NPDB Inhibiting Reduction of Medical Errors? Video from Disclosure Documentary

disclosure documentaryThe recently released Johns Hopkins study showing that medical errors are the 3rd leading cause of death in the US makes it critical to explore solutions. Most agree that dealing in the open with errors – often termed disclosure and apology — is the first necessary step, and anything that inhibits openness also inhibits progress toward reducing medical errors.

One factor that hinders openness is the fear of being reported to the National Practitioner Databank, or NPDB.  Here is a video from the filming of the Disclosure Documentary about concerns with the NPDB: https://youtu.be/woJLVJZTWGI.

During the filming of the Disclosure Documentary, Larry Kraman recorded hours and hours of interviews. Unfortunately, not all of those interviews could be included in a 90-minute movie. There were so many terrific interviews concerning important topics and issues that Larry and Steve Kraman want to share this unused footage with Sorry Works! readers.  Today, we are sharing a series of interviews from the filming concerning the National Practitioner Databank, or NPDB.  Again, here is the link: https://youtu.be/woJLVJZTWGI.   More footage will be released in the weeks to come….stay tuned!

You can purchase your own copy of the Disclosure Documentary by clicking on this link.  Individual copies of the Disclosure Documentary are just $29.99.  The documentary can also purchased as part of the Sorry Works! Tool Kit which is just $49.99 per unit.  To order, click on this link.

 

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Babies Mixed Up; Front-Line Staff Botches Communication with Parents

sibleyWell-known author Karin Tanabe recently delivered a healthy baby girl in Sibley Memorial Hospital in Washington, DC — and then the hospital gave her baby to another mother and the front-line staff did not know how to handle the situation. Training front-line staff how to handle adverse events is critical, and we have so much work to do in this area at hospitals and nursing homes across the country. Ms. Tanabe wrote an essay about her experience for the Washington Post, and this article should be both enlightening and scary for hospital and nursing home administrators. Here are some of my favorite highlights from Ms. Tanabe’s column:

  • First nurse causally tells Ms. Tanabe and her husband their newborn will receive a jaundice test this morning, and, oh by the way, she was given to the wrong mother this morning. The nurse went on to explain that another nurse had committed the mistake, but corrected the situation before the wrong mother even touched the child. No biggie!
  • Ms. Tanabe was initially OK with the flippant explanation, but then questions and fears set in (did the wrong mother have Ebola?!?), so her husband elevated the situation. A more senior nurse came to their room (but only because Ms. Tanabe’s husband requested) and this second, more senior nurse had a different story: The wrong mother held the baby and fed the child formula, but, it was kinda the wrong’s mother fault because the numbers on the bracelets were similar and the wrong mother should have caught the mistake, but, not to worry, the hospital lawyers have been contacted! Huh?
  • Ms. Tanabe’s husband was able to find the “wrong mother,” and Ms. Tanabe and this woman had a chance to talk — and the wrong mother showed Ms. Tanabe that her ID bracelet was a completely different number, not one digit off has nurse #2 had indicated.
  • On the way out of the hospital, Ms. Tanabe requested that the incident be recorded in her daughter’s medical record and that she and her husband be allowed to see a copy of the incident report. Neither has happened. The couple did receive a phone call from the hospital with a promise to follow up, which never happened! As the Gomer Pyle would say, “Surprise, surprise, surprise!”
  • So, Ms. Tanabe — being a professional writer — decided to write an article about her incident, and then things started moving. The hospital apologized, invited Ms. Tanabe to sit down with physicians to discuss the incident, and eventually showed her the changes that have been made (or are being made) to make sure this event doesn’t happen again.

Wow, what a story…and what an opportunity for other hospitals to learn. And I’m not just talking OB staff. Adverse events happen everywhere in hospitals AND nursing homes, and front-line staff need to know how to empathize at the bed side, tell the truth and not get caught in lies without prematurely admitting fault, and elevate the situation so senior leadership can properly work with the family. This story has multiple communication failures, including my personal pet peeve: Promising to follow up with the family, but not doing so. Big NO, NO! Moral of the story: Patients and families shouldn’t have to be well-known authors to get answers and a humane resolution. Front-line staff and leadership should be trained to make it happen with every case.

All of these lessons are covered in great detail in the Sorry Works! Tool Kit…purchase the Tool Kit today to train your front-line staff and develop a successful disclosure program.

