Thanks for Andis Robeznieks' article First Person: To really learn about medical errors, turn off the PowerPoint.
I know too well that personal pain also, having lost my mother from a medical error when they could not trend her laboratory results electronically, and maybe even a sadder story, the horror of a hospital-acquired infection that has left my 26-year-old nephew paralyzed. Thanks for the sensitivity in the article to bring out what really matters -- there are people behind these errors. It is not just a statistic to talk about improving.
Robin Raiford, RN-BC, CPHIMS, FHIMSSDirector of government initiatives, product solutions groupEclipsys Corp.HIMSS Patient Safety and Quality Steering Committee chairwomanCoppell, Texas
Issue hits close to home
Thanks for your article on patient safety. I am a healthcare planner specializing in evidence-based design. I've always used my parents as examples of the need for improved patient safety when talking with clients and co-workers. During a stay in the hospital, my father fell going from his bed to the toilet -- the most common area for patient falls -- which caused a Staph infection in an open wound and ultimately ended in the amputation of his lower leg. My mother has incurred a medication error after open heart surgery, which resulted in a five-day stay in the hospital. Also, during ankle-replacement surgery, the physician pushed too hard on her leg and caused a fracture that extended her healing time. All in all, my family has directly been affected by a patient fall, nosocomial infection, medication error and medical error. At no time did anyone accept responsibility or apologize. Are we as consumers too complacent?
The topic of patient safety has hit even closer to home. On Dec. 6, I had ankle ligament reconstruction surgery. Two days post-op, I returned to the doctor and had dressings changed and was told -- in my 45-second consult -- that all looked well. In the proceeding days, the pain in my ankle became more intense. I contacted the physician and was told to keep it elevated and continue on the pain medication. When I returned to the doctor nine days post-op, the ankle was red and swollen. The doctor said that I had cellulitis. I said, "Oh, it's infected." His response, "No, cellulitis." Now, I'm no doctor but isn't cellulitis an infection caused by bacteria? In my drug-induced euphoria, I didn't argue. Now the doctor isn't too concerned, except about his good name, I'm sure. I, however, am coming up on two weeks off work, which has implications for me.
So as I sit here with my foot above my heart taking an extended course of antibiotics, I came across your article and thought I'd share my personal story, which I'm sure if people took stock of their loved ones around them really isn't that different from anyone else.
I'm planning a class for our office in February on patient safety and thanks to my experience I now have a new catchy lead-in. Lucky me.
Julie KernEvidence-based design coordinatorBSA LifeStructuresIndianapolis, Ind.
Article shared issue with many
I was not able to attend the IHI conference this year, but I especially enjoyed the article Andis Robeznieks wrote.
While maybe only 40 people attended the presentations he attended, "Disclosure: What's Morally Right is Organizationally Right," many more heard about the presentation due to his article.
Matt SavageProject managerXenia, Ohio
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