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Patient safety: who is responsible?

March 6th, 2005 · 3 Comments

Seattle’s Virginia Mason Hospital made headlines last December when a patient died due to a simple medical error.

A Seattle hospital’s recent decision to switch antiseptics from a brown solution to a colorless liquid appears to have played a key role in the death of an Everett woman.

Mary McClinton, 69, a tireless worker for the disadvantaged, died early Tuesday. She was mistakenly injected with antiseptic — rather than a marker dye — during a brain-aneurysm procedure at Virginia Mason Medical Center 19 days earlier, on Nov. 4.

The hospital this week took the unusual step of publicly explaining, and apologizing for, the error.

At that time our daughter’s surgery date was approaching so I noticed this story with horror and fear: what if that happened to our family? Thank God it didn’t.

However, Virginia Mason entered 2005 with a public relations problem, at least in my mind. How will this hospital recover from such a publicized, preventable and deadly error?

In a recent bill from the clinic, I found the hospital newsletter with its theme for the year: Ensuring the safety of our patients.

I applaud Virginia Mason’s disclosure and public apology. I’m grateful the organization wants to focus on patient safety. Our family has received good care at their clinics.

However, whose job is patient safety? Below the message from the CEO is an article describing how Patient Safety Starts With You, listing ways you can be a safety inspector.

Anyone who has undergone intense medical care, such as surgery or birthing a baby, may not be in the best mindset to scrutinize what the staff are doing. Furthermore, I’ve discovered that if I ask many questions, it might seem that I don’t trust my staff and physicians. That too can create tension and issues. While I appreciate Virginia Mason’s suggestions, as a former patient, spouse of a patient and mother of a patient, I know that patients and their families aren’t always able to notice, speak up or effect change in medical care. Emotional and physical fatigue take their toll. We lack information and experience. Personalities can clash. Communication can be ineffective. Shouldn’t we be able to trust the hospital staff? Doesn’t the staff want us to trust them? How do we build the proper bridges between imperfect people in a hospital?

In light of the mistake made at Virginia Mason last year, I find the claim that Patient Safety Starts With You could be interpreted as putting the blame on the patient for failing to prevent a situation. Should Mary McClinton have asked the staff whether the injection contained dye or antiseptic?

Indeed patients should be involved in their care. I try to be a conscious medical consumer, asking questions, researching answers, permitting procedures only when necessary. Yet I know I can’t know or observe everything. I have to trust my doctor and staff, sometimes even blindly. For example, during Michaela’s surgery, we were not allowed in the operating room.

Trust is a delicate dance. Major mistakes result in litigation and more importantly loss of life. Community bridges break. How do we as patients learn to bear our responsibility appropriately and encourage our medical care providers to do their jobs as well as they can? How can we waltz and walk together with grace?

Tags: health

3 responses so far ↓

  • 1 Lucy // Mar 6, 2005 at 6:53 pm

    My personal experience is that staff is often over-worked and under-trained. I learned the hard way as a teenager when my aunt was killed.

    Getting to the point, I learned a few valuable lessons from the lawyers. (1) NEVER stay in a hospital by yourself. (2)Make your “sitter” use a clipboard to record each staff entry into the room and what they’re doing. (3) Make the staff show you the bottle to verify correct meds. (4) Keep a dry-erase board on the wall to track when you had what meds, especially useful around shift-change. (5) Request each-n-every time staff wash their hands when they come through the door. (6) Good staff won’t fault you for double-checking, and bad staff needs to be double-checked. IE you won’t offend anyone that doesn’t need offending. (7) Keep a pharmacist number with you. If you get more than one medication, call the pharmacy to confirm that the drugs don’t interact.

    Even if you’re just going to the pediatrician to get a shot/vaccine, ask the staff to record the lot number of the vial (which they will not automatically do). Without that lot number, they can’t report or track bad reactions. And, heaven forbid something goes really wrong like seizures and brain damage, the federal benefit-programs won’t pay-out if you don’t have the lot number.

    In a way, being agressive about double-checking staff protects them too. I’m sure none of them want the guilt of making a really horrible mistake. In fact, perhaps we owe it to them to be the safety net.

  • 2 enoch choi // Mar 6, 2005 at 8:48 pm

    if you have the option, go to a hospital without “bad staff”. Often, your primary care physician can point out the best hospitall to go for any particular procedure.

    the above reccomendations are good for if you don’t have the option to go to a hospital you can trust.

    i disagree that patients owe it to” providers to “be the safety net”. If you can’t trust the providers, don’t get your care from them. Patient’s knowledge is limited, and although the above ideas are great, there are plenty more things that can go wrong.

    You have to find someone you can trust. And a hospital you can trust.

  • 3 Gerald McClinton // Mar 23, 2005 at 3:50 pm

    Yes while the hospital took the unusual step of apologizing publically there really was no real apology to my family. My mother had her family around her for twenty four hours a day. We were very vigilant and observed her care. While the hospital says it was nobodys fault, still the blame must lie somewhere. The apology was a PR spin. The responsibility lies with the health care professionals that we trust to take care of our loved ones. The rest of the story will soon come out and I would be interrested in seeing whether people still think that the hospital was truly forthcomming with that apology or whether they were forced out with it because of an internal memo that made it public.

    Gerald L. McCLinton

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