To begin, this is based upon my own
experiences. Your mileage may vary.
The Sarasota Herald Tribune recently ran an article about a patient who died at a local nursing home – Harmony Healthcare. The article link is HERE. The error was attributed to nothing nefarious. It wasn’t a drug error, a incorrect diagnosis, an infected bedsore, a fall, exposure after wandering off campus, but rather to an innocent mistake. Someone gave “Patient 15” a cookie. Specifically, the story infers that the patient was given a NPO status (nothing by mouth) due to a tracheotomy. Someone gave the patient a cookie. They choked and died. The chart noted that they were given a cookie and then the charting was crossed out. There are more nuances to the story and I encourage you to read the article and make your own judgment.
Judgments aside, I can tell you that the patients in a long term facility, assisted living facility and acute care facility, who have an advocate, are generally given more attention than those who do not. I entered the health care system as an employee in 1995 and have witnessed this behavior in the aforementioned facilities. This unfortunate fact, in my experience, can be mitigated by involved management, good hiring practices, anonymous reporting with facilities, periodic training / retraining, state ombudsman’s investigations, the state’s periodic inspections, and family involvement. In today’s healthcare environment, all of the aforementioned safety nets are stressed. Again, referring to the news article, several incidents were noted at the facility. The state agency would note the discrepancies and the time frame for correction. Corrections were made and the state deemed them compliant.
However, where there is smoke, there is fire. The fact is that minor infractions can go on and on as long as the quality of the infraction is not too severe by the state’s standards. It is the rare institution that is infraction free AND they do exist. However, if we suspend the fact that these are human lives at stake, then like any other industry (oil, coal, nuclear) there are situations where human oversight, greed or other reasons can result in catastrophes (BP, Coal River Mountain, 3 Mile Island). In the health care industry with multiple variables, how in the world can one person, encumbered by illness and lack of control, hope to navigate these treacherous waters?
I have witnessed situations where the patients having family members and / or other advocates coming by on a regular basis, are physically seen more frequently by the direct care providers. Rather than having to prepare the patient / paperwork for morning rounds, the direct care providers will re-engage with the patient because of a family member or other surrogate (friend, clergy, etc) who visits often and engages the staff.
As both a nurse and a former comatose patient, I have been the beneficiary of the “X factor” that patient-centric advocates provide. I do not ever remember having an empty water pitcher. I do not remember ever having a messy room. I only remember one occasion in a month long stay in a hospital where my call light was not answered. Short of staff and a “Code Blue” meant I had to lie in a wet bed for about an hour. However, when my situation was discovered, five people came in to my room to manage my IV lines, my respirator tubes, deflate / inflate my bed and get me cleaned up. During this time, there was cross talk over me. However, there was also talking to me. I was a patient to be cared for and not a problem to be resolved. The end result is the same but the quality of care I received that night was better than many I have seen on either side of the stethoscope.
The system is rife with opportunities for failure. Yes, there are safeguards in place but no one particular system is infallible. So, like holes in a slice of Swiss cheese, there are gaps. When a gap in a system, lines up with gaps in other safety systems, serious / fatal events occur. The industry refers to them as sentinel events. Having sat in training courses where sentinel events (e.g overdoses of heparin) are examined, contingency plans are developed and training is put into place so that similar errors do not repeat themselves.
So, back to the cookie. Should there be a state law forbidding cookies in health care institutions? Obviously, no. Should individual facilities have a cookie free environment and then market themselves as a safer facility. Again, no. Does the facility have the responsibility of training everyone who comes into contact with a patient to know what NPO means? Yes, they do. Do dietary slips have NPO written on them so that food is not delivered to the inadvertently? Yes. Do facilities mark NPO in patient’s charts and put signs up in the patient’s rooms to prevent those errors? Yes. Did someone give a NPO patient a cookie? Yes, a cookie passed through all of the safety filters and it killed someone.
How could the X factor have possibly played a roll in this scenario? If there was an advocate in the room, there would have been another set of eyes and ears to act as another layer of protection. If there was an advocate focusing the attention of the primary care team, there may have been a reinforcement of the physician’s order of NPO. There may have been a second thought on patient assignments and a more caring / attentive nurse would have had the patient’s status in mind. Then again, the outcome may have been the same. As with any complex equation, a single variable may make a huge difference. To borrow from Mark Twain, it could be the difference between “lightning” and “lightning bug”.
My final thought here is this – when considering your entry into the healthcare system, having an advocate to be another set of eyes and ears is always helpful and many family members can play that role. However, for those of us who are separated from our families, having a health care proxy can at least make sense of all that is going on around you. At most, they can save your life. To that end, you should educate yourself on the following titles: Nurse Navigator, Certified Guardianship, and an Eldercare Care Manager.
