre

A Scene that Scars

There was a horrific event that happened in Milton, Massachusetts, (a nearby suburb of Boston) last week. A troubled young man took the lives of two of his sisters before being gunned down by police officers. There has been a great deal of media coverage, but this past Sunday's Boston Globe included a piece written by Yvonne Abraham. Her article was unique in that it focused on the emotional impact on the police officers (both rookies and veterans) responding to the scene. Read it here. It is a wonderfully written, harrowing account.

As Ms. Abraham points out, those officers were part of a life altering event. She notes, though, that their compassionate and forward thinking police chief immediately called upon the services of the Boston Police Stress Team to support his officers. Their response was swift and decisive.

Wouldn't it be nice if when something went wrong in healthcare, a support team was immediately called in to assist the care providers involved? MITSS has been advocating for just that over the years. This is yet another example of how other industries have just done better!

Check Out This Week's "Grand Rounds"

Paul Levy, one of our favorite bloggers, is this week's host of Grand Rounds, the weekly rotating carnival of the best of the medical blogosphere. His topic is "when things go awry," and there are some incredibly powerful patient, family, and clinician stories about medical errors highlighted. MITSS's own Linda Kenney's story is also featured. Click here to read the full post.

Emotional Support Is So Important

Below is a link to another horrific story surrounding medical error. It is also another example of why support services for patients, families and clinicians are so crucial following these events.



http://abcnews.go.com/Video/playerIndex?id=4318168

MITSS Announces Second Annual HOPE Award

In honor of National Patient Safety Awareness Week (March 8th through the 14th, 2009), MITSS is pleased to announce that we are now accepting nominations for the Second Annual MITSS HOPE Award.

The HOPE Award was established in 2008 to recognize people -- patients, families, healthcare providers, hospitals (or teams or departments therein), academic institutions, community health centers, grass roots organizations, EAP programs, etc. -- who exemplify the mission of MITSS: Supporting Healing and Restoring Hope to patients, families, and clinicians impacted by adverse medical events. The winner of the Award will receive a $5,000 cash prize to continue their work.

Nominations are due by September 14, 2009. The Award will be presented at the MITSS 8th Annual Dinner and Fundraiser to be held at the Boston Marriott Copley Place Hotel on Thursday, November 12th, 2009, from 5:30 to 10 pm.

Take this opportunity to nominate someone who is doing great work! Also note that self-nominations will be accepted. For eligiblity criteria and submission requirements, click here. If you would like more information, check our website; call Winnie Tobin at (617) 232-0090 or e-mail wtobin@mitss.org; or, mail us at MITSS, 830 Boylston Street, Suite 206, Boston, MA, 02467.

Tips from ABC News on Surviving a Hospital Stay

Dr. Franklin Huang is a resident physician in a major academic hospital. He also writes for the ABC News Online Medical Unit. Dr. Huang recently chronicled Linda Kenney's battle with a hospital acquired infection following ankle surgery. He also outlined some tips for becoming an "informed patient." Check it out at http://abcnews.go.com/Health/WellnessNews/story?id=6999952&page=1

The Times They are a-Changin'

If you instantly recognize the title of this blogspot, then you’re probably of my generation. Or, you’ve become familiar with the song title reference (a Bob Dylan song made popular in the 60’s) because of its resurgence during the Obama election.

Last year, Facebook was that “thing” that my son’s guidance counselor warned me to have him clean up so that he could get into a good college. Didn’t understand it, didn’t necessarily want to, and hoped that he would clean it up because I certainly didn’t have access to it! In the past six months, though, it became clear that this Facebook thing was something MITSS might want to take another look at. So, we had to call in an expert. Linda’s 21 year old daughter, Jessica, was kind enough to come into the office and set us up with a Facebook page – a Group and a Cause! We were thrilled – although not sure why. We were now cutting edge, new wave, in with the in crowd (ok, so now I’m dating myself again – remember that Ramsey Lewis song?). Fast forward a couple of months, and we’re bona fide Facebook addicts. Linda and I both have our personal pages, and our MITSS Group has grown to nearly 300 members!

All kidding aside, we have truly begun to see the benefits of community outreach through Facebook. It is an amazing medium – one that helps us to connect with others who share our common interest in patient safety and commitment to supporting anyone affected by an adverse medical event. We know that younger people are getting much of their information through social networking sites. We have also read that in the past six months, there has been a huge influx of “older” people coming onto Facebook – a shift that we have been proud to be a part of.

