13 Years Ago This Week, I Lost My Mother to Medical Error

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Mark's note: I have long appreciated the advocacy work done by Laura Batz Townsend, her family, and the Louise H. Batz Patient Safety Foundation (and I'm honored to serve on their Board). Laura sent this email this week, on the 13th anniversary of her mother's tragic death and I'm sharing it here with her permission.

Mark Graban and Laura Townsend
Mark Graban and Laura Townsend at a Batz Foundation event

13 years ago this week I lost my Mom to a preventable medical error. It still doesn't feel real writing that. It is hard to believe that is how my Mom had to leave this world.

We had no warning… so unexpected.

I thought she would outlive us all.  I was looking through old pictures today and especially videos. I have been wanting desperately to hear my Mom's voice again.  

13 years is a long time to not hear your Mom talk. I miss her voice so much, We would talk so many times a day.

She was always there for us. Always present, Always, Joyful, Always Loving. Over the past 13 years I have shared my Mom's story countless times around the world. It is never easy. There is never a time that I do not cry. I am crying right now writing this email.

Yet, I know that every time I share her story we SAVE lives. So I will continue on until 400,000 lives a year lost from preventable medical error is ZERO.

13 years ago, My Mom made the decision to have total knee replacement surgery.  I came down to San Antonio the night before her surgery so that I could be there for her. That night, we were in the family room watching TV. It was a nightly ritual of ours when I came to San Antonio to visit. With my dad asleep and my two daughters tucked in, Mom and I had time to relax and just catch up.  We were watching “24.” We loved seeing how Jack Bauer was going to save the world yet again in only one day

I always cherished those moments and even now they are some of my fondest memories, Mom was looking over all her paperwork for the hospital, getting ready for her knee replacement surgery the next day. She timed it just right so that she would have enough time to heal and be ready to welcome the arrival of her fourth grandchild, Riley.  

We went to the hospital the next morning. My Dad, my aunt Joanne, and I were all with her in the Pre-operative room. She was still so calm and strong. I was so proud of her. The nurses came and got her and I gave her a kiss and told her I would see her in a few hours. Dad, Joanne, and I sat in the waiting room nervously for a couple of hours. I always thought that this was the scary part, the surgery. The doctor came out and told us everything went great and the surgery was a success. 

They moved her down to the orthopedic floor. They had her on a PCA receiving 2mg of morphine. She was doing well until about 6pm when she started to FEEL nauseated from eating cream soup. The nurse gave her a sedative for nausea. 

We were trying to decide if one of us should stay with my Mom overnight in the hospital. The nurse told us to go home because Mom really needed her rest. She had to get up at 4:00 A.M. to go to her first physical therapy session. We went over with the nurse the medications she was to receive that evening.  The nurse told us that she was to receive her nausea medication, morphine, and another narcotic for pain. We told that nurse that she didn't need all of that medication. If anything, only give her the morphine because her pain and nausea were not bad anymore. 

At 10:00 P.M., I gave my Mom a kiss and told her she was doing great and that I loved her. I never imagined that would be the last time she would speak to me or tell me goodnight and that she loved me. I will forever wish that I had not listened to the nurse. I will forever wish I had stayed with her. 

The phone rang around 3:15 A.M. It was the hospital. The hospital staff informed Dad that Mom was having trouble breathing and that we should come down to the hospital. We immediately got dressed and raced to the hospital. 

I raced into her room, and at that moment I felt a pain that I have never experienced in my life. I thought my Mom was already dead. She was so white and lying still on the bed. The nurse was pumping oxygen into her. She could not breathe on her own. I started yelling and screaming, and it took every ounce of me not to start throwing things at them. How could this have happened to my sweet wonderful Mother? 

It is so hard to describe the emotions that I felt at that moment. It was like a thousand knives going straight through my body. Those first moments were filled with anguish and pain like I have never felt in my life. They told us my Mom had suffered from respiratory depression. The nurse had in fact given my Mom the nausea medication, morphine, and Meperidine at midnight and never went back to check on her or have any type of monitoring on her. 

My Mom was on life support for ten days. During those ten days in the hospital, we asked a million questions about how this could have happened to my Mom. It didn't take long to realize that she was in this condition because of a preventable medical mistake. I felt like my mom had gotten hit by a drunk driver. It was all so sudden and could have been avoided. How could this have happened? 

