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John Senders is Professor Emeritus of Engineering at the University of Toronto and Lecturer in Law at York University in Toronto. He has spoken and written on the nature and source of human error since 1976. He is Principal Scientific Consultant to the Institute for Safe Medication Practices (ISMP) and a member of the board of its Canadian offspring (ISMP-Canada). After a routine visit to his physician he unexpectedly found himself on the cardiac treadmill and 10 days later had a quadruple coronary bypass at a major Toronto hospital with an excellent reputation in coronary surgery. He recovered rapidly and is back at work.
For the first time in many years I entered a hospital not to ask questions and to make recommendations but to undergo a quadruple coronary bypass. Aside from the time spent under anesthesia, I found myself for the next two weeks asking questions and making recommendations.
There had been some dark patches. By the time I had been moved into the intensive care unit I was in a deep depression, with all the attendant distortions of perception and affect. I had not been warned about this, nor was any help given in dealing with it. I was hearing voices, seeing sounds, and completely disoriented. It felt like a bad trip. A fellow patient in an adjoining room was even worse off; he spoke only of suicide. Yet the hospital did nothing for him. He refused to stay in the hospital and it was left to me to talk with him and hold him together until his family arrived to take him home. To my surprise I learned that all the staff were aware that patients coming out of the operation were almost invariably depressed. The failure to communicate and to warn was standard procedure. One wonders what would have been said if the prospective suicide had carried out his plan. They probably would have said “poor chap, he lived a good life. We could not have stopped it …”
The first thing of importance is not to expect a true and complete account from a patient after he has left hospital. Family members recall my saying “the first night on the ward was appalling, the second merely abominable”. By the time I was released I had fortunately completely forgotten those perceptions.
I do not know exactly what happened during the surgery itself. I have begun to have some doubts about the skill with which my leg veins had been stripped for use in the bypass as I continue to suffer from leg swelling 12 weeks after the operation. I was told later that the veins from the first leg were “unsuitable” so the other leg had to be opened as well. There are significant differences in the states of the two legs and I suspect that a different hand had done the second, and in a hurry. Lacking a video record I probably shall never find out what actually happened.
Two family members took turns attending almost continually during the first 3 or 4 days following surgery. It would appear that I was not an easy patient for the nursing staff (see comments by family members).
Towards the end of my stay I became more mobile and wandered about the floor getting my mandatory exercise. I noted with interest the device used to hold patient identity cards. It was identical with the one that had figured in an earlier investigation in which a wrong transfusion led to the death of a patient due to mistaken identity. In 1999 I had spent a significant amount of time in another related hospital, investigating an accidental death stemming from patient misidentification. It was clear that the wrong card had been used to print the labels for the blood to be sent to the laboratory for typing. When patient B was in surgery multiple units of blood (patient A’s type) were sent to the operating room and infused into patient B. B eventually died. The card selection error was easily performed, given the design of the card holder. Apparently the first hospital had not informed the other hospitals of the danger of the defective card holder.
Reports of family members
Report of family member #1
“He requested to see the medication order book before each medicine was delivered. He requested quite often that two nurses independently read the medication order. On one occasion he commented, quite correctly, that the hypodermic needle was poorly designed with a high probability of error.
Food service staff were not informed of medical orders. In one case, before a test procedure there was a sign “nothing by mouth” yet a tray was delivered to him and caught just in time by a family member.
Frequently, food or drink specifically ordered not to be given was sent up. No one seems to check on what or how much a patient eats. On the only evening when a family member was not present during meal service he ate nothing. The tray had been put too far away to reach. It was taken away, untouched, by the attendant, no attention having been paid to the fact that the patient had not eaten. A family member was present at all meal services after that.”
Report of family member #2
“The whole set–up appeared to be a compounding of ongoing procurement failures (failures to have or find), infrastructural failures (failures of function), social-structural (failures to act), and classical errors. Although I did not take notes at the time, and so have reason to suspect my recollections, this is what I saw and still remember:
Procurement: valve and regulator for mobile oxygen units non-functioning. Nurse and visitor worked, without success, to assemble a working unit from old pieces in storage. New regulator eventually procured from another wing.
–(1) non-functioning paper dispenser in bathroom;
–(2) bed controls and nurse call out of reach of patient.
Social-structural: non-response to patient’s urinary distress. Doctors did not offer assistance even under direct appeal from patient.
–(1) oxygen left on even when not used by or connected to patient;
–(2) oxygen line to patient connected, in substitution error, to vacuum line (corrected quickly);
–(3) insulin delivery to wrong room, wrong patient;
–(4) mobile x ray unit brought to patient in error; patient had been brought to x ray less than one hour before.”
By the time I was ready to leave, nurses and doctors alike had become exceedingly careful and answered my questions about my own treatment almost too thoroughly. I often had no need to ask—information flowed to me. Medications were shown to me and explained before they were injected or given to be swallowed. In short, the staff were doing what I had long felt would be the best way to run a hospital—engaging the patient as the final defensive barrier against error. It was clear that I was a customer whose well being and satisfaction were necessary for the well being of the hospital.
When I left I thanked the staff for their excellent treatment and care and apologized for having been a difficult patient. I was assured that I had not been difficult (patently false) and that they had learned a great deal from me (probably true). I was deeply gratified. I had made some improvements in patient safety merely by being a patient and following my own survival instincts!
As it happened, I was quite unaware of what events had occurred immediately following the surgery. The reports of other family members are more revealing (see box 1⇑). The presence of the family members during the first 2 days after surgery was very important. They watched and guarded when I could not do that for myself. We had not thought of keeping meticulous notes. Next time—if there is a next time—that will be added. Of equal importance is the preservation of the dignity and authority of the patient. I refused to be addressed by my first name; I insisted on knowing everything that was to be done before it was done; I made my discomforts known. All patients should be instructed to be aggressively self-defensive. It gets the attention of hospital staff and keeps them alert to the patient’s safety as well as to his or her needs.
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