MITSS-Medically Induced Trauma Support Services Clinicians

Rx for ‘Empowerment’

2010-10-02T21:33:00.001-04:00

This is a great story about patients speaking up and why you should!

Rx for ‘Empowerment’

MITSS 9th Annual Dinner and Fundraiser

2010-09-30T17:26:00.001-04:00

Exciting news, you can now purchase your tickets for the dinner on line! We truly hope you can join us! Just follow the link below.

Do patients want to punish?

2010-09-10T15:55:00.000-04:00

Do patients really want to punish when things go wrong? Good question...

We wanted to point out a great discussion on this very topic. One of our favorite bloggers, Paul Levy, has started this interesting discussion on his blog, Running a Hospital. Click here to read the entire post and comments.

What do YOU think? We would love to hear from you.

Linda Kenney

Justin Micalizzi Memorial IHI Scholarship

2010-08-12T11:04:00.002-04:00

Our colleague, Dale Ann Micalizzi, asked that we share the following announcement. It is a wonderful scholarship opportunity as well as a memorial to a young boy who lost his life due to a medical error.

Justin’s HOPE Project and IHI are pleased to announce the Justin Micalizzi Memorial IHI Scholarship for health caregivers who are committed to pediatric patient safety and providing a safe health care environment for their patients and families. The Scholarship covers the cost of Forum General Conference fees and includes a stipend for travel, lodging, or other conference costs and is intended for those serving vulnerable, underprivileged and underserved pediatric populations. Download scholarship application information or email info@ihi.org to learn more. Deadline is Friday, September 24, 2010.

Click here for more details.

Modern Healthcare's Top 25 Minority Executives in Healthcare

2010-08-02T13:22:00.000-04:00

On Modern Healthcare.com, they have posted short video clips of each of the Top 25 Minority Executive in Healthcare. These clips are sponsored by the Furst Group. You can check out these videos clips by checking here

National Patient Safety Day -- July 25th, 2010

2010-07-20T14:18:00.005-04:00

MITSS would like to join with the organizers, the World Patient Safety Day Committee, and the thousands of organizations and individuals worldwide in commemorating National, World, and Global Patient Safety Day which will be observed on July 25th. Please take a moment this Sunday to reflect and join in a shared vision of safer healthcare and a shared moment to honor the lives of all patients and family members affected by medical errors and harm.

We would also like to congratulate the Veterans Affairs' (VA) National Surgical Quality Improvement Project (NSQIP) team and PULSEAmerica as they have been chosen the recipients of this year's Florence Nightingale and Dr. E. Codman Patient Safety Day Awards.

For more information, go to www.patientsafetyday.com.

"E-Patient Dave" Joins Speaker Lineup for MITSS 9th Annual Dinner

2010-07-16T08:31:00.001-04:00

MITSS is pleased to announce that Dave deBronkart, best known as "e-Patient Dave," will be providing the Opening Remarks for our 9th Annual Dinner to be held on Thursday evening, November 4th, at the Westin Copley Place in Boston, MA.

E-Patient Dave is a cancer patient and blogger who, in 2009, became a noted activist for healthcare transformation through participatory medicine and personal health data rights. The Boston Globe has called him "a recognized online champion of 'participatory medicine'." He is the author of "Laugh, Sing, and Eat Like a Pig: How an Empowered Patient Beat Stage IV Cancer (And What Healthcare Can Learn From It)," just released and available on Amazon.com. The unusual title comes from the positive approach he chose to confronting his disease.

Dave joins a wonderful lineup of speakers for the evening which will feature a Keynote by Dr. Anthony Whittemore, Chief Medical Officer and SVP of Clinical Affairs for the Brigham and Women's Hospital in Boston. And, the Third Annual MITSS HOPE Award will be presented at the event, so save the date -- November 4th, 2010 -- and please join us!

Best Hospitals 2010-11: the Honor Roll

2010-07-15T11:29:00.001-04:00

How does your organization rate? How do you feel about these Honor Rolls for Heatlhcare Systems? Are they accurate or flawed? We'd love to hear from you. Click the link below to read the article and see the top 20 Hospitals across the country.