I started doing some research and quickly realized what a huge problem patient safety is in this country. I had no idea so many people died each year from preventable medical mistakes. Some Studies show that it is the 3rd leading cause of death in this country behind heart disease and cancer. How did I not know this? 

I told her over and over again how much I loved her and what a wonderful mother she was. I kept hoping for a miracle. Hoping that she would wake up and just look at me and tell me everything was going to be ok. But, the damage to Mom's brain was too massive, and eight days later we were told that she would never be able to recover. 

We made the painful decision to take her off life support.  I sat with her until her oxygen finally read zero and the heart monitor had “flat-lined”. Eleven days after her knee surgery, my Mom passed away. 

She didn't die from a terminal illness or serious medical condition; she died from a preventable mistake. Why? 

From that moment on, I had a new sense of purpose and focus. My life took a new direction that night. I got up the next morning and wrote the mission and objectives of the Louise H. Batz Patient Safety Foundation. I was not going to let my Mom's death go unnoticed. I couldn't imagine other families having to experience this pain. My Mom would never want other families to suffer the way we have. 

We asked a thousand questions that day my Mom was in the hospital. We just didn't get lucky and ask the right one. I know that if I had known the RIGHT questions to ask, my Mom would be with me today.

If we could have all worked together with the nurses and doctors as a team, the outcome could have been different. My Mom's death did not lie on the shoulders of one person; it was a team failure. Until we all work together; these mistakes will keep happening. 

I wish every day that I could just have five hours back. If I only knew then what I know now, My Mom would be with us. Yet, through this tragedy there is great hope. We, as a community, don't have to sit idly by hoping and praying for the next brilliant scientist to discover the cure for heartbreaking diseases like cancer, Alzheimers, or Parkinsons to save the ones we love. 

We can do something right now. We can make a difference today. What happened to my Mom was 100% preventable. It doesn't have to happen to you or your loved ones. The time is now to work together to help our doctors and nurses, and to truly become part of the healthcare team. If we are going to make a difference in the staggering numbers of preventable medical errors that happen each year we can no longer be spectators in our healthcare. 

As a family we founded the Louise Batz Patient Safety Foundation, to ensure that patients and families have the knowledge and tools needed to be an effective advocate for yourself and your loved ones. The healthcare community is working tirelessly every day to improve patient safety. Yet, it will take all of us –  families, patients, and caregivers – working together as a team, to truly keep making a difference. We have gone on an incredible journey from tragedy to HOPE.

Over the past 13 years we have:

  • Raised $3.0 million dollars for Patient Safety.
  • Published 10 unique “Batz Guides for Bedside Advocacy” in English, Spanish and Dutch to help patients and families ask the right questions while navigating their healthcare.
  • Developed the Batz Patient Guide App for iOS and Android.
  • Printed and downloaded over 40,000 Batz Guides that have been distributed to hospitals, patients, and families around the world.
  • Shared Louise's story across the United States, Canada, Europe, South America, and India.
  • Established The Batz Foundation Europe in Amsterdam, Netherlands 
  • Establishing The Batz Foundation South America in Buenos Aires, Argentina

We could never have gotten this far without all of you, your support, love, and friendship mean the world to us. We will work every day to help patients, doctors, nurses, and families improve patient safety and education in our hospitals and communities not only in Texas but around the world. 

My girls, Ella and Mary Louise are 17 and 14 now. Richard's boys Sawyer and Riley are 15 and 12. They are wonderful and so close. 

I am in awe of my Mom more and more each passing year that my kids get older. I ask myself often, “How did she do it? How was she so good at being a Mom?” To me, she was the GOAT (Greatest Of All Time).

I wish every day she was here to help me figure it all out, but I know that she is guiding us from heaven. Many of you know, if you have ever played sports with our girls, that my husband Michael is THE videographer. He is so good at it! I am sure you have received a sports clip from him of your kids if you have played any sport with Ella and ML over the years.:) He loves making birthday videos and sports highlights.

As I was looking through old videos tonight, trying to find my Mom so I could hear her voice again, I came across this video that Michael made shortly after my Mom died. I have never shared it before. It is so special and I love that he did this for us. 

I love you Mom, ALWAYS  and FOREVER. 

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