Fatal Care

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Telling Their Stories Sanjaya Kumar, M.D., M.Sc.,
MPH Karin Janine Berntsen, RN, BSN
THE QUALITY COLLOQUIUM - August 22, 2007
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FATAL CARE

• Vision Objectives
• Move the healthcare consumer beyond the
  statistics associated with medical errors.
• Who are the people behind the numbers?
• What are their stories?
• How do errors impact lives of those affected and
  those that are involved?
• Bringing the consumers to the forefront so they
  can relate to the impact of medical errors on the
  personal lives of people.
• Move the consumer into action.

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FATAL CARE

• Rationale for Fatal Care
• Consumer naivety
• Medical overconfidence
• Assumptions can be deadly.

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• Good, non-fiction, literary work exists that is
  beginning to bridge the gap between the consumer
  and caregiver.
• Internal Bleeding - Wachter, Shojania
• Through the Patients Eyes - Gerteis,
  Edgman-Levitan, Daley, Delbanco
• The Patients Guide to Preventing Medical Errors
  -Berntsen
• How Doctors Think - Groopman
• These works mostly emphasize the numbers and
  statistics.
• FATAL CARE is personal - you, your child, your
  spouse, your neighbor, your friend, your
  mother...
• FATAL CARE - The next step to drive change in how
  the consumer interacts in their healthcare to
  help prevent medical errors.

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FATAL CARE Novel Type Non-Fiction Stories
The Janson Directive
Coma
The Scorpio Illusion
Shock
Critical
The Bancroft Strategy
Robin Cook
Robert Ludlum
New York Times bestsellers
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The Ambler WarningLudlum
On Parrish Island, off the coast of Virginia,
lies a psychiatric facility. Far from prying
eyes, it is a government - run hospital for
former intelligence employees in possession of
highly classified information. Former Consular
Operations agent Hal Ambler is one of these
patients whose mind is filled with secrets of
state - and is considered such a security risk
that he is kept heavily medicated and closely
watched. But theres one critical difference
between Ambler and the other patients - Ambler
isnt crazy. Now he must find a way to escape
the facility, find out who put him there, and
uncover the truth of who he wasand why someone
is willing to risk everything to see him dead.
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FATAL CARE

• Each chapter tells a different story of a family
  impacted by a preventable medical error.
• Three Little Angels Indiana Babies - Heparin
  Overdose
• Even the Tough Can Fall Charlie Weis - Surgical
  Complication
• Never Routine Lewis Blackman - Failure to Rescue
  
• Reading Between the Lines Trisha Torrey -
  Misdiagnosis
• Critically Wounded Diana Brookins - Bloodstream
  Infection
• Wrong Turn Benjamin Houghton - Wrong Side
  Surgery
• You Can Have My House Johanna Daly - Surgical
  Site Infection
• The Mission Taylor McCormack - Delay in
  Treatment
• Picking up the Pieces Diane Ford - PCA Pump
  Failure
• They Are Not Listening Ken Simon - Wrong
  Diagnosis
• Coming Together Linda Kenney - Medical Trauma
  
• One of Their Own Liz Augusta - Near Miss

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FATAL CARE
THREE LITTLE ANGELS
Heather heard muffled yelling and crying from
inside the door, but she couldnt make out what
they were saying. She felt a gnawing, sick
feeling in the pit of her stomach, like something
bad was about to happen and her body knew it
before her headNow Heather heard her mother
yelling. What do you mean? Whats wrong with
Thursday Dawn? Whats wrong with the baby?
Joannas voice became increasingly shrill and
hysterical. Accident, Hep-a-rin, what did you do
to her?
11 Percentage of medication errors involving
dangerous high-alert medications, such as
heparin, morphine, insulin, potassium chloride
and chemotherapy agents.
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FATAL CARE

• NEVER ROUTINE
• By Sunday afternoon, Lewis abdomen hurt worse
  than ever. His belly grew rigid and distended.
  His eyes had a sunken, hollow look. Alarmed by
  his condition, Helen knew Lewis needed to see a
  doctor right away. She repeatedly pushed the
  call button, but they had stopped answering the
  call light in room 749

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NEVER ROUTINE

• As morning broke, the awful pain in Lewis
  abdomen abruptly stopped. When the nurse heard
  this news, she took it as a positive sign and
  said, Oh, good. But to Helen it seemed strange,
  like the eerie calm in the eye of a hurricane,
  where things are temporarily quiet before even
  greater trouble lands onshore.

75 Percentage of U.S. hospitals who still have
not implemented a Rapid Response Team (RRT).
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Following Each StorySections that provide
insight and help for the consumer.
FATAL CARE
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FATAL CARE
Fatal points describe breakdowns in the process
that can lead to patient harm.
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FATAL CARE
Critical Safeguards describe steps that a
patient and family can take to help avoid a
medical error.
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FATAL CARE

• Safety Keys are brief snapshots of patient
  resources and tips.

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FATAL CARE - Story Selections
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FATAL CARE

• A balance of positive and negative outcomes
• Fatal Care had a potential to be a downer.
• Limited fatal outcomes, included near misses.
• Altered positive and negative outcome stories.
• Unfortunately, it could have been Fatal Care
  Children.
• Limited children to three stories.

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FATAL CARE

• Geographic locations
• Medical errors happen in every area, city,
  country and in-between.
• Contacts came from all over the world - limited
  to U.S. for this book.
• New York City, LA, South Carolina, Everett
  Washington, Chicago area, Portland, Boston

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FATAL CARE

• All size and types of hospitals
• Medical errors happen in every size hospital
• Teaching/University
• Community based hospitals
• Specialty hospitals
• Outpatient centers

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FATAL CARE

• Cross section of type of errors.
• Generally healthy people that received care or
  treatment for an illness or injury.
• For this book, we did not select chronic illness
  or complex, multiple diagnosis case scenarios.
• Targeting the general healthcare consumer who
  could relate to, or experience a common medical
  error.

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FATAL CARE

• Queries for the Stories
• Fatal Care Website http//www.fatalcare.com/
• PULSE http//www.pulseamerica.org/
• Previous contacts from
• The Patients Guide to Preventing Medical Errors
• Public news stories
• Mothers Against Medical Errors
• Mamemoms_at_aol.com
• National Patient Safety Foundation
• PATIENTSAFETY-L_at_LISTSERV.NPSF.ORG

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FATAL CARE

• Medication errors
• Infections
• SSI
• Device related infections
• Misdiagnosis
• Surgical complications
• Delays
• Wrong site surgery
• Near Miss

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FATAL CARE

• Methodology
• The key method was personal interviews.
• Written accounts
• Published stories
• Professional education

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FATAL CARE

• Stories
• Some are in litigation.
• Some had completed litigation/settlement.
• Others did not have litigation.

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FATAL CARE - its about the people