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Hospital Leaves Tube in Aorta, Doesn’t Tell Patient, Fights Lawsuit — great test case for risk, claims, and legal team. How would they handle differently?

parkland 2I have a 10-year old and 6-year old. My son, Will, the 10-year old, is my buddy, while Claire, the six-year old, is my joy. Will and I do a lot together, while Claire can put a smile on my face anytime, including the worst days. I really love my kids, but there are days when they baffle and anger me over the silliest things. I usually shake my head and say, “Really?

Really, Will?

Really, Claire?”

Any parent knows exactly what I am talking about….

So, when an article was sent me to earlier this week about a hospital leaving a eight-inch fragment of a catheter tube in a patient’s heart, the hospital knew about the tube for seven years but neglected to tell the patient, when the patient found out the hospital was basically non-responsive, the patient sued, the hospital is fighting the lawsuit claiming, among other things, a statute of limitations defense, AND the hospital has a disclosure policy, all I could do was shake my head and mutter, “Really?”

The Dallas Morning News published a story about the lawsuit, and their news story is really a great teaching tool for front-line staff, risk and claims, legal, c-suite, and outside insurers. Moreover, I believe the Dallas Morning News story is really a great test case to see if your defense lawyers and risk and claims folks are on-board with your disclosure program. “How would you handle this situation differently?” is a question that should be posed to every member of your team, especially defense counsel.

Moreover, ask your defense counsel the following hypothetical question: “We know we did wrong and hurt somebody, the case has bad PR and regulatory implications, and could destroy our safety culture and the morale of our staff, BUT there might be a statute of limitations defense…what are YOU, our lawyer, going to advise us to do? In addition to giving us legal advice, what kind of business, public relations, AND ethical advice will you be giving us?”

The hospital in this case is Parkland Hospital in Dallas (where President Kennedy was taken after being shot), and the patient, Mrs. Debra Wilson, age 59, was born at Parkland, delivered her three children at Parkland, and received regular care at Parkland for diabetes and a heart condition, including a life-saving heart procedure in 2007. This was a long-term relationship punctuated with some heroic care. However, according to three experts contacted by the Dallas Morning News, Parkland Hospital knew about the eight inch fragment of catheter tube left in Mrs. Wilson’s heart following the 2007 heart procedure that saved her life, but did not tell Mrs. Wilson until 2014. Mrs. Wilson claimed to have 22 chest x-rays between her life-saving procedure in 2007 and 2014, when she was finally told. The experts contacted by the Dallas Morning News say the medical records clearly shows the hospital knew about the fragment lodged in her heart. For example, a 2012 note in the chart allegedly states the fragment has moved higher “than on examination in 2007.” A month later (October 2012), Parkland doctors allegedly wrote in the chart that removing the fragment might lead to infections — yet, allegedly, no one informed Mrs. Wilson. Going forward, the tube fragment in Mrs. Wilson’s heart could pose serious health problems.

Upon learning of the tube fragment lodged in her heart, Mrs. Wilson complained to the hospital. She claims to have received a “we regret we did not meet your expectations and we’re looking into it” kind of letter. Then, two months passed with nothing from the hospital. So, she contacted the hospital again, got pretty much the same letter, except this letter promised to follow but only after a review that might take “several weeks.” Mrs. Wilson felt she was getting the run-around for a very serious problem.

Really, Parkland? Really?  

So, Mrs. Wilson, who was born at Parkland, delivered her three kids at this hospital, and was a life-long patient, sued the hospital.

Now, Parkland is fighting the lawsuit with several legal theories including statute of limitations, and this lawyer speak: “General knowledge that a catheter was used is not the same as knowledge that a fragment of the catheter was retained.”

Really, Parkland? Really?

The ultimate irony is Parkland has a disclosure policy…the policy was linked in the Dallas Morning News article. It’s not a bad policy, could use some work, but clearly what happened in this story and what is written in their disclosure policy did not jibe.  Not…even….close.

A lot of hospitals have disclosure policies that are simply in place to meet regulatory requirements. When I visit these hospitals – or nursing homes – and ask staff and leadership about their disclosure policy (which I was given before my visit), I often get puzzled looks and questions like, “What disclosure policy?” Usually, only a handful of staff members even know such policies exist, and an even smaller subset have read the policy. Perhaps this is the case at Parkland hospital? Nobody has been trained in disclosure, and there in no institutional expectations or support for disclosure?

What is really remarkable is Mrs. Wilson gave the hospital two (2) chances to get it right. She didn’t run immediately to a lawyer. Instead she returned to the hospital twice — two times! —  and all she got for her troubles was a couple half-baked letters. No meeting. No follow through. No effort to get re-connected. No nothing. 