Best Hospitals 2010-11: the Honor Roll

"Humanity" in the Court System

2010-06-21T14:19:00.001-04:00

Check out this interesting article about a judge in New York - a recipient of one of the Obama administration's healthcare reform grants - looking to inject a bit of humanity into the malpractice system.

What We've Been Up To...

2010-06-10T13:54:00.003-04:00

Yikes, it has been some time since our last blog post! We have committed one of the cardinal sins of social media -- we have allowed our blog to become stale!

In a sincere effort to rectify this unfortunate situation, and in an attempt to "freshen" our blog, we offer the following. Here are highlights of just some of the things MITSS has been working on of late. (With all of these exciting things going on, it's no wonder we've neglected our blog -- if only for a short time.)

-- MITSS has assembled a "blue ribbon" panel of experts from around the country to develop a tool kit for clinician support. We will be working feverishly over the summer and into the fall, and we expect to have something ready for release by the end of the year.

-- MITSS is bringing together nurse leaders from some of the minority communities and will be hosting an educational workshop slated for late August. Our goal is to find new and better ways to reach underserved populations with the MITSS message and our services. Stay tuned for details as they unfold.

-- We are now accepting nominations for our Third Annual HOPE Award. Go to www.mitsshopeaward.org for a description of the award, eligibility criteria, and a nomination form. Help us to recognize someone who is doing great work aligned with the MITSS mission (including yourself)!

-- Of course, we continue to provide educational support groups for patients and their families. We have one group just about wrapping up at the North Shore Hospital in Salem.

You can do your part, too. Let us know what you'd like to see discussed in this space and how we can better serve you. And, don't forget to check us out on Facebook -- become a fan of MITSS and of the MITSS HOPE Award. We'd love to hear from you!

PULSE voices from the heart of medicine

2010-04-11T14:03:00.001-04:00

For those of you who haven't heard of this publication, let us tell you a little bit about it. PULSE voices from the heart of medicine was started by a physician who is now Editor in Chief of this publication, his name is Paul Gross. He wanted to know what it would be like to have a publication that told stories of the way medicine really was not the way it is in controlled studies. The stories that have been published thus far from have captured hearts and minds, especially Friday's release.

Babel: The Voices of Medical Trauma is written by a friend and a colleague of MITSS, Tricia Pill, who is a pedetrician who experienced the "real side of medicine", but don't think she got what she expected or wanted.

What do you think of the current state of affairs? Can healthcare do a better job? How? Can we help doctors, nurses, pca's, etc who are both young and old to leave their assumptions at the door with every patient? Can we teach folks to trust that patients and their family members have valuable information about themselves or loved ones? Would love to know how you think we can change things.

You can get your free subscripiton to the magazine by signing up for it on their site.

Warm regards,
Linda Kenney

Feel free to contact me directly at lkenney@mitss.org, if you'd like to discuss off line.

"Medicine Means Sometimes Having to Say You Are Sorry"

2010-04-07T12:33:00.001-04:00

They are ideals that have been touted for some time in healthcare, but where are we now with regard to disclosure and apology? How do disclosure and apology programs fit into the new healthcare legislation? Whose programs are working, and what are the barriers that prevent others from being successful? Check out Joanne Kenen's article in the April 2, 2010, edition of Miller-McCune.

Check Out This Month's Issue of "Patient Safety and Quality Healthcare"

2010-03-25T14:51:00.000-04:00

The March/April 2010 issue of Patient Safety and Quality Healthcare contains a great article synthesizing the findings of MITSS's 2009 Clinician Support Forum. Click here for a copy of Disclosure and Apology: What's Missing? Advancing Programs that Support Clinicians written by Susan Carr.

Lucian Leape Institute at NPSF Releases New White Paper

2010-03-16T13:41:00.000-04:00

The Lucian Leape Institute at the National Patient Safety Foundation released a white paper on March 10th, 2009, arguing that US medical schools fail to prepare future physicians with the skills and knowledge necessasry to ensure safe delivery of patient care. The report, "Unmet Needs: Teaching Physicians to Provide Safe Care," describes the shortcomings of the current medical education system and issues an urgent call for reform.

To read the press release and to download a copy of the report, click here.

Lucian L. Leape, MD, is the Chair of the Lucian Leape Institute and is also a Special Advisor to the MITSS Board of Directors.

