No One Is Free From Harm: When no one is paying attention to designing systems for patient safety

My mother's and father's recent experiences at two different community hospitals show that everyone needs to have an advocate to ask questions and jump on things if something doesn't look right. The message is don't go alone.

I wish that didn't have to be the case. We have to redesign healthcare to be safer.

In April, my mother, Nayana, had knee replacement surgery at a community hospital affiliated with an academic health center. The plan was for her to stay overnight and go home the next day. But in the recovery room, the nurses told us there were no beds available on the floors and she'd have to stay overnight in the recovery area. They said this bed situation happens every Wednesday.

I had planned to stay with her overnight in the recovery room but there was no place for me to stay, so I had to go home for a few hours. When I returned in the morning, she was still in the recovery room. The physical therapist came to see her there and walked her around, with no privacy, past the other patients.

Usually the physician's assistant does the discharge, but the PA didn't come. So the recovery room nurses did the discharge. They gave us instructions that she could take the wrap off the next day and could shower with the staples the surgeon had used. They gave her a prescription for a standard pain medication.

We went home and my father, Kanti, started calling pharmacies to find the drug. He called six pharmacies but none stocked it. I was getting nervous that her pain medication from the hospital was wearing off, and we would have to take her to the emergency room. Finally, one pharmacy said they had 20 tablets left and we'd better get there fast. I drove like a crazy person, thinking it shouldn't be this hard to get pain medicine for someone who just had knee surgery.

The next day the visiting nurse came to my parents' house and saw my mother was wearing the same wrap she got in the OR. The nurse said they should have changed that wrap before my mother left the hospital. The visiting nurse also said the instructions that my mother could shower were totally incorrect and that she shouldn't shower for four or five days. Clearly the recovery room nurses didn't know how to do discharges, since that's not something they routinely do.

My mother was fine from then on. But a lot of things could potentially have gone wrong, even with a pretty educated family member at the bedside. It highlighted to me that the hospital should be thinking about better patient flow, and how having no beds open on Wednesdays could lead to multiple downstream problems for the safety of patients. They need to find solutions to these kinds of flow problems so they don't routinely occur.

About two years before that, my father, who then was in his late 70s, had to go to the local community hospital because he had a massive gastrointestinal bleed. They got him through it and saved his life.

But then there were a series of problems in the follow-up care. While he was in the ICU, he developed deep venous thrombosis in his left arm from a central line. I was at his bedside and diagnosed it. I went to the attending physician and said you need to look at his swollen arm, and only then he was diagnosed.

This delayed diagnosis was symptomatic of the fact he had a different doctor every 12 hours. Over seven days, he probably had 10 different doctors. Coverage systems need to be better to ensure continuity of care for the patient.

Then my father developed a surgical site infection and a central line infection. The tipping point for me was when the hospitalist told me he was looking at my father's lab work from the day before and “luckily” noticed he had a dangerous bacteria, gram negative rod, in his blood. No one had called the hospitalist about the lab result. He said we have to start antibiotics.

As a safety expert, I know that was so unacceptable. The doctor should be notified within one hour of a positive blood culture. This had gone 18 hours. The doctor said it was lucky he caught it. But no one was thinking about how this significant error occurred and how to prevent it.

During my dad's weeks in the hospital, we had family members with him 24/7, and we made a daily list of what was supposed to happen and what wasn't. The doctors had put up a sign in the room instructing staff not to draw blood from my father's left arm because of the clot. But multiple times the staff tried to draw blood from that arm and family members had to stop them.

Ultimately, my father ended up with three hospital-acquired problems—deep venous thrombosis, surgical site infection, and a central-line bloodstream infection. The clinicians at the hospital saved his life, and that was fantastic. But then these preventable things happened afterward that made his recovery a lot harder and longer. Fortunately, he made a full recovery.

I followed up with the hospital's CEO and risk management director. I told them the staff saved my dad's life and I'm incredibly grateful, but then multiple things happened that could have sent him the other way. I told them you have to make sure you have good safety practices and review these kinds of issues to redesign the systems. They said they would look into it. Whether they did I don't know.

The main thing I thought about was, my father had me, an internist and safety expert, at his bedside 24/7. What about patients who don't have that?

Would I go back to that hospital? At the end of the day the answer is yes because there were some amazing nurses and doctors who were so gentle and kind. These amazing people were working in a really tough system, and I know they weren't always able to give the kind of care they wanted to be giving.

And I'm not sure it would be any better anywhere else. Every place has preventable errors. There's a long way to go to get healthcare to be a safe industry. To prevent these things from happening, there needs to be a deep focus on patient safety and system redesign.

After that experience with my father, I was depressed for a while, because I've worked on these issues my whole career and yet saw these problems are still happening. But the experience validates the fact that the work we're doing at the Institute for Healthcare Improvement and the National Patient Safety Foundation is so important. In the end, it motivated me to keep going.

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