UP CLOSE: Experiences from a Tireless Advocate

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.”

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The Institute for Healthcare Improvement salutes Mallinckrodt Pharmaceuticals for their generous support of this year's Patient Safety Awareness Week.