The Treatment Trap -- A New Book by Rosemary Gibson

2010-03-11T13:51:00.004-05:00

This past Tuesday, Health Care for All sponsored a program featuring Rosemary Gibson, author of The Wall of Silence. Rosemary and co-author Janardan Prasad Singh have just released a new book, The Treatment Trap -- How the Overuse of Medical Care is Wrecking Your Health and What You Can Do to Prevent It. The book explores the overuse, misuse, and underuse of medical care -- including needless surgery and other invasive procedures, out-of-control x-ray imaging, profligate testing, and other wasteful practices that have become routine among too many American doctors.

Click here to check out the book on Amazon.

Look for a profile of the author, Rosemary Gibson, in the upcoming edition of the MITSS newsletter.

2010 MITSS HOPE Award -- Call for Nominations

2010-03-08T16:08:00.000-05:00

In honor of National Patient Safety Awareness Week (March 7th through the 13th, 2010), MITSS is pleased to announce that we are now accepting nominations for the Third 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.

The 2010 Sponsor of the HOPE Award is rL Solutions.

Nominations are due by September 15th, 2010, and the Award will be presented at the MITSS 9th Annual Dinner and Fundraiser to be held on Thursday, November 4, 2010, at The Westin Copley Place, Boston, MA.

For eligibility criteria and submission requirements, click here. Take this opportunity to nominate someone who is doing great work. Note that self-nominations will be acceptable. Visit www.mitsshopeaward.org for all things MITSS HOPE Award -- download a nomination form, check out past winners, and much, much more!!! Also, feel free to give us a call at 617) 232-0090 or toll free at 1-888-366-4877 if you have any questions.

Patient Safety Awareness Week -- March 7 through the 13th

2010-03-05T10:13:00.001-05:00

Commemorate this important week by taking steps to support patients, their families, and clinicians impacted by adverse events. Mark your calendar, and make a "To Do List":

Monday -- Check waiting areas, reception areas, information stations, and libraries to make sure that MITSS brochures are visible and available to patients and their families. If you don't have a supply, download a copy of the MITSS brochure here, or give us a call toll free at 1-888-366-4877 to place an order.

Tuesday -- Circulate the LEND Document to staff. This important tool provides valuable information for staff when addressing the emotional impact to patients and family members in the aftermath of an adverse event. Download here.

Supporting clinicians along with patients is essential to an overall culture of respect, compassion, and patient safety. Download a free copy of the report "Disclosure and Apology...What's Missing? Advancing Programs that Support Clinicians." See what's working in other organizations, where the barriers lie, and what the opportunities are for the future.

Wednesday -- Sit down with your staff and watch The MITSS Story together. Then, have a "Healthy Conversation" about the issues raised in the film. Don't have a copy? Give us a call, or order here.

Thursday -- Schedule a Speaking Engagement with MITSS Founder and Executive Director, Linda Kenney. Click here for more information, or pick up the phone and give us a call.

Friday -- Recognize and highlight important work that is aligned with the MITSS mission of Supporting Healing and Restoring Hope to patients, families, and clinicians who have been impacted by medical errors and adverse events. Nominate an individual(s), organization, or YOURSELF for the 2010 MITSS HOPE Award. This prestigious award will be formally announced at the beginning of next week, so stay tuned for nomination information, eligibility criteria, and more!!!

Above all, we need to foster, encourage, and support Patient Safety efforts all year round. Take the time this week, and every week, to honor and remember those who have been harmed by adverse events.

Tune in to WIHI Thursday, March 4th!

2010-03-03T13:45:00.000-05:00

What should happen in the first hour or first day after an adverse or sentinel event in your health care organization? Wait for all the facts to come in? Sequester yourselves until all the talking points have been agreed upon and legal counsel gives the go ahead to say something? For answers to these questions and more,

Don't miss Message to Managers: Crises Happen. Plan Ahead!

Thursday, March 4, 2010
2:00 PM - 3:00 PM Eastern Time
This is a free audio program, but you need to be registered. Visit www.ihi.org for registration info.

