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THIS WEEK'S EDITION:
- Sorry Works! momentum
- Important announcement coming on Wednesday
- Earline Cox's story
- New speaking engagements
- Question & Answer
SORRY WORKS! MOMENTUM
Over the last 10 days Sorry Works! has been on a roll - a big roll. The website has had over 850,000 hits. We have averaged 1 million hits per year over the last two years. No doubt the CBS story last week and the stories in the Wall Street Journal and Associated Press fueled the momentum.
Please help us keep the ball rolling by forwarding this newsletter to colleagues and friends, and let folks know about the website: www.sorryworks.net. We are making great strides in promoting disclosure and apology, and we just need to keep it going! Thank you.
Here is the link for the CBS story last week.
IMPORTANT ANNOUNCEMENT COMING WEDNESDAY
Stay tuned this Wednesday for an important announcement regarding Sorry Works! Watch your e-mail.
EARLINE COX'S STORY
Below is a story of medical error and cover-up submitted to Sorry Works! by Earline Cox, a RN from Tacoma , Washington . The story concerns the death of Cox's 17-year old niece.
We are bringing this story un-edited to you, our readers. We hope you will think about this story in the realm of if these events could happen to a nurse's family, imagine what can happen to the average patient or family. Cox's story serves as a strong reminder of how far we have to go with disclosure - and why our work is so important.
"Life after August" Submitted by Earline Cox
Today is August 12th 2006. My family has survived the third anniversary of the death of our dear August Joy. She was nearly 17 on July 29th 2003 when she became one of the unfortunate 98,000 each year that has succumbed to medical error.
There are many twists and turns, a labyrinth as it seems, to the journey my family and I have traveled since that morning in July. I will never forget the phone calls between myself and my sister, Tammy, as I drove to work that morning. I remember so clearly Tammy's request for me to "Just pray" not more than twenty minutes before her baby girl took her last breath. Tammy was the witness to the horror that was the last six hours of my niece's life. The horror of a mother recognizing the declining state of her daughter yet no one listened to her cries for help; the horror of having that "impending doom" of imminent death; the horror of watching her only child's life melt away right before her very eyes.
I did not see the horror my sister did. I did however find it in the medical record. The nurses documented clearly the efforts of my sister, and as clearly they documented their inactivity and unwillingness to act as the patient advocate that they were required to be. Through my knowledge as a registered nurse I could clearly see the gaping holes that swallowed August. I was driven to bring what I had discovered to the attention of the facility that cared for her. I could not witness this debacle and not say something. I felt a responsibility to bring this to the attention of those in authority. Not to be vindictive, but because I truly did see there was such a mistreatment of this young woman and oh my God, it could potentially happen again. I could see the need for individual accountability, but mostly could see a system that had failed. A power gradient that declined steeply: at the very bottom was the patient and her mother pleading for assistance, above her a low level nurse (Licensed Practical Nurse) who had a limited understanding and an even more limited ability to communicate critical information to a physician who held ultimate power and refused to come to their aid.
I attempted to speak with the attending physicians initially, but this request was denied. The risk manager stated the doctors would only meet with the family after the autopsy was completed. The efforts of my sister and I did not stop there. We continued to beat against the wall that had been raised, that white wall of silence that so frequently comes up after "unanticipated outcomes." This wall was thick and unyielding even so, we refused to be ignored. I was driven to be heard, the more we were refused an audience, the more insistent this need became. When it became apparent that the hospital and its providers were not willing to hear our concerns I decided I would find a different audience, one that was responsible to govern the actions of the professionals that provided direct patient care as well as the administration of the hospital itself.
I went to the Department of Health, the Joint Commission, the Nursing Board, the MD board and the DO board seeking what I believed would surely be a sympathetic ear and a response of horror similar to my own after seeing the many deficiencies in care and the unbelievable ethics that was shown. I was again surprised by the response I received.
The first response was from the DOH, which did site the facility for inappropriate nursing care. The report was detailed in that it quoted the nursing notes and made a very brief statement saying the care was inadequate, but I wanted more. I needed to see the judgment that I felt they were due.