Question for you: When patients/families return to your hospital or nursing home with serious problems, are you and your team ready to listen to these consumers and take their concerns seriously?  In this case, there should have been a phone call followed up with an in-person meeting, then maybe a letter to memorialize everything with date-specific next steps included. Parkland Hospital should have done everything possible to maintain the relationship with Mrs. Wilson. Indeed, Mrs. Wilson did all she could to maintain the relationship, but she was abandoned by Parkland, so she found a new friend — a lawyer!  

This case appears to be a black eye on the leadership of Parkland. Surely there will be calls for the ouster of the CEO and other c-suite staff. It’s really calls into question the ethics of the organization.  You don’t want this story to happen at your hospital or nursing home…but it could be if a) you don’t have a good disclosure policy; b) nobody knows about your disclosure policy; c) your front-line staff are not trained on disclosure and empathy; d) you don’t have a disclosure program in place to proactively address complaints from patients and families; and e) your legal team is a mismatch for your disclosure principles.

Again, I would ask the following question of any lawyer representing your hospital or nursing home (or any prospective lawyer or law firm): “We know we did wrong and we hurt somebody, the case has bad PR and regulatory implications, and could destroy our safety culture and the morale of our staff, BUT there might be a statute of limitations defense…what are YOU, our lawyer, going to advise us to do? In addition to giving us legal advice, what kind of business, public relations, AND ethical advice will you be giving us?”  

I think this is especially true for religiously-affiliated organizations. I’ve never heard a pastor preach about a statue of limitations with God.

To avoid the legal and PR train-wreck falling down on Parkland Hospital, you need to develop a robust disclosure program for your hospital or nursing home. The Sorry Works! Tool Kit is THE comprehensive resource to help develop your disclosure program, train your staff, and keep your disclosure program alive and vibrant for years to come. To order the Tool Kit today, click on this link.

 

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RN Daughter Develops Video with Hospital Where Dad Died from Medical Errors

deenaToday we have a guest column from Deena Sowa McCollum, BSN, RN. Deena shares the story of the death of her father due to medical errors and how the hospital was initially unresponsive. Deena was extremely persistent, her dogged efforts finally led her to the right person in the organization, and this tragic story has a positive conclusion that will improve care at this hospital and hopefully other hospitals. Here is Deena’s story…

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My Dad – Joe Sowa — grew up in a small Polish town in Texas. He worked for the VA for many years, and then opened his own small business with the help of my Mom, who he was married to for 49 years and 4 days. As the father of two girls, Daddy was not a push over…rules were enforced with consequences, but there was a lot of love in our house. I never went to bed without “I love you.” When I became an adult and started my own family, I never left Daddy’s house without “I love you.” Every day after work I would visit my Dad in the hospital, and he would always say, “Debo (his nickname for me), you look beautiful.”

Daddy had 6 grandchildren: 4 grandsons and 2 granddaughters. Those boys more than made up for him not having a son. One week before his death, he was at his grandson’s college basketball game. He didn’t miss their events! In fact, one of his surgeries had to be changed so he could attend his grandson’s graduation — the Valedictorian. Daddy attended the graduation in a wheel chair with continuous IV antibiotics infusing and a wound vac on his knee.

Daddy was surrounded by a large, loving family, and losing him to medical errors has left a hole in our family.

I am an RN in Texas. I have worked in many areas: Acute Care Telemetry/Progressive Care, Long Term Care/Skilled Nursing, Acute Inpatient Rehabilitation as a bedside nurse, and leadership roles. I went back to bedside nursing after 10 years in leadership. I had to better understand all the missed opportunities that occurred with my Dad.

New Year’s Day 2014 was the beginning of our roller coaster ride through healthcare my family never dreamed we would endure. My Dad was admitted with infected hardware to his right knee. The sequence of events which followed were nothing short of a nightmare for my family. From January 1st to December 1st, my Dad was hospitalized over 100 days and had 15 surgeries. He survived 2 delays in care in less than a week but was unable to survive a 3rd delay in care and a misdiagnosis.

The first delay in care was the placement of a Nasogastric Tube to decompress Daddy’s stomach. From the time the tube was ordered to the time it was placed was 10 hours. My Dad decompensated as a result of this delay and was transferred to the ICU.

We notified the House Supervisor and Unit Director immediately. They apologized and we were assured it wouldn’t happen again. Within a week we received the first of three standard/obligatory letters via certified mail which are required by The Joint Commission that organizations send as follow up to any complaints.