This program features:

Jim Conway MS, FACHE, Senior Fellow, former Senior Vice President, Institute for Healthcare Improvement and Member, MITSS Board of Directors

Timothy McDonald, MD, Professor of Anesthesiology and Pediatrics, Associate Chief Medical Officer for Safety and Risk Management, University of Illinois-Chicago

Richard Boothman, Chief Risk Officer, University of Michigan Health System

Click here for full details.

IHI Podcast Now Available -- Adverse Events and their Aftermath: SOS from Clinicians

2010-02-24T15:52:00.000-05:00

Whenever there's an adverse event or medical error in health care, clinicians are affected, too. As organizations develop more accountable and transparent ways to interact with families and patients who've been harmed, the emotional and professional needs of doctors, nurses, and staff – whether directly or indirectly involved in an incident – also need to be addressed. In a 2000 essay in the BMJ, Dr. Albert Wu coined the phrase “the second victim” to put a face to the health care personnel facing loss of confidence and isolation in the aftermath of a tragic event. Now, a decade later, Dr. Wu's courage in naming a problem and his willingness to openly discuss the “private hell” that can beset even the most talented caregivers have helped many hospitals and health care organizations acknowledge the needs of their staff and create systems to support them.

Listen to the IHI podcast, "Adverse Events and Their Aftermath: SOS from Clinicians," featuring our own Linda Kenney, Dr. Albert Wu, and Sue Scott from the University of Missouri forYOU Team (2009 MITSS HOPE Award winner). Also, check out the resources from this important program. Just click here and scroll down to the program on SOS for Clinicians.

Clinical Cafe -- A Valuable Resource from Quantros

2010-02-18T14:54:00.001-05:00

We'd like to pass along information about a new resource for clinicians. Clinical Cafe is a new free online networking site for health professionals and advocates who are passionate about patient safety, risk management and quality improvement. The online community, developed and run by Quantros, is intended for members to connect, share and learn.

Check it out!

Weekend Update

2010-01-26T12:34:00.001-05:00

As the week draws to a close, we'd like to call your attention to some upcoming deadlines for some wonderful opportunities:

The National Patient Safety Foundation has issued a call for nominations for awards to be presented at its Annual Patient Safety Congress, May 17 to 19, 2010, in Orlando, Florida. MITSS's own Linda Kenney was the recipient of the 2006 Socius Award. The deadline for nominations is February 12.

The American Hospital Association (AHA) and National Patient Safety Foundation (NPSF) co-sponsor a year-long Patient Safety Leadership Fellowship. This a unique and exciting opportunity. Linda was actually the first consumer participant and graduate of the Fellowship in 2005. The deadline for applications is February 15.

The Institute for Safe Medication Practices (ISMP) will accept applications for its Safe Medication Management Fellowship until March 1.

Upcoming WIHI Program on Clinician Support

2010-01-25T10:58:00.003-05:00

MITSS Executive Director, Linda Kenney; Dr. Albert Wu; and, Sue Scott of the UMissouri forYOU Team (the 2009 MITSS HOPE Award winner) will be featured on an upcoming WIHI program on Clinician Support. The program will be moderated by IHI's Madge Kaplan and air live on Thursday, February 4th, at 2 pm. It is free to listen in and participate, but registration is required. Click here for exciting details.

This promises to be an informative and lively program, so mark your calendars and join us!

8th Annual Dinner Videos Ready to View!

2009-12-23T10:52:00.003-05:00

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

2009-11-25T11:41:00.001-05:00

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

2009-11-23T11:05:00.003-05:00

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...

2009-11-17T10:39:00.005-05:00

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...

2009-11-06T14:44:00.003-05:00

...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

2009-11-01T08:13:00.000-05:00

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

2009-10-23T11:03:00.002-04:00

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

2009-10-18T16:40:00.003-04:00

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

2009-10-06T14:20:00.001-04:00

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

2009-09-09T15:23:00.001-04:00

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

2009-08-21T14:05:00.005-04:00

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

2009-08-14T11:09:00.006-04:00

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

2009-08-11T10:45:00.004-04:00

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

2009-07-23T08:48:00.002-04:00

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

2009-07-21T09:54:00.002-04:00

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

2009-07-17T15:03:00.003-04:00

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

2009-07-08T14:22:00.001-04:00

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

2009-07-02T14:59:00.007-04:00

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?

