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/.
Tuesday, July 21, 2009
Friday, July 17, 2009
Progress Slow in Stopping Hospital Harm
MITSS Executive Director, Linda Kenney, is featured on a Channel 5 (WCVB Boston) news story on hospital errors. Included is the compelling story of a nurse harmed at the hospital where she works.
Check out the video at -- http://www.thebostonchannel.com/video/19984320/index.html
Check out the video at -- http://www.thebostonchannel.com/video/19984320/index.html
Wednesday, July 8, 2009
Tune In to Rhode Island Public Radio
Rhode Island Public Radio's Megan Hall produced a wonderful piece on the emotional impact of adverse events. It highlights the work that MITSS is doing with patients and families. It also discusses plans to bring clinician support to Rhode Island hospitals. Tune-in to the link below!
http://www.wrni.org/content/first-do-no-harm-part-3
http://www.wrni.org/content/first-do-no-harm-part-3
Thursday, July 2, 2009
Raising Joy in the Healthcare Workforce
Our Friends at IHI are producing a new free audio broadcast series. We thought an upcoming program would be of particular interest to clinicians -- Raising Joy in the Health Care Workforce is scheduled for Thursday, July 9, from 2:00 – 3:00 PM Eastern Time.
Join WIHI host, Madge Kaplan, and experts Joanne Watson and Katie Bell, for a lively discussion of new research findings and new strategies being deployed to build stronger connections between clinical outcomes, patient-centered care, and engaged frontline employees. Come listen, share your knowledge, and ask questions on IHI’s brand new audio “talk show” - the first of its kind devoted to capturing the best ideas for reforming the health care system through system redesign.
At MITSS, we believe that there is a direct connection between engaged, SUPPORTED staff and the quality of patient care. Check out the audiocast and let us know what you think. To register, visit
http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/WIHI.htm.
About WIHI: WIHI is a new free audio/web broadcast from the Institute for Healthcare Improvement that combines the best of improvement ideas with global experts, a seasoned host, and hundreds of engaged participants. The 60-minute program is offered live every other week and by download whenever it's convenient for you to listen. Produced and hosted by Madge Kaplan, WIHI is your opportunity to meet up with colleagues who want to improve patient care and shape a true health reform agenda.
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.
Monday, June 8, 2009
Patient-Centered Care -- Reality or Fantasy?
There was an interesting piece in last week’s Well Blog of the New York Times. In “Letting Patients Call the Shots,” Dr. Pauline Chen talks with Dr. Don Berwick about his definition of patient-centered care. Many clinicians believe their care is “patient-centered,” but is it really? Are Dr. Berwick’s ideas too radical? Is patient-centered care a really good idea, but just not practical or realistic? Would a true commitment to patient-centered care transform the American healthcare system? What can patients do now to improve their healthcare? The questions seem endless. We’d like to hear what you think.
Friday, May 29, 2009
Impact of Medical Error Survey
Impact of Medical Error Survey
You are invited to take part in a research project investigating the impact of medical error on the family members of the patient. Your participation will be a valuable contribution to patient safety research, and I strongly encourage you to participate if you qualify. If not, please pass it along to others that may be interested in the study.
The invitation that follows is offered by Sherry Worsham, a graduate student at Harvard University. MITSS has agreed to forward this research opportunity to you. We believe this study will be useful for many of us who are doing this work.
Thank you for your time.
Linda K. Kenney
President/Executive Director
You are invited to take part in a research project investigating the effect of medical error on the family members of the patient.
This invitation is offered by Sherry Worsham, a graduate student at Harvard University. The MITSS organization has agreed to forward this research opportunity to you.
Your participation in this study is completely voluntary. If you choose to participate, you will respond to questions about the medical error experience of a family member.
To be eligible to take part in the study, you must be 18 years of age or older and have a family member that experienced a medical error between the dates of January 1, 1999, and January 1, 2009.Only one member of each family in which a family member has experienced medical error should complete this study. If you are the victim of a medical error please select one family member to complete the survey.
If you completed the questions earlier or are not interested in research participation, please ignore this invitation; however, you are encouraged to forward this invitation to others that might be interested in this study.
