A Dose of Healthcare Reality: Real-life, Patient Safety Experience Makes It Personal

Tom Mitchell
March 18, 2017

Tom Mitchell

Having a simple shoulder labrum repair should be a standard procedure. It’s very much a repeatable practice, performed thousands of times a day across the US.

While that surgery is pretty simple, it became a complex and nearly critical journey for my 19-year-old son. While the procedure went well, things started to go downhill about 24 hours after the surgery when he had a preventable adverse medical event related to a wrong dosage of pain medicine which basically started shutting his body down. On top of that, he was suffering from aspiration pneumonia related to the intubation tube not being removed properly post-op. Due to the medication, his kidneys were shutting down (among other issues), and due to the pneumonia, his oxygen levels were dropping quickly.

So off to the ER we go, where he received excellent care, and was provided a reassuring environment. After several hours in the ER – or about 2:30 in the morning – he was admitted to the hospital. The shoulder surgery ended up going from a standard outpatient procedure to a two-day hospital stay which is leading to a longer recovery.

Granted, mistakes do happen in every profession. As long as I’ve worked in healthcare, this week's events really brought it home to me that there is no room for medical error at all. A healthy young person can become critical in a matter of hours, simply from the wrong medication at high doses, along with a simple procedure for removing a breathing tube in post-op care.

On the positive side, the medical staff that ended up treating him in both the ER and inpatient setting were excellent, and he received outstanding care. And they really seemed to care about him and our family. That was encouraging. But the whole experience made me stop and think about all I have been exposed to in healthcare for over the last 20 years and reflect on recurring themes over those years.

1)     Healthcare isn’t perfect. It never has been and probably won’t ever be. No amount of politics or policy will ever fix it. On the business side of healthcare there is a lot of waste that lead to increasing costs and inefficiencies, but in many cases, is not directly life threatening. On the clinical care side, errors can't occur – especially because volume rules. And when a medical error is made, discovering and following up on that error usually starts with the family, which most of the time has no medical care or experience. It's up to them to unofficially diagnose and become the central point of coordination.

2)     Technology can be a game changer, but isn’t the silver bullet without the human component. The shoulder surgery was performed by one health system. The ER and inpatient care were provided by another. The lack of interoperability between the two was eye opening, and it took “antiquated” technology and elbow grease to have the records passed between the two delivery networks. Once in one health system – the ER, the hospital and the primary care physicians – the records were electronic and were accessible anywhere, any time with the same data and information for all. 

3)     Patient experience matters. The overall experience provided by healthcare providers is a deciding factor in outcomes. As the patient and family members, in this case, one health system made us feel like we were part of a “cattle call” type of approach with little personal interaction and a “turn and churn” mentality. The other health system made us feel as if there was nothing more important than my son's health, our wellbeing as a family and comfort level on clinical decisions provided by the care team.

In the end, I believe it was the personal care and attention that helped my son turn the corner and take steps to mend from the medical mistakes. As I weaved through my healthcare career, I have been in many hospitals, practices and care settings. I’ve seen the best and worst of them all. I’ve been part of the healthcare system with other personal emergencies, but none related to potential medical errors and low standards of quality (perceived by me). When confronted with that and being in the middle of that challenge, more than ever, I now really understand why we’re fighting the “good fight” in healthcare, why data matters, why interoperability is important and why quality and outcomes should be measured and evaluated.

From this experience, I saw a clinical team that cared starting at the “front door” of a hospital through admission and an inpatient stay. I’m firmly convinced there’s no substitute for clinical quality, an outstanding patient experience and technology that affords anyone on the treatment team to access needed information and data anywhere and at any time. Also, I firmly believe that physicians, nurses and administrators truly care about the patients, but the processes and regulations actually make the patient get lost along the way sometimes. Clinicians are constantly struggling to pull the patient back in the center, where they belong. Great ones do this well.

There was also plenty of the healthcare "waste" we hear so much about to be seen first hand through this experience. I’ve been exposed to it for the last 20 years and worked for companies that tried to solve it and offer revolutionary clinical solutions However, being confronted with inefficient processes, multiple trips to the pharmacy and dealing with insurance time and again over the last week made me see how the billions of dollars annually wasted in healthcare add up from simple errors.

My hope is that we can find ways to solve these problems and put political differences aside, find happy mediums in new policies that are about the patient while addressing costs that show no sign of slowing down. I’m proud to be part of that mix of people trying to solve for that. Organizations like HIMSS and the American College of Healthcare Executives (ACHE) strive to change the healthcare system through technology, education, advocacy and policy. Let’s make sure they are involved and the clinicians who are on the ground every day as we advance and change healthcare for the better. And never, ever, forget about the patient.

Tom Mitchell

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