2009-06-08T11:14:00.004-04:00

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

2009-05-29T13:26:00.003-04:00

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

2009-05-14T14:15:00.006-04:00

“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

2009-04-07T14:58:00.005-04:00

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"

2009-03-31T11:52:00.003-04:00

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

2009-03-23T10:58:00.004-04:00

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

2009-03-10T13:05:00.002-04:00

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

2009-03-05T16:41:00.002-05:00

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'

2009-02-06T11:48:00.006-05:00

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?!

2009-01-23T09:48:00.002-05:00

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!

2009-01-21T14:19:00.004-05:00

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!

2009-01-19T14:01:00.001-05:00

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

2009-01-15T13:59:00.004-05:00

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!

2009-01-08T14:03:00.003-05:00

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

Sharing the Load of a Nurse "Second Victim"

2008-12-30T15:38:00.002-05:00

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.

A No Cost Gift Idea with Lots of Benefits

2008-12-18T14:22:00.005-05:00

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
IHI

MITSS and CarePages

2008-12-13T12:07:00.004-05:00

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.

Arrogance and Etiquette

2008-12-03T11:55:00.003-05:00

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?

ENGAGE WITH GRACE

2008-11-26T10:52:00.005-05:00

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/)

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

Fox Guarding the Chicken Coop? In the Bag?

2008-11-20T14:53:00.004-05:00

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.

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

2008-11-05T12:20:00.003-05:00

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
MITSS
Executive Director

WE NEED YOUR HELP!

2008-10-17T14:01:00.002-04:00

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!

MITSS ONLINE AUCTION IS READY FOR PREVIEW!!

2008-10-03T14:54:00.003-04:00

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.

EMPATHY -- A CRUCIAL PIECE TO PATIENT/PHYSICIAN COMMUNICATION

2008-09-30T15:20:00.002-04:00

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.

SCRUBS IN PUBLIC -- A HEALTH HAZARD?

2008-09-24T14:19:00.004-04:00

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

THE PATIENT IS DOING WELL!

2008-09-11T10:27:00.000-04:00

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!

OH MY, NOT AGAIN!!!

2008-09-10T11:54:00.003-04:00

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!

TOOLS FOR CONSUMERS AND PRESCRIBERS TO CURB DRUG NAME MIX-UPS

2008-09-04T11:11:00.000-04:00

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.

The Quaid Family Tragedy

2008-08-25T16:05:00.002-04:00

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.

A GREAT READ AND WONDERFUL WAY TO SUPPORT MITSS!

2008-08-11T15:52:00.001-04:00

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.

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

2008-08-08T15:36:00.002-04:00

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?

Physician Frustrated in Efforts to Prescribe Critically Necessary Medications

2008-07-16T16:14:00.002-04:00

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.

THE POWER OF A PERSONAL/PROFESSIONAL STORY

2008-07-15T12:27:00.002-04:00

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.

Linda

Communication Loop Following Adverse Events

2008-07-05T13:01:00.004-04:00

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
MITSS

LIVE GHOSTS IN THE ROOM

2008-06-30T10:43:00.001-04:00

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

DID I GO THE EXTRA MILE?

2008-06-25T12:50:00.005-04:00

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?

A STEP IN THE RIGHT DIRECTION

2008-06-20T10:46:00.005-04:00

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.

A CMO's PERSPECTIVE ON DISCLOSURE, APOLOGY AND SUPPORT

2008-06-05T10:42:00.001-04:00

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

What Do I Tell My Doctor?

2008-05-28T13:56:00.003-04:00

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?

WHAT WE KNOW NOW

2008-05-27T10:54:00.001-04:00

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?

GREETINGS FROM NASHVILLE...

2008-05-16T12:41:00.000-04:00

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!!!

Is This the Tipping Point?

2008-05-09T13:38:00.000-04:00

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”?

TODAY IS NATIONAL NURSES' DAY -- MAY 6th, 2008

2008-05-06T10:02:00.002-04:00

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!

WE NEED TO MOVE TOWARD A CULTURE OF SAFETY

2008-05-02T13:27:00.000-04:00

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.

ANOTHER GREAT BLOG...

2008-05-02T13:03:00.000-04:00

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.

WELCOME TO THE MITSS BLOG FOR CLINICIANS

2008-04-28T16:39:00.000-04:00

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