March 13 through 18 is National Patient Safety Awareness Week.
As I sit here, thinking of what to write, stories of the people who have reached out to the CT Center for Patient Safety over the years are streaming through my mind. I am remembering the story of an infant whose high bilirubin level was not treated after birth and who suffered from kernicterus and now lives with severe complications of cerebral palsy; the story of the young mom who died sitting next to her 4-year-old after getting an allergy shot at the doctor’s office and going into anaphylactic shock. They didn’t have IV epinephrine to help her.
I am thinking of our board president who had to have both of his legs amputated above his knees after a surgeon sewed his aorta shut during routine abdominal surgery. The stories go on and on. They are not just statistics.
We will not forget, but rather, will continue sharing their stories and honoring all of the people, their families and friends who have been impacted by avoidable medical harm in our hospitals and other healthcare settings and whose lives have been forever changed. None of us want anything more than to see aggressive work continue to move us toward the elimination of avoidable medical errors so that what we have experienced will not have to be experienced by others.
Connecticut hospitals are following high-reliability strategies that are used in other industries such as the airline and nuclear fields. But something is terribly wrong and this strategy is not enough.
The October 2015 CT Department of Public Health Adverse Event Report states that there were 15 wrong site surgeries, 24 instances of retained objects, and 78 patients who died associated with falls among the 471 adverse events reported in Connecticut. In a smaller state with three medical schools and some very large, powerful healthcare systems, we find these numbers hard to understand and accept. Four hundred seventy one people, their families and their friend’s lives were impacted by avoidable harm in this one year.
We believe that everyone involved in healthcare wants to see a day when medical errors are quite the exception. We ask if and how patients and their families are meaningfully involved in the conversations about patient safety issues in our hospitals and other healthcare settings. Patients remain the most underutilized resource in healthcare and all too often they are still not included in the substantial discussions behind the closed doors. It is not enough to continue trying and to keep doing the same things that are not working well enough. Things must be done differently!
The Connecticut Center for Patient Safety puts out a challenge to all healthcare entities and systems in Connecticut. We challenge them to reach out to current and former patients and to our organization to meaningfully bring the patient perspective and voice into the solution. We challenge them to publicly commit to greater transparency and to reduce medical errors leading to serious harm and/or death from the third leading cause of death in our nation to one that we seldom hear about.
During Patient Safety week there will be a NPSF Webcast | Patient Safety is a Public Health Issue on 3/17/2016 from 1-2 p.m. ET Register here. There will be a twitter chat titled “Patient Safety in All Settings.” It will take place on Tuesday, March 15, from 2 to 3 p.m. (ET). Participants can join the chat by using the hashtag #PSAW16chat.
Lisa Freeman is the Executive Director of the Connecticut Center for Patient Safety.