Since the MITSS mission is so closely tied to creating a greater awareness and educating about medically induced trauma, it would seem almost irresponsible not to explore new and innovative ways of reaching out to our community – a community that now includes our Facebook “Friends.” So, if you haven’t already, join the MITSS Group on Facebook (just search Groups and type in MITSS). If you’re not on Facebook, don’t knock it until you’ve tried it! Set up a page, and don’t forget to join the MITSS Group.

And, if Facebook weren’t enough, we’ve begun to post many of our video spots on YouTube. MITSS has a YouTube Channel (again, we called in an expert – Linda’s 12 year old daughter, Lindsay – to set it up). Visit www.youtube.com/user/MITSSUtube , and, as always, let us know what you think. We will be updating video posts as we go along.

The times they are a-changin’ and MITSS is a-changin’ with the times!

Winnie Tobin

Flying Trapeze as Therapy?!

We recently read a piece written by a young woman named Megan who had experienced a medical error and lives each day with the emotional fallout. In an effort to heal mentally, physically, and spiritually, she has taken up quite an unusual activity – the flying trapeze! We were moved by her insight and inspired by her tenacity and courage. We were also quite surprised to learn that the trapeze flying business can actually show healthcare a thing or two about safety! We are grateful that Megan has allowed us to use this space to share her story:

In April 2008, I experienced a medication error during an elective outpatient hospital procedure. While there were several factors that contributed to the error, the primary cause was a decision by a doctor that my previous adverse reaction to the medication was not significant enough to warrant deviation from the “standard protocol”. I was given the medication against my wishes and without my knowledge. Upon being informed of the error, my attending physician, in an attempt to be helpful, told me steps I could take to prevent the error in the future. Even though the error was not my fault, the implication was that I was expected to take responsibility for it.

As often happens with medically-induced trauma, I lost the ability to trust others and found that I could also no longer trust myself. I had put myself in a situation at the hospital where I thought I would be safe, but ended up being harmed by it. I blamed myself for my lack of foresight—for not knowing the “magic words” that would have protected me. I became stagnant with the fear that I did not have the judgment to avoid another painful mistake.

After several months, I decided that I could no longer live with the constant fear and self blame. I knew that I had to do something to rebuild my confidence and trust. It was at this point that I happened to see some information about a local flying trapeze school (http://boston.trapezeschool.com). I decided that this would be a good way to challenge my fears. I used a simple risk assessment, “Do you think you could get hurt worse doing this than you already have been hurt this year?” “No.” “Well, OK then.” I signed up for a class. What I experienced in trapeze class was the polar opposite of what happened to me in the hospital:

Safety First—The entire trapeze system is designed around keeping the participants safe. There are redundant systems so that if one fails, a backup will be in place. The systems are checked on every swing, making sure the rigging is working properly. Because all the class participants are at different levels, the instructors always ask the student before each swing to make sure they have the details correct. The instructors always “spot” each other, pointing out if someone forgets a detail without any feelings of blame or embarrassment.

It is OK to be scared—Even experienced flyers get a little nervous their first time up on the platform. Fear of heights is part of human nature! The instructors will help you get up the courage to take that first step, and nobody will think you are a baby or a wimp if it takes a while. Even if you decide not to take the leap, your choice will be respected. Being able to acknowledge fear and take the leap anyway is very empowering.

Trusting others—Much of flying trapeze goes against intuition. If you can do what you are told when you are told, the tricks will work. One example of this is that you need to stand on the starting platform with your hips pushed forward. This feels very scary at first, until you realize that the instructor is holding the back of your belt and the resistance makes you safer. Another example is how the timing of the trick is essential to being able to do it correctly. Too early or too late, and you need to work against gravitational forces instead of letting them help you.

The Catch –For the last part of the class, students get the opportunity to throw a trick to the catcher. The person who is going to be the catcher watches the students do their last round of tricks “to the net” to figure out the time it takes each individual to do the trick. This is important because each person is unique in his/her reaction time to the calls, and swing speed. For the catch to work correctly, the catcher needs to plan for this and time the trick appropriately. Students are not told, “you need to adjust to your catcher’s timing.” It is the catcher’s job to adjust to them.

