NPSF Announces Scholarship Opportunities for Annual Congress

This is a wonderful opportunity for a patient or family member who would like to attend the NPSF Annual Congress this May in Washington, DC:

The National Patient Safety Foundation recognizes the importance of involving patients and their families as partners in our work to create safer healthcare environments. NPSF has developed a scholarship fund that will support the participation of patients and families at the 2009 Annual NPSF Patient Safety Congress to be held May 20 – 22 in the Washington DC area. The scholarship award recipient will receive:

* Roundtrip airfare to Washington DC from anywhere in the United States, arranged by NPSF* Transportation to and from the airport, arranged by NPSF* Complimentary Congress registration* Complimentary registration for the pre-Congress program: Community Engagement from the Patient and Family Perspective* Complimentary hotel accommodations for the nights of May 19 through May 21 (up to 3 nights)* Meals provided as part of the Congress

Scholarship Guidelines and Application Process:

In order to support patients and families who are actively engaged in the patient safety movement, we request a 250-word essay that describes how you and your community will benefit by your attendance at the NPSF Congress.

We are seeking responses to the following questions:* How did you become involved in patient safety?* How long have you been involved with patient safety?* What do you hope to learn at the NPSF Congress and with whom will you share this knowledge?* How do you to plan to disseminate this information throughout your community?

We also request a brief letter of reference that addresses the following questions:* In what capacity do you know the applicant?* How has the applicant demonstrated a value in patient safety work?

Please include your name, address, telephone and email information in the application. Please email your application to:
Christy Norcross, CMP
cnorcross@npsf.org

The deadline for entries is March 23, 2009. For additional Congress information, please visit http://www.npsf.org/npsfac/ or call 617-391-9900.

The Times They are a-Changin'

If you instantly recognize the title of this blogspot, then you’re probably of my generation. Or, you’ve become familiar with the song title reference (a Bob Dylan song made popular in the 60’s) because of its resurgence during the Obama election.

Last year, Facebook was that “thing” that my son’s guidance counselor warned me to have him clean up so that he could get into a good college. Didn’t understand it, didn’t necessarily want to, and hoped that he would clean it up because I certainly didn’t have access to it! In the past six months, though, it became clear that this Facebook thing was something MITSS might want to take another look at. So, we had to call in an expert. Linda’s 21 year old daughter, Jessica, was kind enough to come into the office and set us up with a Facebook page – a Group and a Cause! We were thrilled – although not sure why. We were now cutting edge, new wave, in with the in crowd (ok, so now I’m dating myself again – remember that Ramsey Lewis song?). Fast forward a couple of months, and we’re bona fide Facebook addicts. Linda and I both have our personal pages, and our MITSS Group has grown to nearly 300 members!

All kidding aside, we have truly begun to see the benefits of community outreach through Facebook. It is an amazing medium – one that helps us to connect with others who share our common interest in patient safety and commitment to supporting anyone affected by an adverse medical event. We know that younger people are getting much of their information through social networking sites. We have also read that in the past six months, there has been a huge influx of “older” people coming onto Facebook – a shift that we have been proud to be a part of.

Since the MITSS mission is so closely tied to creating a greater awareness and educating about medically induced trauma, it would seem almost irresponsible not to explore new and innovative ways of reaching out to our community – a community that now includes our Facebook “Friends.” So, if you haven’t already, join the MITSS Group on Facebook (just search Groups and type in MITSS). If you’re not on Facebook, don’t knock it until you’ve tried it! Set up a page, and don’t forget to join the MITSS Group.

And, if Facebook weren’t enough, we’ve begun to post many of our video spots on YouTube. MITSS has a YouTube Channel (again, we called in an expert – Linda’s 12 year old daughter, Lindsay – to set it up). Visit www.youtube.com/user/MITSSUtube , and, as always, let us know what you think. We will be updating video posts as we go along.

The times they are a-changin’ and MITSS is a-changin’ with the times!

Winnie Tobin

Flying Trapeze as Therapy?!

