The Essence of Patient Safety and Bedside Advocacy

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John BurmanOn April 14, 2009, after a successful knee replacement surgery, Louise Batz returned to her hospital room where her medical team prescribed her an unnecessary combination of sedatives and opioids that eventually caused her to fall into respiratory depression.  After spending the next ten days on life support, on April 26, 2009, Louise Batz tragically lost her life.

During the period of time Louise spent on life support, the Batz family asked a million questions. It didn’t take long for them to realize that their mom was dying because of a preventable medical mistake. Laura Townsend, Louise’s daughter and founder of The Louise Batz Foundation, described the moment of this discovery as the worst feeling of her life. She said “I felt like my mom had just gotten hit by a drunk driver. It was all so sudden and could have been avoided. How could this have happened? My mom’s father, brother, son, daughter-in-law and sister-in-law were all doctors.”

Batz foundation director Laura Townsend (left), with her mother, Louise Batz.

Batz foundation director Laura Townsend (left), with her mother, Louise Batz. Photo courtesy of the Batz family.

In the United States, we often take for granted some of the best hospitals in the world. Louise’s story is so alarming because it is so unexpected. How could something like that happen in a medical system as advanced and well prepared as ours? Tragically – and in part because of this mythos – deaths from preventable medical errors are one of the most unknown, least spoken about failures of our system. Each year, in our country alone, an estimated 200,000 people die in hospitals from preventable medical mistakes.

Let that number soak in for a minute: 200,000.

That’s 550 people a day, 23 people an hour, one person every two minutes.

Image courtesy of American Medical Association.

Image courtesy of American Medical Association.

This means that every year, more people in the US die from preventable infections and medical mistakes than from Aids, Breast Cancer, and vehicular accidents combined.  In fact, of all the major causes of death in the United States, medical errors trail only cancer and heart disease.  Scarier still is the fact that in addition to nearly 200,000 deaths, roughly 2 million Americans, or one in 20 people admitted to a hospital will fall seriously ill from infection or medical mistakes. These percentages are even worse for the uninsured and those on Medicare. According to figures from the United States government, one out of seven Medicare patients admitted to the hospital suffered from a harmful or life threatening mistake during their stay.

So what do these numbers have to do with San Antonio?

Everything.

According to studies done by the Leap Frog Group, an independent research group comprising of some of the top patient and hospital safety experts in the world, San Antonio hospital systems fail to meet many of the organization’s standards and in fact, some even fail to show a willingness to produce their patient safety data. This failure to produce data is especially frightening given that, according to the numbers, less than 25% of Texas hospitals get an A rank in patient safety  by Hospital Safety Score and Texas fails to have a single hospital appear on any safest hospital list.

While there are many issues that lead to increased medical errors, one of the major problems is the dearth of workers to properly staff our hospitals. This is an especially large issue in Texas where, if numbers continue at their current rate, by the year 2020 we will see 70,000 more openings for nurses than we are able to supply.  According to the Agency for Healthcare Research and Quality, every additional patient per nurse during a shift is associated with a 53% increase in pulmonary failure and a 17% increase in medical complications.

Even though Texas has a long road to hoe in order to improve its healthcare, there are signs of positive change and many of them are coming from our city. One of the most unique solutions is coming from Louise’s family. Though San Antonio colleges are rushing to address the issue of under-staffing and hospital employees are working tirelessly to cut down on the mistakes, it is crucial that those of us not involved in healthcare do our part to help.

Photo courtesy of the Batz Family.

Photo courtesy of the Batz Family.

The night after Louise died, her family went home and wrote out a mission statement for their non-profit, The Louise Batz Foundation. Their hope was that through a partnership with local hospital systems, the number of medical errors in our city could be reduced and the tragedy of losing a loved one to something so easily treatable would never befall another family.

Over the past four years, the foundation has worked to fulfill this promise by putting out a hospital guide and iPad App that helps people become stronger, better educated members of their own healthcare team. Pediatric and spanish versions of the guide will be available later this year.  The foundation’s hope is that the guide will provide a place for patients and families to keep track of medicines, access to lists of invaluable questions, learn the basics of hospital staffing and learn how to spot the most common medical errors.

Some of the most common errors during a hospital stay stem from improper monitoring, confusions in patient medication and identity, improper hygiene leading to infections, improperly equipped on unplugged equipment and kinked or broken IV lines causing reduced or stagnated flow of medications.

In addition to the myriad of helpful tips found in the guide, the Batz guide has tests to help people determine their risk for sleep apnea in order to inform their medical staff, charts for the patient nursing staff to review what medications were received and at what time and reminders to help ensure the reduced chance of infection.

