During the course of this conference, we hope to accomplish two things: 1) inform the medical industry about the severity of the Epidemic of Medical Errors in the United States and Canada and 2) determine a course of action to be taken to
reprogram these elements and build a team to start the change.

For more information about the conference and the people involved please visit here.

You can also read our latest press release here

Please feel free to contact Cherie with any questions you may have.

Cherie Avery
Business Manager
Phone:(206) 501-4551

The case was settled against the nurse. The defendant obstetrician claimed the patient could have reversal of the tubal ligation or could have more children with in vitro fertilization. A $490,000 settlement was reached in this Virginia case.

Source: Lewis Laska, Editor, Medical Malpractice Verdicts, Settlements and Experts, November 2010, page 27

Comments: Nurses are well informed that surgical procedures require consents. It is common practice to add a tubal ligation to a cesarean section consent form when the woman desires sterilization. The surgical nurses verifies that the consent is signed and witnessed. Witnessing the signature means that the patient appears to understand what she is signing. Nurses can perform this function. Surgeons also commonly obtain informed consent and witness the form.

This interesting Virginia case hinged on the fleeting memories of healthcare workers involved in one surgical procedure among hundreds or thousands performed annually. The absence of the informed consent made it impossible for the nurse to prove the patient requested a sterilization. The obstetrician relied on the nurse to make sure that the consent was signed. However, the obstetrician’s office records showed the patient did not want a tubal ligation and yet he or she went ahead in a rote way and performed the unwanted surgery. Reversal of tubal ligation is not often successful, and in vitro fertilization is a complicated undertaking that is often not covered by insurance policies. Both the nurse and the obstetrician fell through the holes in the safety net of health care.

Patricia Iyer MSN RN LNCC is a former medical surgical nurse who witnessed many consents of patients over the years.

Amanda Abbiehl and I share a similar story. Both of us were on patient-controlled analgesia (PCA) pumps to manage our pain.

However, the difference is that, by the grace of God, an observant nurse who just happened to walk by my room when I stopped breathing, called a “Code Blue”, and that ultimately saved my life. I would have been just another statistic if it wasn’t for that nurse. Unfortunately, Amanda was not so lucky.

What are the odds of a nurse putting her head into a patient’s room just as that patient is experiencing respiratory depression? Slim. What are the odds of that same nurse putting her head into the patient’s room after she had just checked on him 15 minutes before? Almost none. Yet, that is what happened to me and I ask why.

The injury
My story begins in 1990, when I was a state trooper. My squad car was struck by a car driven by a drunk driver. Although the accident left me close to being a quadriplegic, I went through 6 months of physical rehabilitation and returned to work. Although my doctors told me that I would always have trouble with my neck, I was able to function at my job despite the pain. I was even named a district Trooper of the Year in 2001 and prior to that in 1994 received a statewide traffic safety award for arresting the most drunken drivers per capita.

But, despite being recognized again in 2003, as Trooper of the Year for in Bridgman, MI, my neck injury increasingly gave me problems. In December 2002, the neurologist who read my MRI told me that I shouldn’t be a trooper anymore. He said, if I get hit again, I’d be a quadriplegic. In January of 2003, I met with Indianapolis neurosurgeon Dr. Henry Feuer, who was (and I believe still is) a consultant for the Indianapolis 500 and the National Football League. Dr. Feuer told me that my condition had worsened and that my neck looked like that of a retired football player with arthritis, bone spurs and spinal fluid unable to circulate effectively. Dr. Feuer gave me two pieces of bad news. The first was that I needed surgery. The second confirmed that I couldn’t be a state trooper any more.

The surgery
So, I underwent neck surgery that year at Methodist Hospital in Indianapolis. Because of the pain that I was in, I was on a morphine pump after my surgery. The night after my surgery, a nurse had just checked on me and then continued to check on other patients on the very large hospital floor. Another patient she was caring for needed something. Although it was on her cart, she decided to go to the supply room and restock her cart. Fortunately for me, her path to the supply room led her passed my room.

The rescue
So, even though she had just checked on me 15 minutes earlier, she just so happened to be passing my room when she noticed I was not breathing and called a “Code Blue”. She would tell me later while she was crying that she did not know what made her walk past my room. While she continued to sob she told me that she had never seen anyone live after they had coded.