The second delay in care was when Daddy had a decline in condition and the MD ordered for him to be transferred to the ICU. From the time the order was written until he actually arrived in the ICU was 5 hours. Daddy went from only needing a BiPap and observation to needing to be intubated and in multisystem failure. We notified the House Supervisor, the Unit Director and the Chief Nursing Officer. Again, apologies and promises that these were isolated incidents and would not occur again. Within a week, we received the second standard/obligatory letter via certified mail.

During one of Daddy’s surgeries, we were to arrive at 7am and would be admitted and taken to O.R. He was not taken to O.R. until 9pm. We were not kept informed as to the delays, and my Dad had no food or water for almost 24 hours. We notified the House Supervisor and the Chief Nursing Officer and heard the same “sorry speech” for the 3rd time.  Daddy was put in a “fancy room” after surgery and my Mom was given a “comfortable bed” to sleep in (not the recliner she had slept in for so many nights). Within a week, we received letter #3 via certified mail.

I worked for this healthcare organization in the past as a staff RN and in leadership roles. The connections I had were beneficial. I would email the director of any unit we were on that was providing subpar care. I often never heard back. Additionally, I had the C.N.O.s email and I would email her or cc her in the emails. She would always reply. She wasn’t helpful, but would reply.

The final delay in care and the misdiagnosis were over Thanksgiving weekend. It was the worst possible scenario. No leadership was present, and doctors on call for my Dad’s usual doctors. He had no hope… we had no hope…

Daddy died at 7am, the Monday after Thanksgiving weekend. I emailed the C.N.O. while we waited for the funeral home to pick up my Dad’s body. I reminded her who I was and refreshed her memory on our experiences over the last 11 months. Then I said, “My Dad is now dead.” I requested a meeting with her a.s.a.p.

I met with the C.N.O. and the Director of Performance Improvement a week after my Dad’s death. I reviewed all our issues. I explained the missed opportunities were system wide.  Daddy was on 11 different nursing units. These were trends. I told them I could be their biggest cheerleader or their worst nightmare. I want better care at Methodist Hospital! They agreed to work with me.

I heard nothing, a month later I emailed them touching base. “Where are we?” I received a vague response.

I emailed them every month for 6 months. Nothing materialized!

On the anniversary of my Dad’s death, I sent letters to the CEO, CFO, CNO and Board of Directors for the organization. I used letter head with a picture of Daddy and myself at the top. In the letter I shared with them that it was the anniversary of my Dad’s death in their facility. I reminded them of their promise to me the year before to use our experiences to ensure better care at Methodist and had heard nothing. I ended the letter with, “I hope each of you never experience what we experienced at Methodist Hospital and that your concerns are not disregarded as ours were.”

Within a week I received a certified letter from the C.N.O. She misspelled my name 3 times throughout the letter and she was very defensive. At the end she said I would be hearing from the Patient Safety Officer for the Organization. I didn’t hold my breath. The next day I received a call from the Patient Safety Officer, Janet Mirza. After 14 months of persistence, SHE was the game changer for their organization. Janet told me in our first conversation, “I am like a dog with a bone, I don’t let things go.” I was cautiously optimistic. She held to her word. After a few visits, Janet shared with me what she would like to do. Have me tell my Dad’s story in the form of a compassionate care video to be used in many venues (Med Exec meetings, New Nurse Orientation, Nurses week and many others). I was thrilled!!

Throughout the making of the compassionate care video, Janet was consistent in her words and actions. She delivered what she promised. She was tearful during the taping of the video. She always had a hug for me. A hug that was genuine, empathetic. When the making of the video was complete, I asked her a favor: “Janet, if this hospital is ever open to have a patient advocate on their Patient Safety Committee, would you please allow me that opportunity.” She got tears in her eyes and said, “I was going to ask you before you left if you would be willing to consider that?”

I am not “done” fighting for what is right for my Dad. I have been turned down my more lawyers than I care to count. BUT Janet made me a different person. She gave me hope.

I’m sorry does work!

Sincerely,

– Deena Sowa McCollum, BSN, RN

 

Final note: the video is in final stages of completion, not finished yet. She had a professional come do the video with multiple cameras going and so he is “meshing them together” to make the best video.

