http://www.latimes.com/news/opinion/la-oe-sackman29-2009jul29,0,7604525.story
Kathy J. Sackman is a registered nurse and president of the United Nurses Assns. of California/Union of Health Care Professionals. Her recent article, in the Los Angeles Times, July 29, 2009, "Does Schwarzenegger care about nursing care?" made me stop and think that we have more problems in oversight, besides the problems with the California Board of Registered Nursing. Ms. Sackman states, "......governor voices concern about the state nursing board's failure to act on complaints, but he and lawmakers keep denying it the resources necessary to do the job." As a patient advocate, I am aware of California's resource problems with agencies that not only oversee nursing, as the CBRN, but with other agencies that oversee health care facilities to ensure compliance, e.g. California Department of Public Health, Licensing and Certification Division. This agency oversees such as nursing homes and dialysis units.
According to those I have communicated with at the CDPH, L&C, there are problems with resources e.g. not enough surveyors to conduct inspections such as dialysis facilities. Centers for Medicare and Medicaid Services (CMS) has requested that states, as California, inspect dialysis facilities every three years. However, in my recent communications, I was informed that there are dialysis facilities that have not been inspected in over 4-5 years. CMS' responsibility is to ensure that Medicare beneficiaries, and other patients, receive quality safe care. Without adequate oversight e.g. timely inspections, no one will know if a facility is in compliance with governing regulations. Shame on our government for not carrying forth their responsibilitites. Dialysis is a life-saving treatment that can become life-threatening in a second's time. I say to Ms. Sackman, I share in your concern to have sufficient staff in order to timely investigate complaints, however, I would also like your support for our CDPH L&C to timely inspect facilities. Keep in mind, there might be nursing, or other staff, that are not doing their job, resulting in harm, which could result in a CBRN investigation. Let's protect all. Over the years, I have reviewed surveys from 2003 - 2007 and I am convinced that the inspection process identifies that which facility staff do not e.g. ineffective infection control practices, incorrect dialyzers, wrong solutions used, etc. It is evident that the deficiencies cited, during surveys, are in areas that have not been noted by facility staff, therefore, if the surveyor did not identify a wrong practice, who knows what might have happened. My point is that more resources are needed in agencies besides the CBRN ..Timely inspections can prevent errors that can result in death, suffering and harm
If Governor Schwarzeneggar is going to provide additional resources to the CBRN, then I would suggest, just as important, that he add resources to the CDPH, L&C
Showing posts with label Patient Safety Day July 25. Show all posts
Showing posts with label Patient Safety Day July 25. Show all posts
Wednesday, July 29, 2009
Monday, July 27, 2009
Patrick Malone's "Memo to Congress"
http://www.huffingtonpost.com/patrick-malone/memo-to-congress-listen-t_b_243787.html
Memo to Congress: Listen to the Patients on National Patient Safety Day
As I read through Mr. Malone’s blog post, for the secon time, I was reminded of all that I had been aware of in my thirty year nursing career. I could only hope that elected officials read his blog post, or talked with the many families who stood and lit a candle in memory of a loved one who had died, suffered, or was harmed as a result of a preventable error. Hopefully, Mr. Malone has more pull ,with our congress, then the many patient advocates who were involved in World Patient Safety Day, July 25th.
My first introduction, to World Patient Safety Day, July 25th, was when I became acquainted with Ms. Patti O’Regan, ARNP (Nurse Practitioner) who Founded WorldPatient Safety Day (July 25th) in 2001. I am so grateful, and appreciative, that I was able to become involved , with Ms. O’Regan, in World Patient Safety Day. First, because I am a Registered Nurse and have always fought for the delivery of quality safe care. Often, ridiculed by those I worked with, or even told, by my supervisors, or coworkers, ‘hush, leave it alone, ignore it”. However, I could never leave it alone, or ignore it, because that patient deserved to have quality safe care. Second, was because I was a family member of one who, in my opinion, suffered daily, for years, before she died as a result of health care situations and events that should have never happened. Also, my father acquired a health care associated infection (HAI), of which took months and months of recuperation, taking valued time from his life. This continued to place him in an even more vulnerable position.
My philosophy was to treat patients, as I would want myself, or a loved one treated. But, unfortunately, as we see, this does not always happen. My father, 90, who has experienced, more than his share, in the health care system, has a saying of which he has stated to many a staff person, over the years. “If you don’t care about people, or what you are doing, you should not be in the field of helping others.”
Mr Malone mentions being honest when mistakes are made. I believe, wholeheartedly, that when a preventable mistake occurs, it is crucial that health care providers meet with the patient and/or family and discuss that which happened. True transparency is being honest and as stated in Mr. Malone's blog --- learning from mistakes. My thought, at this time, 'mistakes that should have never happened'.