I remember feeling warm, calm and in a better place. There was a point where I had to decide if I wanted to fight back and live or stay dead and remain in that warm pleasant place. I chose to fight and recall being jolted back, I remember doctors over me, bright lights, and someone holding my hand. Miraculously, I survived. The doctors told me that 96% of Code Blue patients die; only 4% live. I remember later on that morning that I was somewhat of a spectacle for the student nurses. They would come into my room and stare at me to see the patient who had cheated death.

I had been without oxygen for 6 minutes. At seven minutes, I was told, I would have been brain dead, if not dead permanently. I died at 4:11am, and for many years after I would wake at 4:11 in the morning remembering what happened to me.

I was never electronically monitored. There was nothing that would have indicated to a nurse that I was about to experience respiratory depression and almost die. I was 39 years old and in terrific health. I was not a high risk patient. Why? Had my PCA pump been integrated with a capnography like the one just recently discussed at the Notre Dame class, the pump would have shut off and alerted my nurse that I was not breathing. Instead, I am alive today because my nurse, who had just checked on me 15 minutes earlier, just happened to be passing by my room when she didn’t have to. I say to Brian and Cindy Abbiehl – My deepest condolences. Know that your daughter died peacefully. Know that that she was not in any pain or under any stress.

I say to all hospitals that care about their patients’ safety and welfare — Electronically monitor ALL your patients, not just the ones at high risk. A human life is too valuable for you not to. All hospitals need a technological safety net for their patients. All nurses and caregivers need that safety net too.

This blog post was shared by the Physician-Patient Alliance for Health & Safety.
About Physician-Patient Alliance for Health & Safety: Physician-Patient Alliance for Health & Safety is an advocacy group devoted to improving patient health and safety. Follow PPAHS on Facebook (www.facebook.com/ppahs) and on Twitter (twitter.com/mikeppahs). The PPAHS website is www.ppahs.org

PPAHS is currently developing a checklist targeting PCA pump use. For more on this initiative, please see this ASC Review article: http://wp.me/p1JikT-8O

Read about another Morphine PCA pump error.

• Turning on the lights of the hospital room at night in order to take vital signs
• Making a patient wait in the emergency department for over an hour to be transported to a nursing unit
• Not responding to a request for help because it is change of shift and the nurses are all charting
• Providing patient education materials written at a college level, which is incomprehensible to many patients
• Not verifying a patient understands instruction
• Not calling the patient after discharge from a hospital to make sure he or she understands instructions or to answer questions
• Designing buildings of the convenience of staff and not for the patient
• Forcing families to spend long hours in waiting areas not knowing what was taking place with their family member
• Keeping a medical record away from patients and family members

There is a different model: the Planetree one, named after the tree under which Socrates sat and taught his students. Here is a brief summary of the Planetree model:

“Since our founding by a patient in 1978, Planetree has defined what it means to be patient-centered. Planetree’s philosophy is based on a simple premise: care should be organized first and foremost around the needs of patients. To understand those needs Planetree turned to the source. Thousands of focus groups—from bedside to boardroom—with patients, long-term care residents, families and professional caregivers across the globe have borne out their needs and desires for a more personalized, humanized and demystified health care experience.”

Here are the four concepts of patient and family centered care:
Dignity and respect: Healthcare practitioners listen to and honor patient and family perspectives and choices. Patient and family knowledge, values, beliefs and cultural backgrounds are incorporated into the planning and delivery of care.

Information sharing: Healthcare practitioners communicate and share complete and unbiased information with patients and families in ways that are affirming and useful. Patients and families receive timely, complete, and accurate information in order to effectively participate in care and decision-making.

Participation: Patients and families are encouraged and supported in participating in care and decision-making at the level they choose.

Collaboration: Patients and families are included on an institution-wide basis. Healthcare leaders collaborate with patients and families in policy and program development, implementation, and evaluations; in healthcare facility design, in professional education; and in the delivery of care. (1)

How does your primary care provider measure up? How does your hospital treat you as a patient or your family member? Share your thoughts.
Watch our videotip on why you need to be a patient advocate.

(1) Robert Bunting, Introduction to a culture, process, and philosophy, Journal of Healthcare Risk Management, Vol. 29, No. 4, 2010

Several years ago I worked on a nursing unit with a nurse who was suspected of diverting medications for his own use. I was unaware of the problem until I saw someone from the pharmacy department counting the pills in the drawers. Then I got a phone call from the pharmacy asking me if this nurse had worked on the prior shift. I said “Yes.” I never saw him again. The pharmacy had been seeing a correlation between the disappearance of certain medications and the nurse’s working shifts.