We recently read a piece written by a young woman named Megan who had experienced a medical error and lives each day with the emotional fallout. In an effort to heal mentally, physically, and spiritually, she has taken up quite an unusual activity – the flying trapeze! We were moved by her insight and inspired by her tenacity and courage. We were also quite surprised to learn that the trapeze flying business can actually show healthcare a thing or two about safety! We are grateful that Megan has allowed us to use this space to share her story:

In April 2008, I experienced a medication error during an elective outpatient hospital procedure. While there were several factors that contributed to the error, the primary cause was a decision by a doctor that my previous adverse reaction to the medication was not significant enough to warrant deviation from the “standard protocol”. I was given the medication against my wishes and without my knowledge. Upon being informed of the error, my attending physician, in an attempt to be helpful, told me steps I could take to prevent the error in the future. Even though the error was not my fault, the implication was that I was expected to take responsibility for it.

As often happens with medically-induced trauma, I lost the ability to trust others and found that I could also no longer trust myself. I had put myself in a situation at the hospital where I thought I would be safe, but ended up being harmed by it. I blamed myself for my lack of foresight—for not knowing the “magic words” that would have protected me. I became stagnant with the fear that I did not have the judgment to avoid another painful mistake.

After several months, I decided that I could no longer live with the constant fear and self blame. I knew that I had to do something to rebuild my confidence and trust. It was at this point that I happened to see some information about a local flying trapeze school (http://boston.trapezeschool.com). I decided that this would be a good way to challenge my fears. I used a simple risk assessment, “Do you think you could get hurt worse doing this than you already have been hurt this year?” “No.” “Well, OK then.” I signed up for a class. What I experienced in trapeze class was the polar opposite of what happened to me in the hospital:

Safety First—The entire trapeze system is designed around keeping the participants safe. There are redundant systems so that if one fails, a backup will be in place. The systems are checked on every swing, making sure the rigging is working properly. Because all the class participants are at different levels, the instructors always ask the student before each swing to make sure they have the details correct. The instructors always “spot” each other, pointing out if someone forgets a detail without any feelings of blame or embarrassment.

It is OK to be scared—Even experienced flyers get a little nervous their first time up on the platform. Fear of heights is part of human nature! The instructors will help you get up the courage to take that first step, and nobody will think you are a baby or a wimp if it takes a while. Even if you decide not to take the leap, your choice will be respected. Being able to acknowledge fear and take the leap anyway is very empowering.

Trusting others—Much of flying trapeze goes against intuition. If you can do what you are told when you are told, the tricks will work. One example of this is that you need to stand on the starting platform with your hips pushed forward. This feels very scary at first, until you realize that the instructor is holding the back of your belt and the resistance makes you safer. Another example is how the timing of the trick is essential to being able to do it correctly. Too early or too late, and you need to work against gravitational forces instead of letting them help you.

The Catch –For the last part of the class, students get the opportunity to throw a trick to the catcher. The person who is going to be the catcher watches the students do their last round of tricks “to the net” to figure out the time it takes each individual to do the trick. This is important because each person is unique in his/her reaction time to the calls, and swing speed. For the catch to work correctly, the catcher needs to plan for this and time the trick appropriately. Students are not told, “you need to adjust to your catcher’s timing.” It is the catcher’s job to adjust to them.

Trusting yourself and having others trust you – The first trick you learn on trapeze is fairly simple and the catcher pulls you off the bar for the catch. After that, you learn tricks where you must release the bar on command (a.k.a. Wait for the Hep!). The instructors will only allow you to throw these tricks to the catcher when they are confident that you can wait for the command. It is very easy to anticipate and let go too early. If that happens there is risk of injury, mainly to the catcher, as you go flying into him. You need to be able to trust yourself, and also know that the catcher trusts you to follow the commands.

Taking responsibility – If a trick doesn’t go as planned, which usually results in a missed catch, the instructors always discuss with the students what went wrong. If it was a timing error, the instructors take responsibility. If the problem is the student not getting into the correct position, that is explained as well. After every missed trick, you will hear someone say, “that was me.” The goal is to improve the process and the student’s experience, not to point fingers and assign blame. Everyone on the team is willing to take steps to make that happen.

