Not Always as Simple as It Seems

Major Medical Error:

I was in the hospital when I saw a story on television about Jesica Santillan, a young woman who had gotten a transplant at a nearby hospital. At the time, I was both a recipient and awaiting my second transplant. It's easy to understand why I had a strong reaction to this story of a woman whose transplanted organs turned out to be the wrong blood type. I was horrified that such a mistake was possible and devastated for the girl and her family. An event that should have marked the beginning of her freedom resulted in the end of her life.

I was not the only one who was shaken to the core by this tragedy. The story quickly became international news. The public blamed and shook their heads. The media villainized doctors and the hospital, calling it a "bungled" transplant. Individuals and communities mourned. Everyone wondered "how could this happen?"

I'll admit, I was a sheep in the heard of people with judgments and criticism. But what I did not think about, and could not know, was what really happened and was going on behind closed hospital doors as a result. As the story rumbled on, it became a constant on television, newspapers and magazines. The case became more complicated (and lost its focus) due to the discovery that Jesica was an illegal immigrant. This only served to add to the complexity, drama and issues the public had to weigh in on.

Years later, I have a better understanding and regret my willingness to not question the media's medical witch hunt. What I did not think about then was the pure devastation, not only for the family, but for the professionals caring for Jesica. I like to joke that "it took a village" to save my life through transplantation. Jesica was no different and there were many physicians, surgeons, nurses and other personnel involved with getting Jesica to that fateful day in the operating room. Not one of those professionals had the intention to do harm. The nightmare happened to them too.

In cases like this one, there are many places along the way where errors are made. From the weather that day to the lack of an electronic data base for potential recipients, this error occurred due to a combination of system inadequacies and particular circumstances. It is easy to say after such an event to say that the system should have included a series of checks along the line for donor/recipient matches but, before Jesica, this kind of error had never happened and no one would have predicted it. It was "the perfect storm" and system issues that once seemed more like individual annoyances collided together to create one massive mistake.

It wasn't as simple as the media made it seem.

After this medical error, Jesica lived roughly two more weeks. During this time, the hospital staff worked with her family to provide the best care and attempted to remedy the mistake with a second transplant. As a part of an effort to collaborate with the family, they kept some details private and only gave information to the media as the family felt comfortable in doing so. This added fuel to the media's fire and professionals, in addition to dealing with this sad and fragile situation, also had to cope with members of the media entering the ICU in costumes and taking unauthorized pictures. Most of the staff members were able to power through this crisis but some could not bear seeing their faces on TV in addition to processing the emotions of such a painful event.

There may be no comfort for Jesica's family in knowing that this mistake was the beginning of a major overhaul of procedures and protocols for this hospital. The media will likely continue to frame the incident as a soap opera with villains and victims. I, however, am able to see this with different eyes and hope you will too. Jesica's death was nothing short of a modern day medical nightmare. At the same time, no individual involved was solely responsible. For this we must blame the faceless system and ask, what is wrong with the procedures and protocols? How can they be changed?

As the hospital website states; "None of us will ever forget the profound sense of loss with the death of Jesica, and none of us wants to relive an outcome such as occurred here. We are committed to providing our patients with the very best available medical care with compassion. We are committed to learning from this event, improving the system, and sharing that information with others. And, we are committed to earning the continued trust of our patients. Jesica's memory compels us all to accept nothing less."

Major Medical Reorganization:

Give me a tool and I want to use it. Show me a tool for healthcare systems and I tap my foot impatiently and ask "Why aren't they using it?" It doesn't always work that way.

For an individual to implement a tool, philosophy or technique, it takes education and the decision to incorporate it into their life. For a family, it may take further discussion and some practice but, with commitment from all involved, the implementation can take place fairly quickly. For a large system, like a medical center, this is not as simple as education, discussion and commitment. It takes detailed planning and reorganization. In fact, it is so complex, there is an actual science dedicated to it.

Systems science is an interdisciplinary field of science that studies the nature of complex systems in nature, society, and science. It aims to develop interdisciplinary foundations, which are applicable in a variety of areas, such as engineering, biology, medicine and social sciences.