What is the risk to you as a patient of having a healthcare provider on staff who is taking drugs? Our first duty is to make sure the patient is safe. Is the professional too impaired to make safe decisions and judgments? One of my colleagues, a now recovered substance abuser, told me of a time she took Demerol 700 mg and passed out in the nursing unit. She was a nurse manager at the time and luckily was not involved in direct patient care. This amount of Demerol would kill someone else without a tolerance to it.

Statistics about the prevalence of substance abuse in healthcare workers are hard to come by. The National Council of State Boards of Nursing released numbers that showed that 25% of the approximately 115,000 disciplinary actions in 2006 involved nurses with substance abuse. These figures do not include nurses who entered substance abuse programs to avoid being disciplined. (1)

• Should an employer fire a nurse with a substance abuse problem?
• Require him or her to enter treatment?
• Remove the employee from patient care areas with access to medications?
• Provide strict supervision of the nurse?
• Require unscheduled drug testing?
• Have a drug-free work place program in place?
• Ask potential employees if they have ever been fired, and why?
• Avoid making judgments about an employee without an admission of drug use or a positive drug test?

The answer to most if not all of these questions is yes. The employer’s first responsibility is to the patients; to protect them from impaired or incompetent employees. These employees create troubling issues within the work environment. They create risks to you. Read more about substance abuse in heatlhcare workers, including what you can do.

(1) Healing versus safety, HealthLeaders, November 2009, 63

Patricia Iyer MSN RN LNCC is president of Avoid Medical Errors.

A nursing home sounded the Code Grey alarm for “missing resident” at about 4 PM when a resident could not be found for dinner. No one had remembered seeing the resident since approximately 2 PM. Protocol was followed but the resident could not be found. In the midst of the search, the facility elevator locked between floors and they waited for an elevator mechanic. By 7 PM, staff were hearing a banging sound. Someone said, “It’s coming from the elevator”. The elevator mechanic brought the car to the first floor, opened the door and found the missing resident. She had wandered in on her way to 2 PM bingo, then the elevator locked. She sat down and fell asleep. When she awoke, she was hungry and knocked on the door to get out. She suffered no permanent or serious injury.

One cold morning in February, the security officer at a center city nursing home opened the door for a woman who worked at a nearby newspaper. She had with her one of the male residents of the facility who was wearing the woman’s coat over a hospital-type gown, a diaper, no shoes or socks and a facility bracelet with his name on it. She stated that when she arrived at work that morning, she found him huddled in the corner of the building entryway. When the security guard had let the cook in earlier, he had used the rest room right afterward and left the lobby area unattended. Apparently the lock on the front door had not engaged as the cook entered, and when the resident got off the elevator, he was able to go right out the door to the street. He had wandered across the street and around the corner to the sheltered doorway of the newspaper office where he was found. Although he waited on the doorstep possibly for an hour, he suffered no permanent or serious injury.

Several years ago in January, a woman with dementia and several other health issues was taken to a nursing home by her children because they were unable to care for her any more at home. The new resident was very unhappy there, refused to eat, and frequently yelled that she wanted to go home. Several days after she was admitted, she went missing at bedtime and could not be found. The facility initiated its elopement protocol and exhausted all recovery efforts unsuccessfully. At 10 AM the next morning, the woman’s body was found in the dumpster of a shopping center near the nursing home. She had left the facility with the visitors, wandered to a nearby mall and climbed up boxes to get into the dumpster. She died from exposure to the elements and dehydration.

The elopement of a resident from a long term care facility is one of the ”never events” that nursing homes dread. The term, first coined by Dr. Ken Kizer in 2001, was used when discussing serious medical errors which are clearly identifiable, measurable and preventable, including fall with injury, pressure ulcer, dehydration, constipation and elopement. No facility wants one of its residents to successfully wander or elope from its safe confines, yet all should be prepared with an emergency protocol to initiate should it occur and a prevention policy to reduce the number of occurrences.

