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….
Author: RRHemphill
I am an emergency medicine physician by training, but have spent much of my career with a focus on trying to improve patient safety and quality of patient care. I have worked in government, military and large academic systems.
The Stories of Harm in Healthcare are Many
If you are interested in patient safety, there remains so very much work to be done. I hope you don’t have a family member that has been harmed by the healthcare system. Rather, I hope many of you are interested in safety and quality because you can see the opportunities available to improve patient care…
How Do We Keep Our Families Safe in the Hospital?
My father entered a hospital with a knee fracture, got a hospital acquired urinary track infection, that continued to worsen with little recognition, and ultimately suffered a cardiac arrest. Somehow, despite being 83 years old, he survived this substandard care. But here’s something you might find equally unsettling, every medical person that I have spoken…
Communication
As I continue to try and manage the care of my father after the catastrophic failure to rescue him, I remain amazed at the problems of communication related to his ongoing care. Teams in hospitals today seem to change every week. If you then factor in asking someone to cover a weekend here and there,…
What Can We Do to Address “Failure to Rescue”?
As discussed in the last few posts, failure to rescue is a serious cause of morbidity and mortality to patients who might otherwise have done reasonably well in their hospital stay. There are steps that healthcare centers can take to reduce the risk of failing to rescue a patient. The below list is not a…
What is “Failure to Rescue”?
I recently talked about what happened to my father when he entered a hospital for a routine surgery to repair a fractured kneecap, had a hospital acquired urinary track infection, then got sicker and sicker until he suffered a cardiac arrest. Though medical systems are working hard to reduce hospital acquired conditions (medicare and many…
Despite Everything I Know, I Could Not Save My Father
Early in my career I was struck by how much I didn’t really understand about how hard it was for patients to access medical care. Long story short, this lead me to a career that has focused on quality and patient safety. I have worked at the national level in the VA and I have…
More Ideas for a Quality and Safety Curriculum
If you have been tasked to set up a curriculum for healthcare quality and safety for medical students, consider the following list of topics. This is a reasonably comprehensive area to start. From here you can develop some of the topics yourself, or you can also look for others who may have background an knowledge…
Standardization and Safety
Sometimes when we suggest that we standardize processes in healthcare, there are people who are concerned that standardizing care is “cookbook medicine” and that we are dumbing things down in the care of patients. People get concerned that standardization takes away the “art” of medicine. But consider this. If there really are proven ways to…
Creating a Quality and Safety Curriculum
It can be a bit overwhelming if you find yourself trying to develop a training curriculum for students, residents, or even faculty in quality and safety. Where to start? Obviously, I can’t cover this in a short blog post, but I can help people who are getting started. To start, recognize that there are now…
Asking People to Change
Our leaders often ask us to make changes. Sometimes they are small, but other times the changes are big. So you have to decide whether you are willing to do the work that comes with making change. When we resist that change, our leaders will often say that we have “change fatigue”. But I think…
Followership
When we think about leadership and the skills of a good leader, it is helpful to think about followers. Is a leader really a leader if he or she has no followers? But here’s the thing, a bad leader really can’t do much damage unless they have a group of bad followers who help do…
What Does Self-Assessment Have to do With Leadership
In the last post I talked about how difficult it can be to assess our own performance. If you believe this to be true (I do) it means that we may not be able to assess when we are performing well, but we REALLY can’t assess our performance when it is poor. So we might…
Can We Assess Our Own Performance
Have you ever walked out of a test thinking you did just fine only to find out that you didn’t do very well? Or….have you ever walked out of a test thinking you bombed it only to find out that you aced it? How can this be? Well, it turns out that we are not…
Rules Based Versus Value Based – Part 2
To create a Fair and Just Culture (FJC) we have to begin to approach adverse events and errors differently. We need to try to imagine what was going on in the mind of the person who made the mistake. Why did it make sense to them in the moment that doing what they did was…