Transcript Document

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Honey
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http://www.healthcareneglect.com
PARTNERING WITH WRHA
LESSONS LEARNED
FROM PATIENTS & FAMILIES
EXPERIENCES IN HEALTH CARE
We would like to acknowledge that the perceptions and experiences portrayed
here, do not necessarily reflect the practices or quality of care given by many
health care professionals. We also acknowledge that many patients & family
members have had excellent experiences with the health care system.
“My mother died of lung cancer in 1980. From 1976 to 1980 every year
her family doctor treated her for pneumonia. X-rays were taken three
out of five times. By the time that she was diagnosed, the tumour in her
left lung was large enough to completely block the lung and the tumour
in the right lung was the size of an orange. I think these should have
been seen on the x-rays and investigated, but they were not. Had the
growths been identified in 1976, perhaps my mother would have had a
chance to live past the age of 48!”
Patients’/Families’
Concerns
About
Quality of Care
Incorrect Diagnosis
Or
Treatment
Failure to Diagnose
Or Treat
Inadequate Interaction
Among the Health
Care
Providers Themselves
“… In Canada … your Family doctor passes
you into the hospital care and a series of
disconnected Specialist doctors “do
things”, largely in isolation but with little
time to co-ordinate things and no time at
all to pass back findings.”
“I have been sick for 22 years with
Fibromyalgia. When I've gone to the
hospital with other problems they always
say it is Fibromyalgia and do not look for
other things. I went to the hospital
Emergency for a problem and they said
it was nothing just the Fibromyalgia. It
ended up being a heart problem that I
am still taking meds for.”
Unsatisfactory
Medical Care
Incompetence (Lack of
Fundamental Skills)
“My husband’s niece is paralysed
from the waist down after giving
birth to her second child because
of an improperly administered
epidural. Finally received a
settlement seven years later (out
of court).”
Lack of Clinical
Follow-up
Deficient Bedside Care
&
Monitoring of Patients
“This example pertains to: my wife with Transverse
myelitis; my mother with cancer and myself with kidney
stones. In all cases the nurses or doctors were more
interested with getting me processed and out of the
hospital, or finishing their shift. I had seen nurses gathered
at their station gabbing when my wife needed help. When I
asked for assistance they made me feel like I was
interrupting.”
Delayed Treatment
“My grandmother had a foot infection and
was given antibiotics that were too strong
for her--for 6 weeks. She wasn't monitored
and it ended up killing both the good and bad
bacteria. The last 72 hours of her life, she
suffered miserably, unable to speak, eat, or
move. The specialist at this last hospital was
so upset with what he'd learned that he
almost cried. Her death was imminent and
unnecessary, and definitely as a result of
neglect.”
“ My husband died of meningitis needlessly. He was told there was
nothing wrong and sent home from
the hospital by ambulance because
"he was unfit to travel by private
vehicle. Thirty-six hours later he fell
into a coma and later died.”
“After emerging from a physiotherapy
bath and sitting naked on a chair with no
towel, I started to shiver. The nurse came
along and said to me: “Stop that!” I asked
her for a towel, and eventually she went
and got one, at her convenience.”
“They really messed up my 15-year-old daughter
when she was in Riverview Hospital. I’ve
complained for a year and a half--to no avail.
They just do whatever they want and damn the
consequences to the patient and family.”
“My wife said to the doctor, “My father is
having a bad reaction to the medication
and explained to him what was
happening. He asked my wife, “Are you a
doctor?” My wife said, “No.” He said,
“Then shut up you are not a doctor.”
Patients, families & Family Doctors Are
Denied Participation:
During Patient Care
&
In any Investigation And
Resolution of an Adverse Event
Interpersonal Relationship Skills Generally Lacking In
Health Care Providers
Inability to Interact
With Health
Care Providers
Patient/FamilyCentred
Care Obstacles
Patient Advocates are Biased Towards the Health Care
Institutions They Serve. This Inhibits Effective Interaction
When Health Care Concerns, Raised by Patients and/or
Families, are Addressed & Resolved
“Seven years ago my father developed angina and was taking medication for the
condition. At that time a lot of doctors were anxious to do the balloon procedure, which is
so common now. However, I was of the opinion that since he had not had a heart attack,
and was able to have fair control of his condition with medication, that they should not
“mess with fate”. The upshot of it is that during the procedure, they blocked an artery,
which caused him to have a fatal heart attack. I, along with my brother decided to seek
assistance form the Patient Advocate who has an office at the hospital. She is a
Registered Nurse, as well as, being a licensed lawyer, who was at that time not
practicing either of these professions. I agree that it would seem that she would be well
qualified to speak to doctors and nurses and have a good understanding of medical
practices as well as knowing the legal end of it. However, unfortunately, I found her
“help” to be next to useless. In retrospect, I guess it’s only obvious that a nurse who
works as a patient advocate in a hospital, being paid by the medical system, could only be
supportive of her “employers”, and would have nothing to gain from helping me. In any
event, my father was dead and she needed her job.”