When I learned in the TeamSTEPPS training about "bedside handoffs," I got very excited. By definition, a handoff is the transfer of information (along with authority and responsibility) during transitions in care. Handoffs include the opportunity for the incoming professional to ask questions, clarify and confirm information about the patients they will be caring for. The bedside handoff takes this process and moves it to the bedside, allowing the patient and family to hear what information is being passed and offer any needed clarification or addition pertinent information.

Shift change is documented as being a key area for communication break down which can result in errors such as; inaccurate medication prescriptions, inaccurate evaluations, longer lengths of stay, and increased use of laboratory tests. When I heard about bedside handoffs I imagined two nurses by my bed discussing my case and was thrilled to have one more way to meaningfully participate in my own care. I immediately began making the patients and families I worked with aware of this option and encouraged them to request a bedside handoff if they were not already implemented in their particular hospital.

Months after I had begun my Bedside Handoff Crusade, I had the opportunity to hear a high ranking leader discuss bedside handoff implementation in his healthcare system. He began to discuss the lines that needed to be drawn and professionals that did and did not need to be targeted for bedside handoffs. Critical staff members include more than just nurses. Bedside handoffs were important for residents, attending physicians and respiratory therapists too, just to name a few. How many professional handoffs should a system expect a patient to participate in during the course of a day? How realistic is it to expect such a high volume of professionals to be able to organize themselves around many beds on many floors before leaving for the day? What about the professionals who leave at night, should patients be woken up to participate in shift change discussions in the middle of the night?

It isn't as simple as I made it seem.

Sitting and listening to the discussion about mapping, training and personnel shortages, my head started to spin. For me, as an individual, the answer remained the same: I will continue to advocate for bedside handoffs. Wait, let me clarify. I will continue to advocate for the nurses changing shift to do bedside handoffs. As for all of the other key players, I humbly respect the complexity of this system-wide discussion and am anxious to hear how the leaders find the best practice for using this useful tool.

A Need for Change Comes with Some Ramifications:

A 15-month study by an Institute of Medicine (IOM) committee reviewed the relationship between residents' work schedules, their performance and the quality of care they provide.

"The Institute of Medicine study provides the clear evidence to prove what we have long-believed is true—fatigue increases the chance for human error," said AHRQ Director Carolyn M. Clancy, M.D. "Most importantly, this report provides solid recommendations that can improve patient safety, as well as increase the quality of the resident training experience."

After this study, changes were made.

1. Limiting the resident’s work week to 80 hours

2. Limiting continuous time on duty to 24 hours (with 6 additional hours to complete all tasks)

3. Requiring 24 consecutive hours off out of every 7 days

While this structure seems perfectly logical and reasonable to the average person (80 hours a week is s till a lot!), this is major change in the ways hospitals and medical training centers have traditionally done business. This new rule has not been easy to implement. There are issues this new rules brings up that may not be obvious to patients and families. Here are a few:

1. Because increasing patient loads, the reduction in residency work hours has forced programs to create new and inventive ways to schedule patient coverage. This is not always as reliable as everyone would like it to be.

2. While patients and families understand the dangers and difficulties that come with residents working long hours, in some circumstances, the new rules may cause friction between staff and patients/families. The reduction in hours means more faces coming and going which feels like less consistent care.

3. These rules impact the medical schools as well. Because of these changes, it may be necessary to increasing the length of residency training as well as the number of medical residents. This would represent a major financial burden to an already strained healthcare system.

So, once again we see, it’s not as simple as it seems.

This very logical and humane decision is an obvious benefit to both the physician in training and the patients. This change signifies a dedication to decreasing medical error but does not come without its own set of complexities and organizational re-arranging.

As patients and families, we are most often experiencing healthcare within the walls of a clinic or hospital room. What we may not be able to see from the exam table or hospital bed is the large picture. Even when a non-controversial decision is made, it may have unpredictable fallout. The cause and effect can be extremely challenging to manage.

It is our job to keep providing feedback, keep letting the leaders know what is working and not working, while remaining aware that it may not be as simple as it seems. When the system isn’t working, we have to keep finding ways to have our voices heard and keep squeaking until we get the grease. Ideally, we will remain aware that Rome was not built in a day and view System Advocacy as a long-term project. Partnering with a whole system can require patience but when policies are implemented that make our care better and safer, I hope you’ll feel like it was worth the wait.