 

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Thanks for sharing your story, Deena. Lots of “teachable moments” in Deena’s story:

  1. Don’t keep saying “sorry” for the same mistakes and problems – fix the problems instead!
  2. When you agree to work with a patient or family after something goes wrong, really work with them! Stay connected. Whenever you close a conversation, meeting, or even an e-mail, set the time/date for the next meeting or conversation. Always keep the ball rolling. And, yes, I appreciate that hospital and nursing home executives are busy people and a few weeks or a month (or even longer) between conversations may not seem a long time to you, but it’s an eternity to patients and families. Stay connected, and never let patients/families feel abandoned – or they may find a new friend!
  3. Look for creative solutions. We are so conditioned in med-mal to think every case must be an angry fight over money, when most families simply want to hear “I’m sorry” and see a genuine effort to learn from the event – and this learning may include an active role for the patient/family. Deena’s story is a prime example of developing creative solutions/resolutions with a family.
  4. Remember to make an interview of the patient or family part of your review process. At the minimum, interviewing someone and getting their side of the story can be an incredibly empathetic act. People who experience tragedies want to be heard! Interviewing patients/families can also teach you a lot about the care your organization is providing.
  5. You can re-build a lot of trust and re-establish relationships with patients/families by listening, taking complaints seriously, and sticking to your word. If you can’t make a promised deadline with a patient or family, give them a phone call or e-mail and say, “I’m sorry, this has been a crazy week, I have not had a chance to complete what I promised, I believe I will have it completed by next Tuesday, thank you for your patience.”
  6. Take the time to spell a person’s name correctly!  And when addressing someone in person try to make sure you know how to correctly pronounce their name.  If you don’t know, ask: “How do I pronounce your name?”  Misspelling or mispronouncing a person’s name at a sensitive time adds insult to injury.
  7. Post-event, patients and families should not have to continually complain — as Deena did — to be heard. After a while, consumers will take their complaints elsewhere (lawyer, regulator, media, or social media). Does your organization have a disclosure program in place to hear patients and families the first time they complain?
  8. Whenever something goes wrong, Deena is absolutely right – the patient/family can be your best friend or worst enemy. The choice is yours. Is your staff and leadership prepared to make the right choice?
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Sexual Assault Victim, Oregon State Univ. Provide Powerful Example for Hospitals/Nursing Homes

brenda and edA friend recently sent me an article about a young woman who had been gang-raped by Oregon State University football players in the late 90’s, the school and local prosecutors shoved the case (and the woman) under the rug…and then sixteen years later the school made the situation right.

The victim, Brenda Tracy, had been unable to let go and was in therapy in 2014 when she contacted Oregon State University to talk about her case — and got nowhere. So, she went to the media. Ed Ray, Oregon State’s President, ordered an investigation, and three weeks later personally met with Ms. Tracy to deliver a tearful apology. But President Ray went even further…he hired Ms. Tracy to consult on sexual assault at the Oregon State Campus. Today, Ms. Tracy regularly speaks to and works with Oregon State sports teams and other student organizations to improve awareness and sexual assault prevention It’s a powerful story and example.

A lot of parallels with this story and medical malpractice. Just like hospitals and nursing homes, many universities and colleges don’t handle allegations of wrong doing in a proper manner. University administrators, worried about the image of their school and keeping rich donors happy, often bungle investigations and fail to stay connected with victims and their families or offer appropriate support. Follow through and tangible change are often completely missing. A lawsuit may follow and possibly a settlement, but the settlement usually only involves money (no apology or admission of fault) and typically freezes out a potential change agent: The victim. Take your money and get lost is the message.

Sound familiar?

So, you want to change your hospital, eh? Or really make your nursing home top notch? Well, your best resource is the patients and families you’ve harmed. Now, I know — I know very well — that not every patient or family is equipped for this work. Moreover, some folks may be a perfect fit but have no desire to participate. But, if you have an open heart and are willing to look you will find many people who are both equipped and willing to help your hospital or nursing home. Nothing sends a message to doctors and nurses like the following: “My name is XXX, I lost my mother at this hospital…today, I am going to share with you my mother’s journey through this hospital due to medical errors, and then we are going to talk about making sure this type of tragedy never happens again.”

Moreover, don’t be afraid to really involve patients and families. By “really involve” I mean more than sticking them on the back end of a patient safety committee overloaded with docs, nurses, and other in-house staff. Use these people….put them to work, and don’t be afraid to listen to their ideas.

The Sorry Works! Tool Kit had many ideas and examples of how to include patients and families in your quality improvement processes. Click on this link to order the Tool Kit today.

 

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Gag Order/Confidentiality Project from Sorry Works! — need your opinion

gagIn last week’s Sorry Works! e-blast about the toddler dying during a dental procedure, there was a quote from a dental professor claiming that most malpractice settlements have gag orders or confidentiality clauses. Here is the quote: “When there are malpractice suits, settlements often include a gag order that prohibits plaintiffs from talking about it, according to Dr. Joel Weaver, a dentist anesthesiologist and emeritus professor of the Ohio State University Medical Center.