Patient/FamilyCentred
Care Obstacles
“ I have had three people close to me that died from
medical neglect. I also used to work at a hospital and
know how things are run, and the staff and doctors even
tried to tell me things that I knew I had the right to, but
even then if I tried to step on their toes, how would they
treat my family members once I was gone because of
this?”
Afraid of Backlash Seeking Involvement Might be
Construed as Interference &
Thereby Jeopardize Medical Care
Frustration & Anger
Over Inadequate
Care Displayed by
Health Practitioners
Distressing Feelings
About the
Health Care System
“For over one year this lady who never complained to anyone in her life started
to have abdominal pain and back pain. She went to doctors asking for help, the
pain was severe. She had to quit her job of 25 years. She was sent to specialists
who told her they saw nothing wrong in her x-rays and blamed her pain on
depression, causing her to have perhaps some chronic pain and was prescribed
Tylenol #3 and anti-inflammatory pills and of course Prozac. Her pain became so
intolerable that she could hardly get out of bed. She was reportedly brought to
the emergency ward of the Riverside Hospital where they simply sent her back
home. Her suffering lasted for a year and a half. One night her son got very
angry and brought her to emergency again and told them that he was leaving her
there and no way was he taking her back home to suffer in agony. They finally
admitted her and within 7 days she died. They discovered at last that she had
died of ovarian cancer.”
Mistrust in the Current Health
Care System Leading to
Fear of Not Getting Safe Care
Futility & Helplessness In
Trying to Address the
Difficulties Encountered
“ Should a member of my family be hospitalized for
a potentially life threatening problem, I would
ensure that someone was with them 24 hours a
day. Someone loud and obnoxious who is capable of
chasing down the Doctors and Nurses and annoying
them enough to take action.”
“My daughter…was operated on for endometriosis
which she did not have. The surgeon took out her
appendix to justify his operation. She has a case
against the doctors, but not much chance of winning
because she had not kept track of dates.”
Patients’/Families’
Recommendations
to Address the
Issues
The Health Care System Must be
Changed to Prevent Adverse
Events
From Happening
Need for Health Care
System Changes to
Improve Patient Care
An Organization Outside the
Health Care System is
Needed to Facilitate & Ensure
Effective Change
“… Urgent and definite need for an
independent organization to push for a
change for better.”
“I have also heard some tragic accounts of people
sitting in Emergency rooms almost endlessly before
some receptionist calls you up to give them your
family history. Can they not delegate at least one
qualified Physician to screen or pair off people in need,
say into groups for example, according to the
seriousness of the complaint. They would be
experienced enough for the most part to differentiate
between the desperate and the hypochondriac,
surely.”
Health Care Providers Should be
Held Accountable for Unsatisfactory
Patient Care if Their Actions
Caused Adverse Events
“Consumers” of the Health Care
System are Eager to Contribute to
Solutions that will Result
in Improved Patient Care
“I had a couple of suggestions to make. The first is the establishment of a
“national registry of medical/surgical complaints” which could be
implemented as a web site. Using a password to access the site, patients
could read complaints about physicians or surgeons or nurses involved in
their care. Or they could lodge complaints about things such as unnecessary
surgeries, or worse still, incompetent techniques, giving enough of a case
history to substantiate the claims. The second would be a requirement that
nurses and nursing assistants have a clear demarcation in duties, differing
education, and that they be educated to national standards to match the
requirements of their job descriptions.”
“… Physicians, nurses and hospitals need to be held
accountable for their actions. Many doctors are
more concerned with the almighty dollar than the
welfare of their patients. Many medical schools admit
only those with the highest GPA rather than those
who would make the best physicians. This is where
one change should be made. Medical schools need to
train compassionate doctors rather than textbook
physicians.”
WHERE PATIENTS & FAMILIES ARE CONTRIBUTING
IN THE WINNIPEG REGIONAL HEALTH AUTHORITY
Patient Safety Advisory Councils Established
Patients Included on Medical Walk-Rounds
Patients Included on Patient Safety & Quality Research Councils
Patients’ Input Utilized in the Redesigning & Lay-out of Hospital Departments
Patients Included in Presentations to Medical & Nursing Students Regarding Patient Safety
Patient Safety Voice Facilitators Established & Hired Within the Region but Outside the Hospitals to Address Patient Concerns
Patients & Family Members Included in Safety Investigations
Research Conducted Seeking Patients & Family Members Perspectives/Recommendations to Address Health Care Safety
A Network of Patients/Family Members Facilitated to Partner in Implementing Safety Initiatives
Mechanisms Created for Patients/Families to Report Adverse Events
Legislation Explored Allowing For a Humane Response Subsequent to an Adverse Event (Liability free apology)
Health Care Advocates Promoted for each Patient (family members, friends)
Patients/Family Members Engaged in Administrative Processes (e.g hiring)
The Voices of Demographics Typically “Unheard” (e.g cultural minorities, women, elderly, disabled) Sought Out
http://www.healthcareneglect.com
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