To find more information and to tak part in this study, please click on this link: Impact of Medical Error Enter the password: CAT (all caps!)
Thank you,
Sherry Worsham
Email: sworsham@fas.harvard.edu
Thursday, May 14, 2009
It's Wasn't Personal
“It wasn’t personal… Nobody intended to harm you… It was a systems error…”
These are the phrases that are often said to patients and family members following a medical error. The reasons behind them are good ones—very rarely are adverse events caused by willful acts of harm from an individual. The vast majority of errors can be traced to problems with the systems of health care, and the “tradition” of assigning blame and punishing individuals does nothing to address the real problems.
But sometimes this line of thinking is taken too far and leads to the discounting of the patient and family experience:
“It wasn’t personal… Physically you are healed, so why can’t you get over it… Nobody intended to harm you, so you shouldn’t feel so betrayed… Don’t take it so personally…”
But for patients and families who are victims of medical errors, it is personal. It is incredibly personal. The damage to the patient’s body is personal. The damage to the patient’s ability to trust is personal. The physical and emotional trauma is personal.
We don’t want to blame the individuals, but how do patients get the acknowledgement and support they need from a “system”? Where is the balance between these two seemingly conflicting ideas? It lies in the recognition that there is a difference between “taking blame” and “taking responsibility”.
There is a popular word used in business—“BLAMEstorming”. When something goes wrong, everyone involved gets together to supposedly brainstorm a solution. But the discussion quickly devolves into figuring out who is to blame, usually the person lowest in the hierarchy (and not present to defend themselves.) That person is punished and everything then continues as before with no changes made to identify or correct what really caused the problem. This activity is about as counter-productive in business as it is in health care.
“Taking responsibility” is completely different. It is the ability to say, “I recognize that there is a problem, and I will make sure it is addressed appropriately, whether or not it was my fault.” It requires a willingness to make it personal—a willingness to connect on a personal level with someone who has been harmed. So, why is this important? After all, it was a systems error, it wasn’t personal.
When patients decide to have a medical procedure, they don’t approach an empty hospital building and say, “That building looks trustworthy; I will have my procedure there.” Patients generally meet with a clinician and decide to trust that person. The trust is personal, so when something goes wrong the feeling of betrayal is also personal. In order for the patient to heal emotionally, the betrayal of trust needs to be addressed on a personal level.
What do patients and family members need to heal? It is specific to that individual but some general needs are: An apology for the harm caused; investigation of the error; disclosure about what happened to cause the error; corrective steps to prevent the error in the future; and support for the patients and family members harmed by the error. The person who takes responsibility for providing these also needs guidance on what these actions entail and how to provide them, or there is a risk they will become checkboxes on a form:
Apology – “The hospital is sorry you think there was an error.”
Investigation – “What makes you think an error occurred? Who did you talk to? Why didn’t you do this…?”
Disclosure – “Nobody remembers what happened, so we can’t tell you anything about it.”
Corrective Action – “Next time you should make sure your history is properly documented in your chart.”
Support – “You can’t seem to get over this; you should go see a psychiatrist.” It is no surprise that the patient or family member feels worse after this exchange and the person assigned by the institution comes to the conclusion that “Disclosure and Apology” doesn’t work.
Again, it comes back to the personal connection. The conversation may be awkward. The patient or family may be angry. They may need to have several discussions over what seems like a long period of time, even years. They may be better one day, and worse the next. This is the nature of trauma response; it doesn’t follow an order or timeline. If the person taking responsibility can think about what they would want if they were harmed, and approach the situation with compassion, the healing process can start even without them knowing all the information or the perfect words to say.
The person taking responsibility should also not be expected to provide all the assistance the patient or family may need, as it may include professional emotional or physical treatment. The goal is for the affected person to feel supported—not abandoned—by the system that caused the harm. By working together for healing, patients, families and clinicians can get away from the adversarial tradition of blame and punishment, keep their personal connection, and even together help repair the “systems” that contribute to adverse events and medical errors.
Megan McIntyre
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
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