Check Out This Week's "Grand Rounds"

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

Emotional Support Is So Important

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



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

MITSS Announces Second Annual HOPE Award

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

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

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

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

Tips from ABC News on Surviving a Hospital Stay

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

The Times They are a-Changin'

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

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

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

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

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

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

Winnie Tobin

Flying Trapeze as Therapy?!

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

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

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

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

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

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

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

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

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

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

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

Keynote Speaker Videos Now Available!

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

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

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

Two amazing people -- two unforgettable presentations!!!