Monday, August 22, 2011

Tragic Toll From Medical Errors'

BUFFALO, N.Y. When Mary Brennan-Taylor lost her mother to a series of preventable medical errors, she wasn't interested in suing the hospital where the mistakes had been made. 
"I wasn't interested in a lawsuit because that wouldn't help anyone," she says, "I was interested in culture change."
Now, Brennan-Taylor is bringing that culture change directly to students at the University at Buffalo. This summer, she was appointed adjunct research instructor of family medicine at the UB School of Medicine and Biomedical Sciences, a volunteer faculty appointment.
"Mary Brennan-Taylor came to being a patient safety advocate the hard way, after her mother died from a health care-acquired infection," says Lisa McGiffert, director of the Consumers Union Safe Patient Project. "She transformed her grief into action, collaborating with a unique University at Buffalo program that educates future doctors and nurses about the human impact of medical harm and the actions they can take to prevent such harm."
On Aug. 22, Brennan-Taylor, a Consumers Union patient advocate, will give a presentation on what happened to her mother to a class of third-year medical students at UB. In this video, she describes her story and discusses how UB is training medical students:
By the end of the fall semester, she will have told her story to all UB students who will obtain their MD degrees in 2013.
"Every doctor that graduates from UB will hear Mary's story," says David Holmes, MD, associate vice chair of medical student education in the UB Department of Family Medicine and clerkship director. "Her story adds a very human dimension to our discussion about medical errors. It helps the students realize that it's not just statistics that we are talking about, it's somebody's Mom."
In July 2009, Alice Brennan, a vibrant, 88-year-old woman who lived independently, went into the hospital for a common medical problem that was not life-threatening. She died six weeks later from multiple hospital-acquired infections and from polypharmacy, the use of numerous medications, often more than are clinically indicated.
"It was a health care system failure," says Brennan-Taylor. "My mother was put on medications that I now know should never be given to elderly patients. It was a deadly cocktail. Then she contracted, not one, not two, but three hospital-acquired infections: MRSA (Methicillin-resistant Staphylococcus aureus), C. diff and VRE (vancomycin-resistant enterococci).
"There should have been some alerts from the pharmacy, there should have been some infection-control procedures. I never thought that a doctor or nurse intended to harm my mother, but there was an utter breakdown in the system," she says.
After her mother's death, Brennan-Taylor began searching for answers. She found that unfortunately, her experience was far from rare.
She learned that as many as one in three hospitalized patients will experience some form of medical error and that, according to a recently released report from the Office of the Inspector General, 180,000 Medicare patients die as a result of medical error every year. "That's just unacceptable," Brennan-Taylor states.
From that tragedy, Brennan-Taylor developed a passion for making sure that what she and her family experienced becomes an extremely rare event.
"I felt that I would be remiss if I didn't reach out," she says.
The UB medical school presentations start with a talk by Ranjit Singh, MD, assistant professor of clinical family medicine at UB and associate director of the department's Patient Safety Research Center; Brennan-Taylor then discusses her mother's case in detail.
Last semester, Brennan-Taylor also served as lecturer and coach to nursing students as part of an innovative patient-safety course ( in the UB School of Nursing.
Eventually, Brennan-Taylor hopes to develop a patient-safety guide or tool kit for consumers. She is working with the UB Patient Safety Research Center on a pilot project aimed at identifying and studying avoidable adverse events to understand what went wrong and how patients and caregivers could have intervened.

"UB is ahead of the curve on this," says Brennan-Taylor. "Instead of circling the wagons, they are asking, how can we be better doctors and nurses?"
In the meantime, she says, patients and their loved ones can help ensure better outcomes. She suggests:
--Before being admitted to a hospital, ask about the infection rate of the hospital and the surgeon who will perform the procedure. Ask if there has been an outbreak of C. diff, MRSA or VRE and how it was handled. Are infected patients isolated? Are visitors required to gown up before visiting infected patients?
"If the hospital can't tell you what its infection rate is and what its infection control procedures are, you might want to shop around," she says.
--Take sterile wipes when admitted to a hospital. "Wipe down the bed trays, the handrails, the telephone, any surfaces that you will be touching," she says.
--Talk to everyone who comes into your room, whether they are nurses, doctors, cleaners or visitors.
"Tell them to wash their hands before they touch you," she says. "If they open a privacy curtain with their hands and are about to perform a procedure on you, tell them to wash their hands first."
--If possible, have a family member or loved one with you at all times.

"This person is your advocate," she says, "they can be telling hospital personnel to wash their hands and they should also be asking lots of questions. Ask everyone who comes in to do a procedure on a patient, what is the procedure, why are they doing it? What is this medication and why is it being prescribed? What are the test results? What is the prognosis? What is the next step?"

--Have your advocate write everything that happens in a notebook. If possible, patients also should keep a notebook with them to record things where possible.

"Make sure you ask questions and that you get answers to your questions," Brennan-Taylor says. "And if you don't get answers, keep asking until you do."

The University at Buffalo is a premier research-intensive public university, a flagship institution in the State University of New York system and its largest and most comprehensive campus. UB's more than 28,000 students pursue their academic interests through more than 300 undergraduate, graduate and professional degree programs. Founded in 1846, the University at Buffalo is a member of the Association of American Universities.


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