Published in: The Philadelphia Inquirer
Written by: Michael R. Cohen, Ph.D.
6/15/2015 – Several tragic deaths about 15 years ago were compelling factors that led to patient- and family-initiated “Rapid Response Teams” (RRT) that were mentioned in my June 3, 2015 blog. The first was a tragic death of an 18-month-old child, Josie King, who had been hospitalized for treatment of burns from a bathtub accident. Josie had been healing well, but she died 2 days before she was supposed to go home. Hospital staff failed to recognize that Josie had become seriously dehydrated, despite frequent pleas by the child’s mother, Sorrel, that her daughter was listless and extremely thirsty—and that something was very wrong. The child’s mother was the first to notice her daughter’s desperate thirst. When the child saw a drink, she would scream for it. And when bathing, she would suck frantically on the wet washcloth. She then developed a fever and diarrhea—another cause of serious dehydration. When she became listless and her eyes rolled back in her head, Sorrel frantically tried to get help for her child because she felt something was not right. But in the end, the young toddler died of a third-world illness—dehydration—in one of the best hospitals in the world, despite repeated attempts by her mother to draw attention to the problem.
The other tragic death involved a previously healthy 15-year-old boy, Lewis Blackman, who went into the hospital for an elective surgery and died 4 days later from excessive blood loss caused by a serious side effect of his pain medicine. His mother, Helen Haskell, reported that her son was pale and was experiencing excruciating pain in his abdomen, which she thought was unusual given that the surgical site was his chest. Lewis developed a high fever, low blood pressure, very pale and cold skin, and many other signs of internal bleeding and clinical deterioration. The boy’s mother repeatedly insisted that her son be evaluated by a veteran doctor, rather than the new residents on duty over a weekend, because she knew something was very wrong with her son. But her repeated demands were never honored. Lewis died from internal bleeding caused by an ulcer, a known and serious side effect of the pain medicine, ketorolac, he was receiving.
Sorrel King and Helen Haskell have no doubt that access to a RRT could have saved their children, as the errors that caused their deaths were preventable and detectable. Likewise, we have no doubt that a patient- or family-activated RRT could have mitigated harm that has resulted from other life-threatening and deadly medication errors.
Allowing patients and families the ability to summon a RRT may be one of the most significant ways that healthcare providers can make patients an equal partner in their care and safety. To make the most of this opportunity, consider the following recommendations to best protect yourself and your family from accidental harm while hospitalized.
First, learn about the disease, medical tests, and the treatment plan for you or your hospitalized family member. Also learn what medicines are being administered, the prescribed doses, and when and how they are given. Write down important information. A patient or family member who knows what to expect can help recognize when something is not right.
Next, ask how to call an RRT. When admitted to a hospital, ask whether patients and families can call a RRT and under what conditions such a call would be appropriate. Be sure you and your family know how to summon for one. Report anything that worries you or does not seem right with you or your family member. Do not be afraid to speak up. Although doctors and nurses are highly trained regarding your medical condition, or your family member’s condition, you know yourself and your family better than anyone on the medical team. Your observations are extremely important.
If you have questions about your care or family member’s care, you need to ask. Also, if you do not understand the answer you get, you need to ask again. Keep asking questions or voicing your concerns about your condition or care, or your family member’s condition or care, until you get an answer that makes you comfortable. If you feel no one is addressing your concerns, do not hesitate to summon a RRT using the directions provided upon admission. If the hospital does not offer a RRT, ask to speak to the doctor in charge (medical director), nurse in charge (nursing director), and the patient representative.
Speak up about the care provided. If you believe something is not being done correctly—perhaps a medicine or medicine dose does not seem right—do not be afraid to speak up. Healthcare professionals are human; they could make a mistake. Sadly, patients, families, and healthcare providers often live with regret because they did not follow through on a suspected problem. The lessons they want to share with all is to speak up and be persistent, even if there is just a hint of a potential safety issue.
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