Skip to main content
Sister Publication Links
  • ESG: THE NEW IMPERATIVE
Subscribe
  • Sign Up Free
  • Login
  • Subscribe
  • News
    • Current News
    • COVID-19
    • Providers
    • Insurance
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • Transformation
    • People
    • Regional News
    • Digital Edition (Web Version)
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • Midwest
    • Northeast
    • South
    • West
  • Digital Health
  • Insights
    • ACA 10 Years After
    • Best Practices
    • Special Reports
    • Innovations
  • Opinion
    • Bold Moves
    • Breaking Bias
    • Commentaries
    • Letters
    • Vital Signs Blog
    • From the Editor
  • Events & Awards
    • Awards
    • Conferences
    • Galas
    • Virtual Briefings
    • Webinars
    • Nominate/Eligibility
    • 100 Most Influential People
    • 50 Most Influential Clinical Executives
    • Best Places to Work in Healthcare
    • Excellence in Governance
    • Health Care Hall of Fame
    • Healthcare Marketing Impact Awards
    • Top 25 Emerging Leaders
    • Top 25 Innovators
    • Diversity in Healthcare
      • - Luminaries
      • - Top 25 Diversity Leaders
      • - Leaders to Watch
    • Women in Healthcare
      • - Luminaries
      • - Top 25 Women Leaders
      • - Women to Watch
    • Digital Health Transformation Summit
    • ESG: The Implementation Imperative Summit
    • Leadership Symposium
    • Social Determinants of Health Symposium
    • Women Leaders in Healthcare Conference
    • Best Places to Work Awards Gala
    • Health Care Hall of Fame Gala
    • Top 25 Diversity Leaders Gala
    • Top 25 Women Leaders Gala
    • - Hospital of the Future
    • - Value Based Care
    • - Supply Chain
    • - Hospital at Home
    • - Workplace of the Future
    • - Digital Health
    • - Future of Staffing
    • - Hospital of the Future (Fall)
  • Multimedia
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Video Series - The Check Up
    • Sponsored Video Series - One on One
  • Data Center
    • Data Center Home
    • Hospital Financials
    • Staffing & Compensation
    • Quality & Safety
    • Mergers & Acquisitions
    • Data Archive
    • Resource Guide: By the Numbers
    • Surveys
    • Data Points
  • MORE +
    • Contact Us
    • Advertise
    • Media Kit
    • Newsletters
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Safety & Quality
April 12, 2018 01:00 AM

No One Is Free From Harm: The danger of having no one in charge of coordinating care

Harris Meyer
  • Tweet
  • Share
  • Share
  • Email
  • More
    Reprints Print
    Patricia Morrill

    Patricia Morrill
    President of PM Healthcare Consulting; former hospital operations and project manager Caledonia, Wis.

    "Keeping patients safe has to be a core focus for senior leadership and not get pushed down to lower levels. Until we do that, we aren't going to make the kind of progress we need to make."
    –Patricia Morrill

    Working for more than 30 years in healthcare did not prepare me for the chain of medical errors and uncoordinated care that led to my mother Clara's death following knee replacement surgery.

    I started sharing the story of my mother's poor care as a way to help me in my personal grieving process. That launched me into focusing on safe care in my consulting work and publishing a book last year on eliminating preventable harm.

    Eight years ago, my mother, a retired controller who was 81, went with my sister and me to see an orthopedist to find out if she should get a total knee replacement, because she had severe knee pain. The orthopedist said she would need the signoff of her cardiologist and two other doctors. That was the start of a seven-month ordeal for my mother.

    Morrill's mother, Clara, seven months before her death.

    The pre-operative care was lengthy and costly, including a cardiac catheterization and implantation of a stent. Finally, the orthopedist said my mother was OK for surgery, and he did the knee replacement procedure at an excellent hospital. It went great, and the rehab went great.

    I flew back from my home in Wisconsin to take care of her when she returned home from rehab. It was clear she needed continued help. So we hired a nursing assistant.

    A couple days after I left to return home, she was brought to the emergency room and had to go back into surgery to clean out an infection, then returned to the rehab facility. She then developed a pressure ulcer on her foot, which no one noticed until it was very deep.

    She was admitted to the hospital for the third time. The medical staff determined it was a MRSA infection that was sticking to the prosthetic, and said the implant should be removed in a third operation and replaced in a fourth operation. Alternatively, they said they could amputate her leg.

    The orthopedist was very apologetic and wanted to try a less invasive procedure. I told him to please talk to the cardiologist. My sister and I had to direct the coordination of care between them, because it clearly wasn't happening. The cardiologist said there was no way her heart could withstand a third surgery.

    While my mother was still in the hospital, the staff made a medication error where she was receiving two different blood thinners. We saw blood in her catheter bag. Fortunately, I knew enough to talk to the doctor, and they stopped one of the blood thinners.

    During this five-day hospitalization, the physician ordered food my mother couldn't tolerate, forcing the nurses to take time from their busy schedule to get soup and coffee that my mother could tolerate.

    Ultimately, my mother decided not to have any heroic treatment and just go home. My sister and I took leaves from our jobs, and I left my family behind to take care of our mom and basically watch her die. She spent her final six weeks at home in hospice care.