This touched a nerve with some readers, and, to be frank, I have heard numerous complaints about this topic over the last eleven years from both clinicians and consumers. Both sides basically saying the same thing, namely how can medicine improve and learn from events if we don’t talk about lawsuits and closed claims? Many clinicians tell me they see or hear about adverse events, but then the lawyers sweep in, everybody clams up, and they (the clinicians) never find out what happened with a particular case. I have had countless nursing managers and front-line physicians state that cases literally disappear into a black hole.

How can we expect medicine to improve with such behavior?

Look, some estimates peg medical errors as the third leading cause of death in the United States, behind cancer and heart disease.  When it comes to cancer and heart disease we can’t — rightly — stop talking about these villains. There are countless news stories and books about life and death with cancer or heart disease from the perspective of patients, families, and clinicians. There are Facebook pages, fundraisers, rallies, t-shirts, etc, etc.  Lots of learning and support going on.   But medical errors?  Eh, shove it under the rug!

I want Sorry Works! to work on this issue. Now, I do NOT envision lobbying for passage of laws, or pushing for regulations to be changed. In fact, I don’t want anything to do with our dysfunctional political system — just look at the Presidential primaries. Sorry Works! has been successful over the years because we have completely side-stepped politics and, instead, focused on education and awareness which has shown healthcare professionals they can fix the malpractice crisis on their own with disclosure. You don’t need political help (including so-called “apology laws”) to build a successful disclosure program.  It’s a message that has empowered people — you can fix your own problems!   We have shown healthcare, insurance, and legal professionals why disclosure not only makes ethical sense, but also economic sense, and then we have given them practical guidance and step-by-step instructions on how to start their own disclosure programs.  I intend to do the same with gag order/confidentiality issue…show people why it is in their own best interest to change their behavior.

Here is where you come in: What are the arguments for maintaining the status quo? Why do lawyers and executives from hospitals and insurers insist on gag orders or confidentiality clauses? And really important question: How often are gag orders or confidentiality clauses inserted in settlements? Is this more urban legend than fact? Is this the monster under my six-year old’s bed, or is this a real problem?  Please share your thoughts with me by e-mailing doug@sorryworks.net or calling 618-559-8168. Your answers will be completely confidential.

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Sponsored Sorry Works! Tool Kit for April — Who Should Win?

Tool Kit coverRecently a patient safety advocate purchased/sponsored one Sorry Works! Tool Kit per month for the next year, and asked us to donate the Kit to anyone we wish.

In March we awarded the Tool Kit to a hospital system working to implement disclosure. Who should receive the sponsored Tool Kit for April?

We are looking for suggestions. We are looking for the names of individuals, hospitals, nursing homes, insurers, or lawyers. And you can self-nominate! In fact, some of our best nominations from March — including the winner — were self-nominations. Ultimately, we want recipients who will use the Kits. Nominations are due Friday, April 15th.

Send us a short e-mail message stating why your organization, or one you know of, should be the monthly recipient. Send the name of a hospital or nursing home including the name of an executive (risk manager, claims manager, CEO, General Counsel, etc). We will NOT publicize who receives the Kit. We can share your name (as the nominator) with the recipient, or not — your choice. E-mail suggestions to doug@sorryworks.net.

Or perhaps you would like to sponsor a Kit yourself? Now, this is the first time we’ve had a person sponsor a Kit (or any content) for 12 months, but we’ve had plenty of people make one-time purchases and tell us to ship content to a certain person or organization. If you are interested in sponsoring a Sorry Works! Tool Kit, e-mail doug@sorryworks.net or call 618-559-8168. The Tool Kit retails for $49.99 per unit, but the “sponsor price” is just $39.99 per unit. To sponsor a kit, e-mail or call.

The Sorry Works! Tool Kit is the complete resource for organizations and individuals wanting to implement disclosure. Everything you need to begin your disclosure program is found in the Sorry Works! Tool Kit. Included are the Sorry Works! Tool Kit Book, which is the blue print for any hospital, nursing home, or large practice wanting to start a disclosure program. From developing your policy, to educating your staff, and sustaining your disclosure program, the Tool Kit Book has it all. Also included in the Tool Kit is the Disclosure Documentary, a powerful movie developed by Lawrence and Steve Kraman that not only shows your leadership and staff the importance of disclosure, but will inspire them. The Sorry Works! PowerPoint presentation and Little Book of Empathy (great for front-line staff) are also included in the Tool Kit along with Pocket Notes.

