JKF Journal: Patient Safety Week

Monday, March 9, 2009

Patient Safety Week

It's Patient Safety Week- a time to reflect on all of the great patient safety projects and initiatives that have been under way. So many people have done so much to make our hospitals safer and for that I am forever grateful. But this is also a week to look ahead towards an even safer, better health care system. From what I can see, we have come a long way, but the journey is not over yet. There is work to be done.

I've heard from nurses and doctors all around the country who are planning on commemorating Patient Safety Week. There will be speeches announcing new safety programs, and ceremonies honoring caregivers who have done remarkable safety work. Patient safety is front and center, and I am excited about that.

Let's stay invigorated. A few quick hopes of mine:

If you are a caregiver, keep focusing on improving how you communicate with your co-workers and patients. Even if your team communicates well, the nature of team work is one of continual change, and it helps to check in every now and then to make sure everything is still working well.

If you are a student, keep learning about patient safety and preventing medical errors. Ask your professor or mentor about the changes they have seen with regard to medical errors since they started practicing.

If you are a patient or family member, thank your health care team for incorporating patient safety techniques into their daily routine.

I'll be commemorating Patient Safety Week with a few groups around the country this week. I hope that everybody is able to support Patient Safety Week in a way that is helpful and meaningful for them.

Keep up the good work!

-Sorrel

Labels: by Sorrel, Patient Safety Week

4 Comments:

At March 13, 2009 at 2:02 AM , Anonymous said...

Thank you for having the courage and pesilience to share your story- Josie's story with the world. It's made me a better Nurse, mother and a much better Patient Safety Officer. I have shared your story with staff at the hospital where I work, you are helping make healthcare better. THANK YOU for a selfless legacy!
At March 21, 2009 at 4:24 PM , Anonymous said...

Sorrel,

I'm the corporate director of a clinical decision support department of a healthcare system in the south and I'm also a student finishing my master's degree in health administration. My wife died last summer after 3 years of being in a persistent vegetative state. It was a decision we made to let her go, to withdraw hydration and nutrition, a hard and painful decision.

The difficulty was compounded by the fact that, as the days turned into weeks, I discovered that the physician's orders for pain medication entailed crushing the pills mixing them with water and delivering them through her feeding tube, preceded and followed by a flush of water. So, although nutrition had been cut off, she was getting hydration enough to hang on. I didn't know this until four weeks later we had made the decision to let her go.

As we waited and watched I had multiple conversations with the doctor and the hospice nurse. Can you imagine the guilt I felt at asking the doctor whether there was anything we could do to hasten her death? Whether the medication could be adjusted to make this easier? How much longer we would have to watch her slip away?

Finally, after the hospice nurse implied that she was suspicious that the nursing home staff were secretly continuing nutrition and hydration, I demanded a meeting with the nursing home staff, the doctor, and the hospice nurse. That's when I discovered the orders that were keeping my wife hydrated just enough to stay alive, but not enough to keep her body healthy.

I'm sure if anyone can, you can imagine how I felt, discovering that the people I had trusted for so long had been so negligent, so careless, that they didn't see what they were doing.

Finally, the medication orders were changed, and my wife passed away within a few days.

I decided to finish my degree because I want to continue to make a difference in healthcare. Today I am working on a paper for my leadership class on the systems issues that contributed to your daughter's death. I can't stop thinking about Josie or my wife. I am sobbing as I work.

I don't believe in prayer anymore, but my thoughts are with you and your family.

Keep up the good work. There are lots of us fighting the good fight with you.
At March 24, 2009 at 1:07 PM , JosieKingFoundation said...

Hello Daniel,

I was so sorry to hear about the circumstances of your wife's death. End-of-life issues are wrenching, and to have those emotions compounded unnecessarily must have been even more difficult. Thank you for deciding to bring your dedication to the healthcare industry. If there is anything we here at the Josie King Foundation can do to help, please be in touch.

Best,

Sorrel
At July 22, 2009 at 2:15 AM , Sharlie Clay said...

Sorrel,
I wanted to tell you that your daughter's story has touched my heart and will remain with me forever. I am a nursing student and I recently took a job at a large hospital nearby as a nurse extern. During my two day orientation I was shown numerous slides and videos on every aspect of healthcare that you can imagine... from safety to finances. One of the videos shown was Josie's story. Almost immediately it hit so close to home for me because my son is only 2 years old and I automatically put myself in your shoes... not the nurses. He is an only child so I understood when you said that if it weren't for your other children you wouldn't have survived this. If I lost my son, I would lose everything. I'm just overflowing with emotion anyway so as you can imagine I felt a little foolish sitting at this orientation with a room full of people I didn't know, crying and sniffling. But I think that it's GREAT that Josie's story is so touching. That means it will reach people and they will remember. As parents, we relate everything to our own children and then we must learn to be thankful that these horrific tales are not our own. But they are someone's and this one is yours! My heart aches for you! Josie was not the first or last to suffer for the mistakes we make but I promise that I will do my part in making sure that this doesn't happen to another child or parent. I just finished a research paper about common medical errors and included parts of her story as an example. I also plan to forward the website address to as people as I can, including my professors. I hope that they will be just as touched and use it for upcoming classes to help the foundation and its cause. You are a very strong person and I admire you for what you're doing out of love for your daughter and concern for everyone else! May God bless you and your family in unimaginable ways! Thank You!
Sincerely,
Sharlie

Monday, March 9, 2009

Patient Safety Week

4 Comments:

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