Download IHI Open School Online Course Video Transcript: Patient Safety 100

IHI Open School Online Course Video Transcript: Patient Safety 100, Lesson 1
Linda’s Story
(Produced by Health Care for All — Massachusetts.)
In early 2003, my mother entered a Boston teaching hospital. Within 48 hours, she was dead due to
preventable errors. Here’s the story.
On a Friday, my mother’s cardiologist told her to go to the hospital for a few days of intravenous diuretics.
This was a routine procedure, and we thought nothing of it. At the time there were no beds available, and so
she was left on a gurney in the emergency room for over 24 hours.
The following morning, my mother said the nursing staff had been hostile and rude during the night. It took
a long time for a nurse to arrive to stop the bleeding on her right side.
On Saturday, we noticed the area was turning black and blue. We brought this to the attention of the staff.
They looked at it, drew a circle around it, and said they’d monitor the area. It kept expanding and her blood
pressure became erratic. The resident ordered an ultrasound, and although the ultrasound showed there
was a hematoma, very little was done. A blood transfusion was ordered but not done for 10 hours.
On Sunday evening, my mother decided she’d like to take a short walk. She got up and we walked into the
corridor. Within moments, she started screaming that she was in terrible pain, and we rushed her back to
the room.
This was the beginning of the end. In a short time a code was called, and in a few hours she was dead due
to preventable errors. Despite the warning signs, she was allowed to bleed to death internally.
My initial reaction was total disbelief. I was very angry because no one apologized or took responsibility. I
also felt a great sense of guilt. I went through a list of “if onlys”: if only I hadn’t left her alone overnight, if
only I had been more aggressive in getting someone to pay attention to the hematoma that was rapidly
expanding.
My mother didn’t die because she was old. She died because errors were made in her care. Between the
time of her admission and the time the code was called, many people could have identified the problems and
corrected them, but no one bothered to connect the dots. The fragmented nature of my mother’s care and
the lack of individual responsibility contributed to her death.
Ann’s Story
(Excerpt from a speech given by Don Berwick, former president and CEO of the Institute for Healthcare
Improvement, at the 1999 IHI National Forum on Quality Improvement in Health Care)
This summer and fall has left me more impressed than I have ever been before, than I ever thought I could
be, with the goodwill and the kindness and the generosity and the commitment and the dignity of the people
who are out there to help us in health care — all of them, day after day, night after night. Ann and our
children and I have been thoroughly touched by acts of consideration and empathy and technical expertise
that these people — and they’re all over the system, nurses, doctors, technicians, housekeepers, dieticians,
volunteers, aides — have brought to her bedside.
Ann recalls a housekeeper who every evening would come into her room and, while cleaning, would simply
talk about her children and our children. She remembers a young infectious disease fellow who, at a time
when we were very confused, a very dark hour, came into Ann’s room and sat down and said what we were
feeling, just labeled it. “Not knowing,” she said, “is the worst thing of all.” We were fortunate to have these
caring people in our lives, and we were really fortunate to have access to care in several of the finest
hospitals in our country.
That makes it really hard to tell the other side of the story, because put very simply, the people work very
well, by and large, but the system often doesn’t. Every hour of our care reminded me and alerted Ann about
the enormous, costly, and painful gaps between what we got in our time of need and what we needed. It
has persuaded me more than I ever have felt before about how much we can improve, and I know if what
happened to Ann can happen in the best of our institutions, we need to wonder a lot about what the average
must be like.
We needed, first, safety — and Ann was unsafe. I’ve read Lucian Leape’s work documenting medication
errors, and I’ve taught about it. I’ve seen them now firsthand, at the sharp end, sitting by Ann’s bed for
week after week of acute care. The errors weren’t rare. The errors were the norm.
The neurologist in one admission told us in the morning — he said, “By no means should you get any
anticholinergic agent.” And a medication with profound anticholinergic side effects was given that afternoon.
An attending neurologist in another admission called us by phone — he was in Amsterdam — he had decided
that a crucial and potentially toxic drug should be begun immediately because of the pace of Ann’s
deterioration. I remember he said on the phone, “Time is of the essence.” That was on Thursday morning at
10 AM. Ann got her first dose 60 hours later, Saturday night at 10 PM. Nothing I could do, nothing I did,
nothing I could think of made any difference. I almost went out of my mind.
Colace was discontinued by a physician’s order on day one in one hospital, and it was nonetheless brought
by the nurse every single evening through the following 14-day admission. Ann was supposed to receive five
doses of a very toxic chemotherapy agent, and the nurse labeled dose number three as dose number two.
For half a day no one could find a record that dose number two had ever been given, even though I had
watched it drip in myself. I can tell you from my personal knowledge that not a day passed, not a single
day, without a medication error. Most weren’t serious, but they all scared us.
Dennis Dunn’s Story
[Excerpt from Beyond Blame, a film produced by Bridge Medical, Inc., and distributed by the Institute for
Safe Medication Practices.]
DENNIS DUNN, RPh, Hospital Pharmacist: There was a night — they referred to it as the night of many
codes. There were four codes in the hospital (codes meaning emergencies where people needed to be
resuscitated), and there was a possibility that these four patients might have been given a drug in error.
And since the medications were dispensed on my tour — they were IV medications — I reported it and took
the responsibility. One patient died two days later, another patient died about a month later, and the other
two patients survived.
When I realized that the error was my responsibility, it was total devastation. It’s the biggest nightmare to
hurt somebody. And I got a call from a contact of mine at another VA [Veterans Affairs] hospital, and he
advised me to go immediately and resign, because they were going to fire me that afternoon. The word had
been passed down from on high that I was not to be hired under any circumstances, so then I was really out
in the cold.
MICHAEL R. COHEN, MS, FASHP, President, Institute for Safe Medication Practices: What happened in the
Denny Dunn case was primarily a packaging issue. For a number of years, the hospital had been using an
antibiotic known as metronidazole, which was well-wrapped. Without any knowledge of the pharmacist or
the pharmacy staff, a new medication was brought in called mivacurium, which is a paralyzing agent, a
neuromuscular blocker, and it was in identical packaging. And neither of the packaging had real clear
information about what the drugs actually were. The names weren’t visible.
DENNIS DUNN: That assured an accident or error was going to happen. The only thing was, who was going
to be the unlucky one. And that, by fate, was me.