Lots of great stuff in the Sorry Works! Tool Kit. So, again, we need to find homes for 12 Kits over the next 12 months….where should they go? Please e-mail suggestions to doug@sorryworks.net by Friday, April 15th. Moreover, if you want to sponsor some Kits, please e-mail doug@sorryworks.net or call 618-559-8168. The regular price for a Kit is $49.99, but the “sponsor price” is $39.99 per Kit. Finally, if you simply wish to purchase a Kit for yourself, click on this link.

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Toddler Dies During Routine Dental Procedure; Mom Wants Answers

daisy

14-month old Daisy Lynn Torres went to the dentist last week to have two cavities filled. Daisy needed to be put under during the procedure, but never woke up. A few weeks hours later she was pronounced dead at a local hospital. Her mother wants answers.

Think about it….this little girl went to the dentist to have two cavities filled and died. It doesn’t getting any more routine than filling a cavity, right?

Here is the link for this story. And here’s a link for the death of a healthy teenager during a wisdom tooth extraction.

How would you handle these “routine” procedures gone terribly wrong? Could you handle it? What would you say? What would you do? What would you not say??  And how would you to stay connected with the family moving forward?

When I do Grand Rounds presentations, I start with a similar case….a true story about an ordinary test — CT guided biopsy of the liver — which turns tragically wrong. A 53-year old woman dies during the procedure, and I ask my audience to role play with me by pretending that I am the widower whose wife just died during this test. Instead of taking my wife home, I will be going to a funeral home that evening to pick out a casket. “What are you going to say to me? What are you going to do for me?” I ask my audiences. Most of the time it’s silence. People look at their hands, the floor, their smartphones…anything but my eyes. It’s painful yet revealing. “And this is why I am here,” I tell my audiences. “Because if you can’t handle this hypothetical with a paid speaker, what will you do when this case really happens in your hospital next week or next month?!?”   

We can ask the same question of our dental friends…what will you do when the mundane turns tragic? What would you say to Daisy’s mom, or the parents of the dead teenager?

The Little Book of Empathy is a must-read for front-line clinicians…it shows them exactly what to say and how to behave following adverse medical events, and the book can be read in 30 minutes or less. Great tool for front-line staff….order a copy today.

Interestingly, in the article about Daisy’s tragic death there is a quote from an Ohio State University dental professor: “Currently, there are no publicly available statistics on how many injuries or deaths result from dental procedures in children, said Dr. Joel Weaver, a dentist anesthesiologist and emeritus professor of the Ohio State University Medical Center. ‘Most states require that there be a reporting of any dental office death to the dental boards, but they generally don’t share that information,’ said Weaver. When there are malpractice suits, settlements often include a gag order that prohibits plaintiffs from talking about it, he said.”

A lawsuit followed by a good ‘ol gag order.  Not doggin’ the Ohio State dental professor…he’s just telling the sad truth.  Heaven forbid anyone learn from an adverse medical event! Heck, if clinicians actually learned from tragedies we might put the poor old lawyers out of business, and, well, we can’t have that! The article above about the dead teenager had plenty of “no comments” following the settlement of the lawsuit. Let’s all be quiet because we don’t want anyone to learn. Shhhh!!!

So, when the everyday procedure or test goes wrong, do you know not only what to say in the immediate aftermath of the event, but do you have a disclosure program in place that allows you to hit the finish line? And when I say hitting the finish line I want to see people talking about the case, possibly involving the patient/family in the fixes, and meeting the emotional needs of all sides, clinicians included, as well as addressing financial implications for the patient or family. To design, launch, and sustain a successful disclosure program, be sure to get a copy of the Sorry Works! Tool Kit.

 

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Absolutely Shameless Plug for Sorry Works! Content

sponsorNow a word from our sponsor.

Sorry Works! provides YOU with absolutely great content through our e-newsletters, website, and social media. Lots of ideas, stories, and tips on how to make your disclosure program better. Sorry Works! shows you how to stay connected with your patients and families AND doctors and nurses after something goes, and how to meet the economic and emotional needs of all parties after a true medical error. And you get all of this amazing content for….for….(wait for it)….FREE!

Well, sorta.

Look, if Sorry Works! doesn’t generate revenue my wife will scream at me and demand that I find a real job. You know, the type of employment situation that actually pays the mortgage, the fees for the 10-year old’s soccer and baseball teams, the 6-year old’s dance and gymnastics lessons, and the vet and feed bills for our two crazy dogs.

