Join the campaign and share a memorial and honor someone who has been harmed or died as a result of a medical error. Below insert a title to your post and the first and last name in your honor (less than 1000 characters). All posts will be reviewed and posted later if approved if you abide to the campaign rules.
My father-in-law passed away May 4, 2013, the day of our daughter's senior prom. He was 10 days post CABG, and suffered a pulmonary embolism. This should not have happened - he was 74, otherwise healthy, and had discharged home on post-op day 4. This was not due to any one person or entity's fault, as many things contributed to this event (mother-in-law refused HH visits; unclear on need for blood thinners; unclear on activity level; potential delays in the ED; etc...). I work in patient safety, and events like this are why I do what I do every day.
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.
My dad was misdiagnosed with pneumonia when he had congestive heart failure. During the spring of 1997, as we excitedly toured colleges and prepared for high school graduation, dad had this persistent cold. He kept going back to the doctor about it but they kept saying it was just a cold and then finally, they said it was pneumonia. A few weeks later, he went in for a previously scheduled (unrelated) surgery to address an old running injury to his ankle that required general anesthesia. He had already had one on his other leg the previous year. When we came to visit him afterward, we were not prepared for what we found: He was weak, having trouble breathing and on oxygen. Of course, if they had know he had congestive heart failure, this procedure would have been postponed or cancelled. He left the hospital in a wheelchair instead of crutches. Later that year, he was placed on the donor list for a new heart and received a transplant the following year.
Sharing in honor of my courageous mother for whom I was a healthcare advocate and to help educate others and transform unsafe healthcare practices. During multiple years that I advocated for my mother, I observed myriad gaps in care delivery and in communication and often observed "unsafe/harmful practices" including during the last weeks of her life. The following are examples: no central case coordinator for complex needs and connecting multi-stakeholder communication; ineffective communication and lack of accountability during hand-off among hospitalists; medication errors (both type and dose of Rx); no communication to family regarding onset of MRSA; care without compassion; copying and pasting previous notes within the EMR system; discharging without necessary prescriptions; no provision of risk/benefit information when it was so critical. As Dr. Francis Peabody of Harvard Medical School said in 1927, “The secret of the care of the patient is in caring for the patient.”
Fredericka Emile Utz Sims