Emergency response protocol for elopement usually includes first searching every conceivable space of the unit (behind doors and curtains, under beds, in showers, closets, and cabinets). Then the search extends to the entire building, and then the neighborhood. Generally, administrators and the police are notified. One person is assigned to call all family members/friends the resident may contact and also all local hospitals with a description of resident. It is a good idea to fax a recent picture to hospitals if possible. If the search must extend to the neighborhood, teams are assigned to grids on a map and they should have a picture of the resident and a cell phone to check in every 15 minutes.

Hints for family and friends when visiting a nursing home:
• be careful whom you hold a door for, you may be facilitating an elopement
• to residents asking how to leave the facility, direct them to a dead-end corridor
• reply to questions about exits by involving staff
• offer ignorance to questions about leaving: “I’m from out of state”

Here are some resources for further information and statistics on elopement:
(1) http://www.portal.state.pa.us/portal/server.pt/community/hospital/14149/chapter_51_questions_and_answers/558509
(2) https:www.guideone.com/SafeeyResources/SLC/…cs_elopement02 Resident elopement and case study
(3) www.nccdp.org/wandering.htm
(4) www.ncbi.nim.hig.gov/pubmed/15633945

Sara Jean Fisher is a nurse who works in a nursing home educating staff. She is one of the contributing authors of our free monthly digital magazine, Avoid Medical Errors Magazine. Sign up for this valuable resource on our site.

Deepa in England, on left

When an EKG performed by Deepa’s physician showed an abnormal heart rate, Deepa went to a cardiologist. She learned she needed heart valve surgery – soon.

Symptoms of heart valve disease are:

• Shortness of breath
• Fatigue and weakness
• Dizziness or fainting
• Swelling of the feet, ankles or abdomen
• Irregular, rapid heartbeats
• Pressure sensation in the chest

Deepa began doing research on cardiac surgeons. She interviewed two or three doctors before selecting a cardiac surgeon. One of the primary questions she asked was: How many of these surgeries have you done? One physician said he had done 400. Another had done 10,000. She chose the more experienced doctor. Deepa’s procedure was done by inserting a tube into her groin. She did not require an open incision. Other patients require open heart surgery.

We saw Deepa two months after her operation. She felt well and was getting ready to return to work.

What you need to know
1. Heart disease is the number one cause of death in women.
2. You can lower your risk of cardiac disease by adopting a healthier lifestyle. Check out your cardiac risk factors by taking a quiz at GoRedForWomen.org.
3. Eat a healthier diet, don’t smoke, and take part in regular physical activity.
4. Have your blood pressure, cholesterol, blood sugar and weight and waist circumference checked.

You might experience only one symptom. The key point is that this is a sudden change. Women are more likely to have confusion, headache and dizziness. Only 25% of women who have a stroke will fully recover. The faster you act when you see signs of a stroke in yourself or others, the better your chances of decreasing the damage from the stroke.

ACT FAST:
Face: Does one side of the face droop when you are asked to smile?
Arms: Does one arm drift downward when asked to raise both arms?
Speech: Is the speech slurred or strange when asked to repeat a simple phrase?
Time: If you observe any of these signs, call 911 immediately.

Source: National Stroke Association, Act FAST

Which women are at highest risk for a stroke?
Black women have the highest risk of stroke, followed by whites and then Hispanic women. Other risk factors include getting older (the risk rises with age). High blood pressure, excessive alcohol drinking, depression, obesity, diabetes, excessive sodium intake, elevated blood lipids, smoking, and drinking diet soda. Also, women who take estrogen supplements after menopause are at higher risk. There is also an association between women who have migraines with an aura (warning signs) and strokes. Atrial fibrillation, which can cause small blood clots to travel to the brain, can cause a stroke.

What can you do to reduce your risks?
Maintain a normal body weight. Eat a diet lower in sodium and cholesterol. Learn more about nutrition. Snack on fresh fruit and vegetables instead of cookies, white bread, and cakes. Control your blood pressure if it is increased. Drink less diet soda, which helps to decrease sodium intake. Stop smoking. (Smoking doubles your risk of stroke.) Ask your doctor about taking a baby aspirin a day to reduce your risk of a stroke.

You can reduce your risk of stroke by choosing a healthy lifestyle. Start today.
Source: Susan Simmons, Acute Stroke in Women, Nursing 2012, March 2012, page 30

Pat Iyer is a nurse who has cared for many people after stokes. She knows that prevention is the best way to handle this serious problem.

Learn more about protecting your health by reading our free monthly digital magazine: Avoid Medical Errors magazine. Sign up for it on this site.