To keep my wife from yelling at me, consider purchasing some stuff from Sorry Works! What stuff, you ask? A lot of people purchase books, movies, and other content from Sorry Works! Our best sellers include the Sorry Works! Tool Kit, which has everything you need to develop, launch, and sustain a successful disclosure program for just $49.99. We also have the Disclosure Documentary developed by Lawrence and Steve Kraman which inspires organizations and individuals to embrace transparency — just $29.99 per copy. And we have sold thousands upon thousands of copies of the Little Book of Empathy, which any doc or nurse can read in 30 minutes or less to understand their role in the disclosure process — just $9.99 per copy or less depending on volume. To order any of this great content, simply click on this link.

Also, many hospitals, nursing homes, and insurers hire Sorry Works! to provide CME-accredited Grand Rounds presentations and on-site disclosure training for leadership and staff. Sorry Works! has visited hundreds of hospitals and nursing homes in 41 states, Canada, Australia, and Poland over the last 11+ years teaching countless clinicians how to stay connected with patients and families after something goes wrong. To inquire about a Sorry Works! presentation, e-mail doug@sorryworks.net or call 618-559-8168.

Revenue from book sales, presentations, and training seminars allows Sorry Works! to continue educating healthcare, insurance, and legal professionals. Sorry Works! has literally educated thousands of people over the last 11+years. We are exclusively focused on disclosure and apology, and we have an extremely large following in hospitals, medical practices, nursing homes, insurance companies, and law offices. I can say without bragging that Sorry Works! is the leading educator in the disclosure space, and Sorry Works! is the voice and moral compass of the disclosure movement. Help keep this work alive by:

  1. purchasing some content;
  2. inquiring about a presentation/training by e-mailing doug@sorryworks.net or calling 618-559-8168; and
  3. by sharing this absolutely shameless plug with colleagues and friends.

Many thanks!

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Wrong Rib Removed at Yale + Inadequate Disclosure = Lawsuit

yale 2

Wrong Rib Removed at Yale + Inadequate Disclosure = Lawsuit

Doozy of a case from Yale. Wrong rib removed from a female patient, and there is disagreement about what was told to the patient, Mrs. Craven, and her husband after the surgery. First surgeon apparently told the truth, while the family alleges the second surgeon lied and said Mrs. Craven needed to go back to surgery because they didn’t get enough of the correct rib. Yale tells the media they apologized, but that’s all they are saying (no specificity on what exactly they did for Mrs.  Craven), and Yale did not respond to follow up questions from CNN about the case. Neither did the doctor who allegedly lied. The plaintiff’s lawyer is saying his client never received an apology, because if she had received an apology there would never be a lawsuit in the first place. Moreover, the lawyer’s press release included the following quote: “As the old adage goes, the cover up is worse than the crime.”

And now the whole entire mess is splattered across CNN and Google for the whole entire world to see!

Hey, the next time your CFO says, “We don’t have the time or money to train our staff on disclosure,” or your General Counsel worries aloud, “The docs just aren’t ready for truth telling yet,” take this story and staple it to their foreheads. Seriously. Forget about the lawsuit for a second (which will be costly), think how much this bad PR will cost Yale? How many billboards will Yale have to erect proclaiming their greatness and bragging their docs are amazingly awesome to overcome the stain of this case?  This…is…a…mess.

From my read of the story, it appears 1) the front-line staff froze and didn’t know what to say, who should say it, etc because they haven’t been trained; and 2) Yale’s disclosure program (or lack thereof) couldn’t hit the finish line in this case. This is a slam dunk, clear liability case which laid bare the disclosure short comings of a major hospital. These are classic/typical problems for hospitals and nursing homes working to embrace disclosure. News flash: This could be your hospital or nursing home tomorrow, next week, or next month unless you develop a disclosure program and train your people! The Sorry Works! Tool Kit provides the blueprint for your disclosure program…..purchase the Tool Kit today.

Here is a link for the CNN story.

A perfect resolution to this case would be the following: 1) Yale leadership and the doctors involved sitting down with Mrs. Craven and her attorney; 2) apologizing for the error and alleged unethical behavior that followed; 3) waiving all bills; 4) providing fair compensation; 5) developing disclosure training for their front-line staff, and involving Mrs. Craven in that training. Yale could video tape Mrs. Craven’s story and play it for their staff and new hires….Yale could invite Mrs. Craven to give a talk to their staff….Yale could involve Mrs. Craven on the committee that oversees their disclosure program; 6) Showing Mrs. Craven how they fixed the errors that led to her wrong-site surgery, and perhaps name the fix after her. Lots of creative ways to resolve this situation that can benefit all parties, but it will take leadership and ethics from Yale.

 

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