March 9, 2017

Turning loss into hope

A nationwide movement to make health care safer.

“We thought it would be like getting braces,” said Helen Haskell, remembering the day she and her husband brought their son Lewis to the hospital for an operation to correct an indentation in his chest known as pectus excavatum.

For years they had rejected the idea of elective surgery to correct the condition, which involved opening the chest and removing ribs and cartilage. But after reading an article in a local newspaper about a “revolutionary” new approach being used at a large medical university hospital near their home in South Carolina, they reconsidered. The article described a one-hour surgery, performed through two small incisions. Patients could expect to be swimming and playing basketball “in a month or two.”

Haskell and her husband discussed the procedure with their son and his physicians and decided to move ahead. Four days after being admitted to the hospital, Lewis Blackman was dead at the age of 15, the victim of a medical error.

“That day the color drained from our lives,” said Haskell, speaking to Kaiser Permanente physicians and employees last year. “My husband and I prepared to bury the son for whom we had such high hopes, and embarked on a journey to learn why he died and to reform the system that allowed it to happen.”

Free from harm

patient safety awareness week logoHealth care professionals and consumers across the country will join together to highlight the need for safer health care during Patient Safety Awareness Week from March 12 to 18, 2017. Presented annually by the National Patient Safety Foundation, the event highlights the role that everyone plays in keeping patients like Lewis free from harm.

Medical error has been estimated to cause the deaths of 44,000 to 98,000 hospital patients a year in the United States. One recent study puts that estimate even higher at 250,000, calling medical error the nation’s third leading cause of death, just behind heart disease and cancer.

Hospital-acquired conditions such as bedsores, fall injuries and infections are another significant risk, with 1 in 10 hospital patients affected. Adverse drug events are among the most common, affecting about 2 million hospital stays each year.

“That’s what fundamentally killed Lewis,” said Haskell. Put on the anti-inflammatory drug Toradol (ketorolac) to control post-operative pain, he developed a perforated ulcer, a well-known side effect. Despite his complaints of severe stomach pain, the medical residents caring for him failed to recognize the signs of internal bleeding. An autopsy later found close to three liters of blood in his abdomen.

Listening to the patient voice

lewis blackman“Lewis’ story illustrates how essential it is for health care professionals to engage with patients and their families,” said Cara Steinkeler, MD, medical director for Risk Management and Patient Safety at Kaiser Permanente. “We need to fully embrace shared decision-making and encourage the free flow of information between patients, families, and the health care team in order to provide safe, reliable care.”

A national leader in quality and patient safety, Kaiser Permanente is committed to achieving the best health outcomes for its patients.

The problem of medical errors first gained national visibility in 1999, with the publication of the Institute of Medicine’s groundbreaking report “To Err is Human.” Since then, progress toward improving patient safety has been steady but slow. Hospital-acquired conditions fell by 21 percent between 2010 and 2015, according to the Agency for Healthcare Research and Quality, saving 125,000 lives.

A mother’s fight

Nearly 17 years after her son’s death, Haskell remains committed to preventing medical errors. She is the founder and president of Mothers Against Medical Error, a nonprofit patient safety organization, and serves on the boards of organizations including the Institute for Healthcare Improvement and Consumers Advancing Patient Safety.

“This is the legacy we have tried to create for Lewis — to make the health care system a safer place for patients,” she said. “We still have a long way to go, but we have many tools and many allies. We understand now that patient safety is not a project but a lifelong journey.”