Over the many years of my working in health care, I have seen a lot and have been certainly informed of a great deal, more than I wanted to know, at times. However, the bottom line is that there is no room for preventable mistakes.
Another aspect of patient safety is that health care providers must buy-into the fact that patients and their loved ones have a right to ask questions and question what which is being done to their bodies.
San Diego Mayor Jerry Sanders, Senator Denise Moreno Ducheny and Assemblymember Mary Salas have all recognized July 25th, 2009 as Patient Safety Day.
Hopefully, we will have more of our elected officials, both at state and federal level, recognized July 25th, each year, as World Patient Safety Day.
In my last thought, I wonder how many, of our elected officials, have a loved one who has died, suffered, or been harmed as a result of a preventable error? If there are any of you out there, did you recognize World Patient Safety Day, July 25th?
Memo to Congress: Listen to the Patients on National Patient Safety Day
As I read through Mr. Malone’s blog post, for the secon time, I was reminded of all that I had been aware of in my thirty year nursing career. I could only hope that elected officials read his blog post, or talked with the many families who stood and lit a candle in memory of a loved one who had died, suffered, or was harmed as a result of a preventable error. Hopefully, Mr. Malone has more pull ,with our congress, then the many patient advocates who were involved in World Patient Safety Day, July 25th.
My first introduction, to World Patient Safety Day, July 25th, was when I became acquainted with Ms. Patti O’Regan, ARNP (Nurse Practitioner) who Founded WorldPatient Safety Day (July 25th) in 2001. I am so grateful, and appreciative, that I was able to become involved , with Ms. O’Regan, in World Patient Safety Day. First, because I am a Registered Nurse and have always fought for the delivery of quality safe care. Often, ridiculed by those I worked with, or even told, by my supervisors, or coworkers, ‘hush, leave it alone, ignore it”. However, I could never leave it alone, or ignore it, because that patient deserved to have quality safe care. Second, was because I was a family member of one who, in my opinion, suffered daily, for years, before she died as a result of health care situations and events that should have never happened. Also, my father acquired a health care associated infection (HAI), of which took months and months of recuperation, taking valued time from his life. This continued to place him in an even more vulnerable position.
My philosophy was to treat patients, as I would want myself, or a loved one treated. But, unfortunately, as we see, this does not always happen. My father, 90, who has experienced, more than his share, in the health care system, has a saying of which he has stated to many a staff person, over the years. “If you don’t care about people, or what you are doing, you should not be in the field of helping others.”
Mr Malone mentions being honest when mistakes are made. I believe, wholeheartedly, that when a preventable mistake occurs, it is crucial that health care providers meet with the patient and/or family and discuss that which happened. True transparency is being honest and as stated in Mr. Malone's blog --- learning from mistakes. My thought, at this time, 'mistakes that should have never happened'.
Over the many years of my working in health care, I have seen a lot and have been certainly informed of a great deal, more than I wanted to know, at times. However, the bottom line is that there is no room for preventable mistakes.
Another aspect of patient safety is that health care providers must buy-into the fact that patients and their loved ones have a right to ask questions and question what which is being done to their bodies.
San Diego Mayor Jerry Sanders, Senator Denise Moreno Ducheny and Assemblymember Mary Salas have all recognized July 25th, 2009 as Patient Safety Day.
Hopefully, we will have more of our elected officials, both at state and federal level, recognized July 25th, each year, as World Patient Safety Day.
In my last thought, I wonder how many, of our elected officials, have a loved one who has died, suffered, or been harmed as a result of a preventable error? If there are any of you out there, did you recognize World Patient Safety Day, July 25th?
Sunday, July 26, 2009
The Day After Patient Safety Day
The day, after Patient Safety Day, brings a sense of calm for many who have shed tears that have been shed before, many times. However, common sense tells those of us who have been affected in our life (or the life of a loved one) by a preventable error that every day is Patient Safety Day. This might be the opposite for many who have never experienced a negative outcome as the result of a preventable medical error.
The recent series, by Propublica and the Los Angeles Times, http://www.propublica.org/series/nurses conveys a reality to many readers who are unfamiliar with the truth of that which happens in health care settings, e.g. hospitals. This is not to say all care is substandard, but to speak the truth and state 'mistakes happen and mistakes take lives'.
Patient Safety is serious business . Patients (and their loved ones) must ask questions and become as educated as possible regarding the care that is being delivered. Patients can ask a nurse, or physician, to wash their hands before entering their hospital room, however, this is not true when such as surgical procedures are being conducted. Therefore, patients must trust that providers are implementing safe practices.
Those delivering care must ask themselves, "Is this the care that I would want myself, or loved one, to receive?"
