On July 20 of this year, my father suffered a cardiac arrest after developing a hospital acquired urinary tract infection. He did not respond to antibiotics and his worsening symptoms were unrecognized until he pretty much died. He survived, but spent a month in the intensive unit, 10 days of which were on a ventilator. After 2.5 months of repeated setbacks, delirium, new complications, poor communication, my father was discharged to a rehabilitation facility. We anticipate it will take 2-3 months of rehab work for him to even begin to return to some of the things he loves. Reading, gardening, being with his granddaughter. He loves to walk, but that may be an even longer way away, if ever. Mistakes in healthcare have consequences for patients and families. Many, if not most, mistakes are not intentional, but the one thing that is necessary for systems to improve is for systems to take accountability for the mistakes they make.
I think it is fair to say that from the perspective of my family, the facility that harmed my father has not fully accepted their responsibility for what happened. There has not been a meeting with a formal disclosure. There is no documentation in his chart that states an error was made. The facility claims that they have done a review, but that review is “confidential”. This suggests to me that they have not done a Root Cause Analysis, because some of the findings can be shared and improvement plans can absolutely be shared with the family.
I don’t know what improvements that hospital has made to make things safer for my dad. But if they won’t talk about them and they haven’t accepted any responsibility, then it is hard to imagine that anything is really any better.