    Morrill-family

    A family photo celebrating Mother's Day. Morrill is pictured in the top row with her husband, son and sister. Clara is below with Morrill's daughter and her family.

    In retrospect, my mother never should have had the knee replacement surgery in the first place because she was a very high-risk patient.

    Before my book recounting these experiences came out last year, I went back to the hospital where this happened and talked to the chief medical officer and the person heading performance improvement to alert them to the book's publication.

    Their reaction was beyond my expectation. They said they were happy that I came forward because that's how they learn, and that they would have all members of their leadership team read it. I was very appreciative.

    Healthcare-caused harm is the third-leading cause of death in the U.S., and we don't talk about it. Health system board members and executives have to have patient safety in their strategic plan.

    Keeping patients safe has to be a core focus for senior leadership and not be pushed down to lower levels. Until we do that, we aren't going to make the kind of progress we need to make. We have to make it more discussable.

    The type of uncoordinated care my mother received is a major cause of patient harm.

    What scares me with all these healthcare mergers is we're creating larger and larger systems. How are we going to be able to do better with coordinated care with everything getting so big?

    We want these stories to inspire you to share your experiences, both good and bad.

    Send us an email at [email protected].

    BACK TO MAIN PAGE

    Letter
    to the
    Editor

    Send us a letter

    Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.

    Recommended for You
    Nursing Home covid
    AHCA sounds alarm on nursing home staffing crisis
    Collage of images, medication pills, elderly man in hospital, bacteria, and triangle caution symbol
    High adverse event rate paints ‘serious’ picture of inpatient harm
    Most Popular
    1
    More healthcare organizations at risk of credit default, Moody's says
    2
    Centene fills out senior executive team with new president, COO
    3
    SCAN, CareOregon plan to merge into the HealthRight Group
    4
    Blue Cross Blue Shield of Michigan unveils big push that lets physicians take on risk, reap rewards
    5
    Bright Health weighs reverse stock split as delisting looms
    Sponsored Content
    Get Newsletters

    Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox.

    Subscribe Today
    MH Magazine Cover

    MH magazine offers content that sheds light on healthcare leaders’ complex choices and touch points—from strategy, governance, leadership development and finance to operations, clinical care, and marketing.

    Subscribe
    Connect with Us
    • LinkedIn
    • Twitter
    • Facebook
    • RSS

    Our Mission

    Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data.

    Contact Us

    (877) 812-1581

    Email us

     

    Resources
    • Contact Us
    • Advertise with Us
    • Ad Choices Ad Choices
    • Sitemap
    Editorial Dept
    • Submission Guidelines
    • Code of Ethics
    • Awards
    • About Us
    Legal
    • Terms and Conditions
    • Privacy Policy
    • Privacy Request
    Modern Healthcare
    Copyright © 1996-2023. Crain Communications, Inc. All Rights Reserved.
    • News
      • Current News
      • COVID-19
      • Providers
      • Insurance
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • Transformation
        • Patients
        • Operations
        • Care Delivery
        • Payment
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition (Web Version)
    • Digital Health
    • Insights
      • ACA 10 Years After
      • Best Practices
      • Special Reports
      • Innovations
    • Opinion
      • Bold Moves
      • Breaking Bias
      • Commentaries
      • Letters
      • Vital Signs Blog
      • From the Editor
    • Events & Awards
      • Awards
        • Nominate/Eligibility
        • 100 Most Influential People
        • 50 Most Influential Clinical Executives
        • Best Places to Work in Healthcare
        • Excellence in Governance
        • Health Care Hall of Fame
        • Healthcare Marketing Impact Awards
        • Top 25 Emerging Leaders
        • Top 25 Innovators
        • Diversity in Healthcare
          • - Luminaries
          • - Top 25 Diversity Leaders
          • - Leaders to Watch
        • Women in Healthcare
          • - Luminaries
          • - Top 25 Women Leaders
          • - Women to Watch
      • Conferences
        • Digital Health Transformation Summit
        • ESG: The Implementation Imperative Summit
        • Leadership Symposium
        • Social Determinants of Health Symposium
        • Women Leaders in Healthcare Conference
      • Galas
        • Best Places to Work Awards Gala
        • Health Care Hall of Fame Gala
        • Top 25 Diversity Leaders Gala
        • Top 25 Women Leaders Gala
      • Virtual Briefings
        • - Hospital of the Future
        • - Value Based Care
        • - Supply Chain
        • - Hospital at Home
        • - Workplace of the Future
        • - Digital Health
        • - Future of Staffing
        • - Hospital of the Future (Fall)
      • Webinars
    • Multimedia
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Video Series - The Check Up
      • Sponsored Video Series - One on One
    • Data Center
      • Data Center Home
      • Hospital Financials
      • Staffing & Compensation
      • Quality & Safety
      • Mergers & Acquisitions
      • Data Archive
      • Resource Guide: By the Numbers
      • Surveys
      • Data Points
    • MORE +
      • Contact Us
      • Advertise
      • Media Kit
      • Newsletters
      • Jobs
      • People on the Move
      • Reprints & Licensing