The recent series, by Propublica and the Los Angeles Times, http://www.propublica.org/series/nurses conveys a reality to many readers who are unfamiliar with the truth of that which happens in health care settings, e.g. hospitals. This is not to say all care is substandard, but to speak the truth and state 'mistakes happen and mistakes take lives'.
Patient Safety is serious business . Patients (and their loved ones) must ask questions and become as educated as possible regarding the care that is being delivered. Patients can ask a nurse, or physician, to wash their hands before entering their hospital room, however, this is not true when such as surgical procedures are being conducted. Therefore, patients must trust that providers are implementing safe practices.
Those delivering care must ask themselves, "Is this the care that I would want myself, or loved one, to receive?"
Saturday, July 25, 2009
A Day of Remembering
Today, a day of remembering those we loved who died as a result of a medical error. As I lit a candle, tears quickly formed making it difficult for me to see the match striking. A pain shot up in my stomach as I remembered how much my wonderful, caring, loving mother suffered. No one should have to endure that which she encountered in the last years of her life. Her decline, daily pain and agony, the result of a physician not listening to what she and her family were saying. The quality in her life was gone, but she lived on in pain, day in and day out. The lack of a complete medical record, at the time of her office visit, in conjunction with a physician who insisted that a certain prescribed medication would be okay, inspite of our concerns about prior medication reactions, led, in my opinion, to my mother's slow death. I can remember calling the physician's office, to provide what I considered to be important information, to an apathetic nurse's assistant. Important information about what I considered an adverse reaction. And, as we feared, my mother fell, as a result of taking the medication, and that was the end of her quality of life. We tried to tell the physician that the medication was having an adverse effect, but according to the physician's nursing staff (a medical asssistant, not a nurse) the physician said to decrease the medication, but do not stop it. I often wonder till this day if the physician really told the medical assistant to tell us to continue the medication. From that point on, my mother suffered daily, at times, needing help to the bathroom, unable to sleep in a bed because the pain was so severe. For a long, long time, she slept in a chair in the living room, with me on the couch, sleeping with one eye open in case she needed anything. The pain for her to even get out of the recliner was more than she could handle. The pain I felt watching her go through her last years in agony tore me apart and still tears at my gut.
We filed a complaint against the physician and, ofcourse, all we received back from the insurance provider was a form letter. And, the physician, till this day, has never said, "I'm sorry". But, the pain of knowing how much my mother suffered still lives on within my heart and soul. Shame on you, a physician who is suppose to listen to patients, as well as listening to their loved ones, who act as their advocate in hopes of receiving safe care.
We filed a complaint against the physician and, ofcourse, all we received back from the insurance provider was a form letter. And, the physician, till this day, has never said, "I'm sorry". But, the pain of knowing how much my mother suffered still lives on within my heart and soul. Shame on you, a physician who is suppose to listen to patients, as well as listening to their loved ones, who act as their advocate in hopes of receiving safe care.
Friday, July 24, 2009
Patient Safety Day, July 25, 2009
Patient Safety Day, July 25, 2009 means so much, to so many. Patient Safety Day, a day to remember those patients, loved ones and friends, who lost their life as a result of a preventable error. This day is also to remember those patients, loved ones and friends, who have lost the quality in their life as a result of a preventable error. And, we recognize those health care professionals who provide and will continue to provide safe care to their patients.
Patient Safety Day, July 25, 2009 http://www.patientsafetyday.com/
Since Patient Safety Day has been publicized, I have received so many emails from individuals who have been on the receiving end of a negative outcome as the result of a health care professional making a mistake. Some individuals have called me to tell an even sadder story of one they loved, who died because of a mistake in a hospital. Saddened by these stories, I realized that there are many consumers of health care who have no idea of what true quality safe care is about.
Because a health care professional is nice, pleasant, or makes you laugh, does not mean that this health care professional is providing quality safe care.
Many have come to me and said how much they loved their nurses and physicians because they were so nice. Then, something happened and they realized that nice does not mean safe care.
Be educated. The more educated you are, the safer you will be.
Patient Safety Day, July 25, 2009 http://www.patientsafetyday.com/
Since Patient Safety Day has been publicized, I have received so many emails from individuals who have been on the receiving end of a negative outcome as the result of a health care professional making a mistake. Some individuals have called me to tell an even sadder story of one they loved, who died because of a mistake in a hospital. Saddened by these stories, I realized that there are many consumers of health care who have no idea of what true quality safe care is about.
Because a health care professional is nice, pleasant, or makes you laugh, does not mean that this health care professional is providing quality safe care.
Many have come to me and said how much they loved their nurses and physicians because they were so nice. Then, something happened and they realized that nice does not mean safe care.
Be educated. The more educated you are, the safer you will be.
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