This week is National Patient Safety Awareness Week. See my thoughts on this from 2012. Every week should be National Patient Safety IMPROVEMENT Week, as the problem is that dire. But, it’s great to try to bring to light the risks of our modern healthcare system in the U.S. and other countries.
I often point out the organizational culture problems that lead to bad systems and bad processes (this is not a “bad people” problem). There are many great people working hard in healthcare every day.
But, I’d like to highlight some of the amazing people who are really working to make a difference in improving our broken system.
Louise H. Batz Patient Safety Foundation
The Batz Foundation was started by a woman, Laura Townsend, who grew up right near where I now live in San Antonio. Her mother, Louise Batz, died tragically after a medication error that occurred during her hospitalization after a knee-replacement surgery. Read her story.
Like others in the patient safety community, Laura and her family had the amazing strength to channel their energy into helping improve the system to prevent problems for others. I realize admire that people like Laura can focus on the future instead of being angry about the past.
It’s a guide I would recommend to my own family and friends. The guide prompts patients to track important information about their health and care, before, during, and after a hospitalization. The guide also recommends important questions to ask about your own care and safety.
I gave a copy of the guide to a friend who recently had surgery. She used the book a lot before her procedure and here was her comment part-way through her recovery:
“I loved the workbook you gave me. It’s AMAZING how much I had to manage my healthcare under the influence of narcotics.”
That’s not right. We need to improve the system so patients don’t have to do that and so that the Batz Guide isn’t necessary. But, today, I’m glad it is.
I’m also honored to be on the Batz Foundation’s board and I’m happy to volunteer with them.
The Emily Jerry Foundation
In 2006, young Emily Jerry died as the result of a preventable chemotherapy medication error at an Ohio hospital.
The pharmacist, Eric Cropp, who was the supervising pharmacist at the time was convicted and jailed, something that I think is a travesty (as I blogged about in 2010). Who else agrees that blaming the pharmacist does nothing to protect future patients? Emily’s father, Christopher Jerry.
Chris started the Emily Jerry Foundation as a way of helping others by preventing future medical errors. Chris has often shared a stage with the pharmacist to talk about what healthcare needs to do to improve safety.
I have talked with Chris before and we managed to cross paths recently in Orlando, where I was attending the Society for Health Systems conference and Chris was speaking at a HIMSS event.
Why did Emily die?
Because she was given a saline solution that was erroneously too high in concentration.
Why did this occur?
The pharmacy technician mixed the solution instead of using a pre-made bag.
Why didn’t the pharmacy tech use a pre-mixed bag?
Because there was a supply shortage and the hospital didn’t have them. Note, this is still a problem today. Salt water bags??? A shortage? Good grief.
There were other contributing factors in the case. The technician was surfing the web planning her wedding. The pharmacist says they were slammed and overworked. The pharmacist didn’t catch the error. The technicians claims she tried to speak up but was brushed off.
What hospital CEO or supply chain VP has ever gone to jail due to a supply shortage? What pharmacy director has ever been jailed for having bad processes or an overworked department? None that I’m aware of.
I don’t think the answer is jailing MORE people. The answer is fixing processes, systems, and culture. I’m glad Chris Jerry is leading this charge. As he said in his talk:
“Where did the systems break down? Where did the processes fail Emily, a beautiful little girl?… I believe we can get to zero deaths from preventable errors because they are that preventable.”
He blames systems, not individuals.
Chris has agreed to be a podcast guest in the near future.
The Josie King Foundation
There’s also, of course, Sorrel King, the founder of the Josie King Foundation. Sorrel was my guest for episode #78 of my podcast series.
Like Laura and Chris, Sorrel was able to channel her energy into working with Johns Hopkins and others to improve patient safety.
As you can read about here, Josie died at Johns Hopkins after a number of factors, including nurses and physicians not listening to Sorrel’s concerns that something was wrong with her little girl.
I hope we can all do something to help support the important mission that these three foundations all share.
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the VP of Customer Success for the technology company KaiNexus.