A Tribute to Dad - Ernst Both

I’m lighting this candle today for my dad, Ernst Both, who died 12-days after he walked into a hospital for an overnight left carotid endarterectomy procedure. During the surgery his heart rate went to 38bpm and his blood pressure to 38/20. 3-units of blood later and a combination of 32 doses of 18 different drugs over the next day and a half, led to a bizarre sequence of adverse drug events that led to 145 doses of 29 different drugs being administered over the first 7-days in the hospital. Atrial fibrillation, wheezing, stridor, angioedema, anxiety, agitation, aggressiveness, delirium, COPD, hypertension, intubation, pneumonia, central line placement, hematuria, “bladder spasms”, gross hematuria, sepsis, and multi-system organ failure.  It was a combination of events that may never have occurred if a program like TeamSTEPPS was used to improve communication and teamwork within this hospital, putting the patient and the family members at the top of the Team Structure pyramid.

Showing 3 reactions

Please check your e-mail for a link to activate your account.
  • commented 2017-03-18 06:54:49 -0400
    Thank you Patricia. I really do hope that communication and teamwork are improved. I’m an airline pilot and I’ve seen how CRM (Crew Resource Management) has opened the communication channels in the airline industry and built up teamwork among cockpit crew members as well as with the flight attendants; making for a safer industry. I know that TeamSTEPPS could do the same in the health care industry and possibly save thousands of lives each year.
  • commented 2017-03-15 16:33:17 -0400
    Jerry – I am sorry for what your father and you endured and agree that tremendous lack effective communication and robust teamwork drives many errors and unsafe conditions.
  • published this page in Share a memorial and honor someone 2017-03-15 11:34:55 -0400

Discussion Forum

Six Ways to Be a Safe Patient
Sharing this advice, from the Arizona Department of Health Services, http://directorsblog.health.azdhs.gov/our-work-t...
Marlborough Hospital Celebrates Patient Safety Awareness Week and Pi Day
We are still seeing reports of activities that took place last week. Read this piece about Marlborough (MA) Hospital'...
Patient Safety Awareness Week 2017—The Week in Review
Patient Safety Awareness Week took place March 12-18, 2017, with health care organizations, patients, and health prof...
See All Stories

Patient Safety News

See More News

Twitter: #UnitedForPatientSafety

The National Patient Safety Foundation salutes Mallinckrodt Pharmaceuticals for their generous support of this year's Patient Safety Awareness Week and their ongoing commitment to patient and workforce safety.