Seven Years Ago and a Week: A Patient Safety Story

Mark’s note: Today’s post is written by Laura Townsend, the founder of the Louise H. Batz Patient Safety Foundation. I learned about the foundation when I moved to San Antonio four years ago and am honored to serve on their board. Laura and her family, like others in the patient safety movement, have found the strength and faith required to turn a preventable tragedy, the death of her mother Louise Batz, into something that helps others and their loved ones avoid a similar fate.

You might have seen the headlines this week about a new study that, again, says that medical error is the third leading cause of death in the U.S., at about 250,000 people a year. See one article here.

Below is this year’s version of an letter that Laura shares annually. As I suggested a year ago, if you and your organization are willing to partner with the Batz Foundation to measure the results of using their Batz Guides, please let us know. 

By Laura Townsend:

A little over seven years ago, we came down to San Antonio to celebrate Easter with my Mom and Dad and our Holshouser family members. It was such a joyous day and we had so much to be thankful for.

My dad was recovering so well from heart surgery. He has always been such a fighter. He looked great. Our girls were so precious and precocious! Mary Louise was just a little over one year old and Ella was 4 and a half years old. We were laughing in these pictures because Mary Louise kept grabbing at Ella’s hair. Ella was a little grumpy about it at first, then we all ended in laughter. I love this last picture because my mom and Ella are laughing the exact same. So funny.

Ella and Mary Louise loved my mom so much. I cherish that Easter we had together. I still have the matching outfits mom and dad gave the girls. My brother Richard and his wife Ginger were expecting their second little boy to be born in June. Life, I would say, was just perfect at that moment.

My mom and dad were settling into their grandparent years and having so much fun. My dad was called granddaddy. His name stuck right away. It took longer for a name to stick with my mom though. I remember mom really trying to find a clever name that the girls and Sawyer would call her. She went through Mami, Mimi, and the nickname her nephews called her, Weezie… none of those stuck. Then, one day when Ella was two and half, she called her grandmother! And the way Ella said it made it just sound perfect. I think Ella would hear granddaddy say the word “grand” all the time. One of his favorite adjectives.:) Whether he was telling one of his “grand stories” that would end in such laughter that your stomach hurt or If something looked beautiful he would say “Oh, isn’t it Grand.” In Ella’s mind, the word grand was marvelous, amazing and wonderful filled with love and laughter.

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These were the last two pictures of my Mom. Seven years ago today, our world turned upside down. Seven years ago today, my mom died from a preventable medical error. We had no idea what that really meant.

My mom went into have routine knee surgery. I honestly wasn’t too worried about it at all. My dad had just recovered from quintuple bypass surgery two months before, so this was supposed to be no big deal. I will always remember the doctor coming out and saying to us that she did great through surgery and she had a beautiful new knee. I remember taking Ella to see Mom at the hospital and that she had a huge smile on her face and was trying to act that she was in absolutely no pain.

I remember talking to the nurse for such a long time about my mom’s care. She was so kind and patient and she answered all my questions. I remember telling them only to give her morphine if she needed it, but to please not give her the Demerol and Vistaril. I remember the nurse telling us to go home so mom could get her rest. I remember giving her hug and kiss and telling her that I loved her.

That was the last time I ever got to feel her arms around me giving me a hug. I will never forget getting a phone call from the hospital at 3:15 in the morning telling us that my mom was having trouble breathing and to please hurry and come. I will never forget that feeling of seeing my mom laying lifeless in her hospital bed thinking she had already died. I will never forget when I figured out my mom had been given Demerol, Morphine, and Vistaril and went into respiratory depression and suffered an anoxic brain injury.

I will never forget when I learned that my mom’s preventable medical error was one of over 200,000 a year. 200,000 other families had felt the anguish ours was feeling at that moment.  I will never forget having to take my mom off life support. We will NEVER forget.

When I go around the country each year to share my mom’s story, I know there is never a time that it will be easy to share it or a time I will not cry when I share it. It is a hard story to tell. But if we did not share her story we would have never realized the triumph and hope of what her story has become. Over the past seven years, since those last pictures of her were taken, we have all gone on an amazing journey of HEALING, HOPE and PROMISE.

The Louise H. Batz Patient Safety Foundation has raised close to $1.5 million dollars for patient safety. We have printed 35,000 Batz Guides that have been sent to hospitals, patients, and families around the world. We have shared my mom’s story across the United States, Canada, Europe, and South America. Preventable medical errors and patient safety cuts across all diseases and countries. It is a universal issue. Truly amazing.

We are getting ready to celebrate our 5th anniversary of Bingo De Mayo! It is always such a special event for our family. It is celebration of the commitment our community has made for working together to improve patient safety. Most importantly, I love that her grandchildren get to experience and see how many people loved and cared about my mom and the important mission we are trying to achieve. None of it would have been possible without all of you. It humbles me, inspires me, and drives me to work as hard as I can every day to achieve our mission and to honor her life and memory.

I want to thank all of our hospital partners, medical advisory members, board members, doctors, nurses, patient safety leaders, family and friends for all of the wisdom and encouragement you have provided us over the past seven years.  Your support proves that that, if we all work together as a team, we can save lives! Preventable medical errors and patient safety cuts across all diseases and countries. It is a universal issue. We will continue to work and never give up until the 200,000 lives lost every year is at zero.

Most of all and always I want to thank my mom.

I miss my mom each and every day, but Even though she is not here she is SO much a part of our lives and her grandchildren’s lives. There are traits and characteristics of my mom in each one of them. Each year as they get older I am  more in awe of my mom. How did she do it! She was a wonderful mom and grandmother. Looking back Ella chose her name perfectly…. She truly was GRAND!! I love you mom! Your legacy lives on!  

– Laura


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

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