Contact: Preventingmedicalerrors@cox.net
Why Write the Book?
By writing this book to the general public, I hope to lessen the chance of some
medical errors by sharing the patients’ stories that are written. A story for
the patient or family, or one of the tips that is provided here may encourage
them to be extra careful, stop, speak up and ask questions, all of which may
help to identify circumstances that lead to errors.
This information may alert the public to be more involved in their care.
I was moved by “To Err is Human” and relieved that an official report
substantiated my observation - too many people were being harmed by preventable
medical errors. Throughout a 25-year career in health care, I have witnessed
many “near misses” and encountered serious medical errors as well. As a
registered nurse and former paramedic specializing in trauma, emergency
medicine, cardiac and medical care, I recognized that health care services were
fragmented and prone to error.
The IOM report quickly moved hospital leaders into action – participating in
national conferences, creating patient safety plans, collecting data and
implementing patient safety projects. All of these initiatives are steps in the
right direction. Clearly, health care leaders have developed the passion needed
to change the equation of harm.
Yet, as Vice President of a large multi-hospital heath care system in Southern
California, I led hospital safety committees, coordinated patient safety seminars,
taught on the reduction of medical errors and researched best practices - which
were all designed to reduce medical errors - I consistently noted that patients
were not at the core of this new culture change. I was troubled by the fact that
hospital professionals were failing to work with the public to design safer
systems. I also recognized that strategies to involve consumers were complex.
How do we ask patients about medical error prevention without frightening them?
How do we collect and incorporate consumer ideas into safety planning when they
don’t understand the intricacies of complicated health systems? Will
soliciting public involvement slow the progress that we as professionals need to
accomplish?
These questions led me to review the literature on safety resources available to
the public. I found a myriad of information on reducing medical errors designed
for professionals, but very little targeted for the consumer. Moreover, there
was little material that focused on formulating partnerships of error prevention
with the public.
In
writing this book, I hope to inform consumers about the problem of medical
errors and begin to forge the partnership of change. Real stories are used and
selected based on illustrations of health care system vulnerabilities, as
opposed to targeting the individual blame factor. Even though there are numerous
other stories that could be shared, these illustrations reveal the complexity of
interactions that are built into health care systems thus allowing for medical
errors.
These
stories of actual accounts have occurred and continue to occur in U.S.
hospitals. Some use the patient’s name, as they have been willing to publish
their experiences. Other names, times, and places have been changed to protect
patient identity. Some events occur repeatedly within hospitals and key factors
of several cases are combined to illustrate common hospital system breakdowns.
This
book focuses primarily on the hospital experience with some examples of
outpatient settings and doctor’s offices to help illustrate health care system
vulnerabilities. Additional books and research are warranted on the outpatient
setting, physician’s offices and long term care facilities, as the problem of
medical errors is not isolated to hospitals.
Although
selecting to write about the vulnerability of health care systems, I do not
address the complex problem of the nursing shortage. This problem alone warrants
a book or publication exploring the many issues and solutions of this critical
situation. No doubt, the nursing shortage has an impact on system breakdowns.
However, this book is written to address the broader problem of failed health
care systems and to move the consumer into action.
Given
all of this, there is a need for the consumer to demand change in health care.
Since the IOM report, there is little consumer pressure on legislative bodies to
reduce medical errors and improve health care systems. This may be due, in part,
to the fact that consumers don’t have ongoing, relevant information on medical
errors. The public knows there is a problem and yet the means to help people
take steps toward error reduction is lacking. Almost without exception, each
person I told that I was researching and writing this book, described a story of
a friend or family member that had a medical mishap. Even with these stories,
people felt a lack of empowerment to change the fragmented health care systems.
Until
safer systems are designed, patients and families must take a leading role in
driving what happens to them while receiving health care services. Patients
should move away from blind trust and begin speaking up and avoiding assumptions
of safety. Often people feel intimidated or rushed when they question
clinicians. Other times people feel they are at the disposal of a surgeon or
specialist and being careful not to “make the doctor mad” because they have
to receive ongoing treatment from that practitioner. Ultimately, this culture
needs to shift into a patient centric model. This book is written as a guide to
assist the consumer with this shift by moving them with information so they feel
more confident and less intimidated in speaking up about their concerns.
Last
and just as significant, the intent of the book is to provide practical
educational resources in the form of tips for the consumer and information on referral
organizations so the public can gain knowledge, maneuver through the complex
medical system and possibly prevent errors from occurring.
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Revised:
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