The Sarasota Herald Tribune recently ran an article about a patient who died at a local nursing home – Harmony Healthcare. The article link is HERE. The error was attributed to nothing nefarious. It wasn’t a drug error, a incorrect diagnosis, an infected bedsore, a fall, exposure after wandering off campus, but rather to an innocent mistake. Someone gave “Patient 15” a cookie. Specifically, the story infers that the patient was given a NPO status (nothing by mouth) due to a tracheotomy. Someone gave the patient a cookie. They choked and died. The chart noted that they were given a cookie and then the charting was crossed out. There are more nuances to the story and I encourage you to read the article and make your own judgment.
Judgments aside, I can tell you that the patients in a long term facility, assisted living facility and acute care facility, who have an advocate, are generally given more attention than those who do not. I entered the health care system as an employee in 1995 and have witnessed this behavior in the aforementioned facilities. This unfortunate fact, in my experience, can be mitigated by involved management, good hiring practices, anonymous reporting with facilities, periodic training / retraining, state ombudsman’s investigations, the state’s periodic inspections, and family involvement. In today’s healthcare environment, all of the aforementioned safety nets are stressed. Again, referring to the news article, several incidents were noted at the facility. The state agency would note the discrepancies and the time frame for correction. Corrections were made and the state deemed them compliant.
However, where there is smoke, there is fire. The fact is that minor infractions can go on and on as long as the quality of the infraction is not too severe by the state’s standards. It is the rare institution that is infraction free AND they do exist. However, if we suspend the fact that these are human lives at stake, then like any other industry (oil, coal, nuclear) there are situations where human oversight, greed or other reasons can result in catastrophes (BP, Coal River Mountain, 3 Mile Island). In the health care industry with multiple variables, how in the world can one person, encumbered by illness and lack of control, hope to navigate these treacherous waters?
I have witnessed situations where the patients having family members and / or other advocates coming by on a regular basis, are physically seen more frequently by the direct care providers. Rather than having to prepare the patient / paperwork for morning rounds, the direct care providers will re-engage with the patient because of a family member or other surrogate (friend, clergy, etc) who visits often and engages the staff.
As both a nurse and a former comatose patient, I have been the beneficiary of the “X factor” that patient-centric advocates provide. I do not ever remember having an empty water pitcher. I do not remember ever having a messy room. I only remember one occasion in a month long stay in a hospital where my call light was not answered. Short of staff and a “Code Blue” meant I had to lie in a wet bed for about an hour. However, when my situation was discovered, five people came in to my room to manage my IV lines, my respirator tubes, deflate / inflate my bed and get me cleaned up. During this time, there was cross talk over me. However, there was also talking to me. I was a patient to be cared for and not a problem to be resolved. The end result is the same but the quality of care I received that night was better than many I have seen on either side of the stethoscope.
The system is rife with opportunities for failure. Yes, there are safeguards in place but no one particular system is infallible. So, like holes in a slice of Swiss cheese, there are gaps. When a gap in a system, lines up with gaps in other safety systems, serious / fatal events occur. The industry refers to them as sentinel events. Having sat in training courses where sentinel events (e.g overdoses of heparin) are examined, contingency plans are developed and training is put into place so that similar errors do not repeat themselves.
So, back to the cookie. Should there be a state law forbidding cookies in health care institutions? Obviously, no. Should individual facilities have a cookie free environment and then market themselves as a safer facility. Again, no. Does the facility have the responsibility of training everyone who comes into contact with a patient to know what NPO means? Yes, they do. Do dietary slips have NPO written on them so that food is not delivered to the inadvertently? Yes. Do facilities mark NPO in patient’s charts and put signs up in the patient’s rooms to prevent those errors? Yes. Did someone give a NPO patient a cookie? Yes, a cookie passed through all of the safety filters and it killed someone.
How could the X factor have possibly played a roll in this scenario? If there was an advocate in the room, there would have been another set of eyes and ears to act as another layer of protection. If there was an advocate focusing the attention of the primary care team, there may have been a reinforcement of the physician’s order of NPO. There may have been a second thought on patient assignments and a more caring / attentive nurse would have had the patient’s status in mind. Then again, the outcome may have been the same. As with any complex equation, a single variable may make a huge difference. To borrow from Mark Twain, it could be the difference between “lightning” and “lightning bug”.
My final thought here is this – when considering your entry into the healthcare system, having an advocate to be another set of eyes and ears is always helpful and many family members can play that role. However, for those of us who are separated from our families, having a health care proxy can at least make sense of all that is going on around you. At most, they can save your life. To that end, you should educate yourself on the following titles: Nurse Navigator, Certified Guardianship, and an Eldercare Care Manager.
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