Trusting yourself and having others trust you – The first trick you learn on trapeze is fairly simple and the catcher pulls you off the bar for the catch. After that, you learn tricks where you must release the bar on command (a.k.a. Wait for the Hep!). The instructors will only allow you to throw these tricks to the catcher when they are confident that you can wait for the command. It is very easy to anticipate and let go too early. If that happens there is risk of injury, mainly to the catcher, as you go flying into him. You need to be able to trust yourself, and also know that the catcher trusts you to follow the commands.

Taking responsibility – If a trick doesn’t go as planned, which usually results in a missed catch, the instructors always discuss with the students what went wrong. If it was a timing error, the instructors take responsibility. If the problem is the student not getting into the correct position, that is explained as well. After every missed trick, you will hear someone say, “that was me.” The goal is to improve the process and the student’s experience, not to point fingers and assign blame. Everyone on the team is willing to take steps to make that happen.

So while my recovery from my medical error continues, I am very happy to have found an activity that I can enjoy and feel safe doing. One of the school slogans is “Forget fear, worry about the addiction.” This has certainly been true in my experience. Friends say to me, “I don’t know how you can do that, I would be terrified!” For me, I am trying to limit what I am willing to fear. I don’t know if I will ever get over my fear of hospitals, but at least I can scratch “Fear of Flying” off my list.

Keynote Speaker Videos Now Available!

As promised in a previous post, videos from the MITSS 7th Annual Dinner and Fundraiser are now available. If you weren't able to be there, or if you would like to experience these amazing presentations again, go to the MITSS homepage and click on Margaret Murphy and Paul Levy's pictures.

Margaret Murphy, a Patient Advocate and Member, Patients for Patient Safety of the WHO World Alliance for Patient Safety, pays a loving tribute to her son, Kevin, who died from a series of preventable medical errors. It is a moving, heart wrenching story of one family's tragic experience with a healthcare system that failed them. It concludes on a hopeful note, though, because of one woman's strength, courage, and determination to find some meaning from the death of her son.

Paul Levy, President and CEO of the Beth Israel Deaconess Medical Center in Boston, provides the second keynote address outlining his own institution’s commitment to creating a consistently excellent patient experience. He shares that BIDMC’s Board of Directors recently adopted two audacious goals: (1) by January 1, 2012, to be in the top 2% of hospitals in the country; and, (3) to eliminate all preventable harm by January 1, 2012. Paul speaks candidly, with wisdom and wit, about the BIDMC’s journey thus far in pursuit of these seemingly unreachable goals.

Two amazing people -- two unforgettable presentations!!!

Apparently, It's Just Not That Simple!

In our previous post regarding surgical checklists, we asked the question "Can it really be that simple?" The answer is -- apparently not!

For a lively and informative discussion, see Paul Levy's blog post (including the comments) on the same topic. Barriers to change include a "broken" medical education system, a physician culture that resists "standardization," and a lack of consumer/patient input. Also, it seems that if the medical community cannot adopt such system changes (like the use of a surgical checklist) relatively soon, the likelihood of further burdensome regulation and legislation is very real. While the exchange is fascinating to read, I found it quite dizzying trying to sift through the differing perspectives and important issues raised!

I guess the appropriate question then would be -- Are we making any real headway or just continuing to spin our wheels?

Simple Checklist Can Make Surgery Safer

A Harvard School of Public Health study indicated that deaths and complications from surgery dropped by one third when operating room teams used a simple 19-step checklist. While the results of the study are certainly promising, doctors, nurses, and institutions may still be reluctant, for various reasons, to adopt the entire checklist.

As with any patient safety initiative, the authors of the study note that a strong commitment by hospital leadership is required to effect this kind of change. Check out the full text of the article in today's Boston Globe.

Can it really be this simple?

Obama is going ELECTRONIC!

In his economic policy statement today, President-Elect Obama reiterated his goal of electronic medical records for the country. He stated that this is fiscally responsible, as it alleviates the cost of maintaining paper records, and will reduce medical errors and their subsequent cost. Here is a quote from his statement transcript, taken from the Wall Street Journal website:

“To improve the quality of our health care while lowering its cost, we will make the immediate investments necessary to ensure that within five years, all of America’s medical records are computerized. This will cut waste, eliminate red tape, and reduce the need to repeat expensive medical tests. But it just won’t save billions of dollars and thousands of jobs – it will save lives by reducing the deadly but preventable medical errors that pervade our health care system.”

Does this seem feasible? Will electronic medical records produce this kind of financial and patient safety change? Does it have a privacy cost? Should patients have access to these records?Any thoughts or discussion on this issue is welcome.

Erin O'Donnell
MITSS Support Team Member