Rather than taking the anguish of losing their mother out on the individual hospital where the mistake occurred, the Batz family realized that the issue of patient safety is systemic and that the only way to fix the problem is through teamwork.

Since the development of the guide, the San Antonio hospital systems have worked together in a way rarely seen from competing industries in order to produce the guide, train their staff  and patients to use it, and fund further patient safety research.  According to Ken Davis, CMO of Methodist Hospitals systems, this guide is crucial to contributing to the reductions of medical errors because “care is so complex and we caregivers need to know what family history is, what medications have been taken and what those reactions were, and what are some care nuances that we are not aware of.”

Although many different people from the family and care team asked thousands of questions in the days leading up to and after the accident that took Louise life, they simply never asked the right ones.  In Louise case, this meant that no one thought to check if she was one of the more than 25,000,000 Americans with undiagnosed sleep apnea. If this would have been discovered earlier, she would not have been prescribed the drugs she was and she been more carefully monitored during her stay.

National patient safety week starts March 3
 and this year, in memory of Louse and her family, make it a priority to learn about what you can do to safeguard your loved ones from harm, educate yourself before you go to the hospital, and find ways to work with the local medical community to cut down medical errors in our hospitals.

For access to a Batz Guide for Bedside Advocacy, check out the Louise Batz Foundation’s website, the guide is available for free as a PDF or you can purchase a hard copy at Amazon.

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8 thoughts on “The Essence of Patient Safety and Bedside Advocacy

  1. This story is only the tip of the iceberg. If there are 200,000 accidental deaths, how many more illnesses and injuries are caused by medical errors? How many times have you seen your doctor or nurse sanitize their stethoscope before touching it to your skin? It’s supposed to be standard infection-control procedure, but is rarely followed. Just one of many sloppy practices that lead to iatrogenic (physican-caused) infections. In these days of antibiotic-resistant flesh-eating bacteria, this news should give you pause. Stand up for your patient rights and insist that your provider sanitize any reusable tools as you watch. And those scrubs that you see so many people wearing in public? Do they actually change into sterile ones before going into surgery? Inquiring minds want to know.

  2. This problem has been solved in places like NY or Massachusetts, where checklists are required for every action taken for every patient, like an airline pilot going through his checklists before takeoff.

    • I work in quality improvement and process improvement in healthcare… I can tell you the checklist being “required” doesn’t mean that it’s actually done in the proper spirit. Many “check the box” half-assed checklists or pre-op “time outs” really don’t do anything if the culture hasn’t changed so that anyone in the O.R. can speak up if they think there is a safety risk.

      This all requires a lot of leadership — I applaud the Batz Foundation and local hospital leaders who ARE making strides toward fixing these preventable errors. I don’t think we can legislate our way toward perfect patient care anymore than laws against drunk driving lead to zero drunk driving deaths.

  3. Betty,

    Interestingly, studies show that up to 90% of hospital infections are caused by people not washing their hands. We are going to specifically focus on this problem in an upcoming article because the current methods for sanitizing surfaces are archaic. There is another group in SA who are looking to correct the problem and all early studies are showing wild success!

  4. John, I read your article when it was published and bookmarked it, assuming I’d go back and get the iPad app The Louise Batz Foundation created. I thought I’d have plenty of time. But I thought wrong. My mother was admitted to the hospital last Sunday (here in San Antonio) and today she suffered a serious medical error.

    My mother is in the hospital with pneumonia. She was slowly beginning to recover after a weeklong stay, until this morning.

    When I arrived to visit she was barely responsive and didn’t at all resemble the awake and aware woman my father said goodnight to when he left the hospital last night. After realizing she wouldn’t fully wake up, I had the nurse come check her vitals. Her pulse ox was only 82. This meant she was dangerously low on oxygen.

    Her nurse and I discovered that my mom’s oxygen had been turned off sometime during the night, probably accidentally. But my mother’s pneumonia required that she receive oxygen. It took the better part of today to help her begin to recover from this grave error that may have set her recovery back and which could have led to a far worse outcome.

    I’m definitely checking out the iPad app now and sharing your article with all of my social networks to help spread the word about the overwhelming number of medical mistakes that take place in our country every day. Thank you for writing about this. It’s so important.

  5. Colleen,

    I am so sorry to hear about what happened to your mother and I am incredibly grateful for your willingness to share your story. Since the App doesn’t come out until mid March, I would love to give you several copies of the hardcover book so that you can have them and you can share them with friends and family. My email address is john.s.burnam@gmail.com Send me an email if you are interested.

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