Because of this strong need, I found my way to Joint Commission. This governing body, the "god" of the hospitals, the one who holds in its power to grant or deny accreditation, would surely hear my voice. I was deeply disappointed that this was not the case. JACHO, which is a private organization and receives monies for their accreditation services from the very hospitals they are supposed to "govern," was reluctant and ultimately refused to label August's death a sentinel event. Through many faxes, emails and phone calls, it was decided the death was technically not "unexpected" because of the severity of my niece's initial insult from the car crash which caused her injuries. I will forever believe that this decision was made from the representation of the hospital of August 's condition, portraying her as much more critical than she actually was the final days of her life. While her initial injuries were extreme, August had originally received top notch care that brought her from the brink of death and her youth and base line health had done the rest. She had been recovering and getting up with physical therapy only days before her death. I can only believe the hospital did not portray August's condition as it truly was and that is why JACHO took the stance that it did.
Similarly, the Nursing Board did take formal actions against three nurses to severely reprimand their licenses, but the Physician Board refused to take formal actions, stating they had taken "internal actions" and "If there was a repeat offense they would do more the next time." This divided response from the governing bodies was difficult to take. I still believe in my heart of hearts that not only did the hospital and its providers misrepresent the circumstances to me and my family; they actually could not even be honest to their own authorities.
The desire to be heard, to find that audience that would listen and understand all that happened on July 29th 2003, continued to burn. Because of this drive I began to research and found my way to some amazing people who are also attempting to shine a bright light into the dark world of "unanticipated outcomes." I discovered there are many of us who have been wounded and have similar stories of primary and secondary damages including the death or disability caused by the medical error as well as the refusal to accept accountability. While these new relationships have brought some camaraderie and increased understanding, it has also brought a fire that burns even hotter. "The time is now" was the watch phrase of a recent Patient Safety Congress I was invited to attend. I agree that now must be the time. Too many lives have been lost. Too many stories have been buried by building up that deep and wide white wall of silence. We can not improve until we face the reality of what damages are caused by the errors in health care today. We must be willing to look and see what is real if we are to ever correct the processes that allow these deaths to occur.
NEW SPEAKING ENGAGEMENTS
Sorry Works! lined up two new speaking engagements last week: Sun Rise Hospital in Las Vegas in June and Highmark Hospital CEO Conference in October.
Sorry Works! wants to speak to your organization! For more information, contact doug@sorryworks.net or 618-559-8168. Thank you!
QUESTION & ANSWER
Question: "Our facility is implementing disclosure, and one of the first stumbling blocks is an incident involving a surgeon who made a mistake, but he (the surgeon) doesn't think he made a mistake. Our staff and outside experts believe the surgeon made a mistake. How do we get this surgeon to disclose?"
Dr. Geri Amori: This is a good question and one that comes up regularly. To begin with, disclosure isn't for communicating only mistakes. Disclosure is for communicating unanticipated events. If we limit opportunities to communicate with patients and families to those situations where there has been an error, we are likely to have many disagreements about whether the conversation should occur at all. In addition, at the time of the unanticipated outcome, we often cannot be assured that an error has occurred or not. By insisting that the physician admit to an error, we are jumping the gun, and possibly alienating the physician from the process of open, humane communication with the the patient.
If a patient has experienced an outcome that is not a normal expectation of care, then out of respect for the patient, discussion should occur. Many disclosure policies state that the attending must be involved in the disclosure discussion. Although, certainly it is preferable for the attending to participate in the disclosure discussion because of their relationship with the patient and to answer medical questions, it is not always necessary, and sometimes it is not wise to insist. What is most important is that someone who can answer medical questions and who is caring, open, and willing to talk with the patient engage in a dialogue about the unanticipated outcome, the steps the organization is going to take to handle the patient's ongoing care and to ensure that if, in the process of analyzing the situation, they find there were an error, that it is addressed, both internally and with the patient. It is also important that the physician feel supported and involved in the exploration of the event.
Doug Wojcieszak: This question underscores why it is so important to establish a disclosure program where issues like this are discussed ahead of time. If an error is clear and confirmed through an investigation, the physician is at fault, and the physician is an employee of the hospital but not willing to disclose, then a person from administration, risk management or the head of the medical staff may conduct the disclosure, apology, and compensation discussions with the family.
On the other hand, if the physician is not a hospital employee and covered with different insurance, then the program says that the physician's insurer needs to be part of the disclosure program. Again, these issues need to be discussed ahead of time with the insurance company. In this instance, after reviewing the opinions of experts saying an error was committed, the insurer might move to apologize and discuss compensation with the patient/family, even though physician resists. Under Sorry Works, the insurer will have no interest in defending a clear error simply to assuge a physician's ego.
However, physicians must understand in cases where there is no error or mistake, the hospital and/or insurer will back them all the way to jury verdict, if necessary, under Sorry Works! Physicians are never sold out under Sorry Works! when they did their job. A disclosure program must be credible to all the participants, including the physicians.
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