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

"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.

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.

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?

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