So while my recovery from my medical error continues, I am very happy to have found an activity that I can enjoy and feel safe doing. One of the school slogans is “Forget fear, worry about the addiction.” This has certainly been true in my experience. Friends say to me, “I don’t know how you can do that, I would be terrified!” For me, I am trying to limit what I am willing to fear. I don’t know if I will ever get over my fear of hospitals, but at least I can scratch “Fear of Flying” off my list.

Keynote Speaker Videos Now Available!

As promised in a previous post, videos from the MITSS 7th Annual Dinner and Fundraiser are now available. If you weren't able to be there, or if you would like to experience these amazing presentations again, go to the MITSS homepage and click on Margaret Murphy and Paul Levy's pictures.

Margaret Murphy, a Patient Advocate and Member, Patients for Patient Safety of the WHO World Alliance for Patient Safety, pays a loving tribute to her son, Kevin, who died from a series of preventable medical errors. It is a moving, heart wrenching story of one family's tragic experience with a healthcare system that failed them. It concludes on a hopeful note, though, because of one woman's strength, courage, and determination to find some meaning from the death of her son.

Paul Levy, President and CEO of the Beth Israel Deaconess Medical Center in Boston, provides the second keynote address outlining his own institution’s commitment to creating a consistently excellent patient experience. He shares that BIDMC’s Board of Directors recently adopted two audacious goals: (1) by January 1, 2012, to be in the top 2% of hospitals in the country; and, (3) to eliminate all preventable harm by January 1, 2012. Paul speaks candidly, with wisdom and wit, about the BIDMC’s journey thus far in pursuit of these seemingly unreachable goals.

Two amazing people -- two unforgettable presentations!!!

Apparently, It's Just Not That Simple!

In our previous post regarding surgical checklists, we asked the question "Can it really be that simple?" The answer is -- apparently not!

For a lively and informative discussion, see Paul Levy's blog post (including the comments) on the same topic. Barriers to change include a "broken" medical education system, a physician culture that resists "standardization," and a lack of consumer/patient input. Also, it seems that if the medical community cannot adopt such system changes (like the use of a surgical checklist) relatively soon, the likelihood of further burdensome regulation and legislation is very real. While the exchange is fascinating to read, I found it quite dizzying trying to sift through the differing perspectives and important issues raised!

I guess the appropriate question then would be -- Are we making any real headway or just continuing to spin our wheels?

Simple Checklist Can Make Surgery Safer

A Harvard School of Public Health study indicated that deaths and complications from surgery dropped by one third when operating room teams used a simple 19-step checklist. While the results of the study are certainly promising, doctors, nurses, and institutions may still be reluctant, for various reasons, to adopt the entire checklist.

As with any patient safety initiative, the authors of the study note that a strong commitment by hospital leadership is required to effect this kind of change. Check out the full text of the article in today's Boston Globe.

Can it really be this simple?

A No Cost Gift Idea with Lots of Benefits

Frank Federico, Executive Director, Strategic Partners at IHI and former MITSS Board Member, was kind enough to send along a wonderful and useful idea for holiday giving --

Medications are the most common intervention in health care. It is estimated that over half of older adults take 5 medications or more. In addition, many may be taking over-the-counter and/or herbal remedies. When these patients visit a hospital or their doctor’s office, it is difficult for them to remember all of their medications. The names of the medications do not make this task any easier.

Jennie Chin Hansen from AARP came up with a great idea. Encourage people to give their loved ones a list for Mother’s Day and Father’s Day. I am jumping ahead. Get started right now. For Christmas, why not ensure that each member of your family, immediate and extended, has an up-to date medication list. Imagine how much easier it will be for the patient to remember the medications he/she is taking, and for health care providers to review when providing care. And, promise to help keep that list up to date.

There are many formats to choose Check out http://www.macoalition.org/initiatives.shtml (Medication List) or visit the Institute for Healthcare Improvement (www.IHI.org ) for examples from participants in the 5 Million Lives Campaign (key word search: medication list).

By the way, if you or your loved ones do not take medications, how about a card that indicates that you do not take medications. In the event of an emergency, healthcare providers will not have to spend time trying to collect information about your medications.

Frank Federico
Executive Director, Strategic Partners
IHI