Inside the Book

We have grouped patient stories into categories based on how you may be dealing with the healthcare system: preparing for a visit to the doctor’s office, in the hospital, as a surgical patient, or as a patient being discharged from the hospital.

There is also a chapter focused on communicating with the care team and one focused on minimizing the most common risks: falls, infections, and medication errors.

Naturally, many of the same safety recommendations are repeated in several stories. For example, there are tips for managing your medications as part of your home care, when you are hospitalized, and when you may have new prescriptions upon discharge from the hospital.

Clear communication between you as a patient (or an advocate for a loved one) and your care team is so critically important that almost every story touches on improving the exchange of information. In fact, ineffective communication contributes to more than 70 percent of deadly medical errors in hospitals.

So it is not important to read every story or read the stories in any particular order. The table of contents and the index will help you go directly to the information you need at any given time.

We’ve also suggested reliable resources so you can learn more, download checklists and other tools, and find patient support and advocacy groups.

Remember, patient safety starts with the patient. The more you know, the more protected you are.

Primary care describes your ongoing relationship with your family doctor, the person who has the most comprehensive view of your medical history. A specialist, internist, or nurse practitioner might fill this role. For example, some women consider their OB-GYN doctor their primary care physician.

Your primary care provider should be your first stop for routine check-ups and preventive care, such as vaccinations, family planning services, and management of common, chronic conditions such as arthritis, asthma, and high blood pressure. To address more serious ailments, your primary care provider will refer you to specialists and then take the lead in coordinating your care.

If you are insured, your insurance company probably encourages you to develop a relationship with a primary care physician in order to avoid emergency room (ER) visits and hospitalizations. While this makes good sense in terms of your overall health, it has the additional benefit of lowering healthcare spending overall. Nationally, the average cost of an ER visit for a minor event (that does not require hospitalization) is $1,233.1 The average cost for an existing patient to visit their primary care doctor is only $158.00.2

Time is money, too. Nationally, the average wait time in the ER is over 55 minutes according to the Centers for Disease Control and Prevention. A recent study puts the average ER visit, from admittance to discharge, at more than 11 hours.

The days when primary care physicians made hospital visits are gone in most communities. If you are hospitalized, it is increasingly likely that your day-to-day care will be provided by a new kind of specialist that emerged in the 1990s, the hospitalist. Hospitalists are physicians based in the hospital, but who consult your personal physician about your health history.

There are efficiencies in this system, but you may find it disappointing if you have a long relationship with your primary care physician. You’ll be starting over with someone who has familiarized herself with your medical record, but doesn’t know you and all the details of your medical history. You and your family will need to be vigilant that your hospitalist has all of the relevant facts in your history correct. This becomes even more important during a prolonged hospital stay because you will be under the care of several hospitalists who are simultaneously overseeing dozens of patients.

The good news is that hospitalists are typically paid by insurance (including Medicare) as part of hospital services.

The not-so-good news is that the flow of information between your primary care physician and a hospitalist, or anyone else in the hospital, may not be timely or complete. You must serve as a clear and reliable source of information about your medical history and condition. Once information is entered into an electronic patient record, you could be unaware of misinformation that continues to influence your care.

Do not take it for granted that your doctor has all the facts. Communication helps ensure you receive safe, competent care. Whether you are seeing your primary care physician in the office or dealing with a hospitalist, there are three important reasons to communicate clearly with whoever provides your primary care:

  • They are the guardians of your medical history.
  • They are an informed source of referrals to specialists. This is the person you can ask: If your mother had my condition, where would you send her? What do you know about this specialist’s success record?
  • They have the greatest opportunity to coach you on wellness and prevention strategies and monitor your progress.

Here are five tips to improve communication between primary care and the hospital:

  1. Write down any questions and concerns so you remember to discuss them.
  2. Get your questions answered to your satisfaction.
  3. Ask your doctor to repeat what you tell them to verify you have been clear.
  4. Repeat what the doctor says to you to verify you understand what you are told.
  5. Invite a trusted friend or family member to be present and take notes.

The stories in this chapter will help you understand how hospitals and medical teams function so you will be prepared to ask better questions, recognize and address risks to your safety as a patient, and safeguard loved ones when they are hospitalized.

Effective communication between you and your doctor is the foundation of patient safety. Your doctor needs to listen to you to identify symptoms, come to a diagnosis, and gauge how well treatment is working. You need to listen to the doctor to determine what information it is important to share and what to do to participate in your healing.

Clarity and courtesy should flow in both directions.

It may be difficult to be direct and respectful when you are sick, anxious, and perhaps frustrated when you feel your doctor is not listening to you or understanding your concerns.

It may be difficult for your doctor (and other members of your care team) to provide simple and straightforward information and take the time to answer all your questions when they are struggling with fatigue and time pressure.

Language and cultural differences can add another layer of confusion and potential misunderstanding between you and the people caring for you. So can memory and mental lapses exhibited by elderly patients or those suffering from impairment due to dementia, brain injury, or the effects of medication.

Patients sometimes keep important information from doctors because they are embarrassed or do not want to be judged. Doctors sometimes keep important information from patients because they feel they may not be able to understand or cope with their diagnosis.

The stories in this chapter provide suggestions to help you improve how you listen, how you share information, and how you verify that you are understood.

Hospital stays are stressful, even when the visit is brief and for a relatively minor or easily-treated condition. You find yourself in an unfamiliar environment, feeling at the mercy of a system you cannot control.

If you know in advance that you will be hospitalized—or you are supporting a friend for family member—there are some proactive steps you can take to make your hospital stay safer.

Before you check in:

  1. Go to the Hospital Comparewebsite and check your hospital’s overall grade and infection rates.
  2. Check in with your doctor for important pre-admission instructions related to tests, medicationchanges, and your diet. Ask about your heart attack risk and whether MRSA screening is advised. (You may have no symptoms but still be a carrier.)
  3. Update your list of medications (including vitamins, supplements and herbs, and over-the-counter drugs). Be honest about any recreational drugs or narcotics you are taking (or have taken in the past). Take a copy of this medicationlist with you.
  4. If possible, schedule surgery Tuesday, Wednesday, or Thursday for the best staffing and least likelihood of having your procedure bumped or delayed.
  5. Ask a friend or family member to monitor your care and serve as a second set of eyes and ears during your care, especially when you receive your discharge instructions.
  6. Prepare a living will and designate a health-care proxy. Give copies to the admitting doctor and the hospital.
  7. Pack a few personal items that will make you feel comfortable, but leave valuables at home.

The stories that follow will help you understand how hospitals function, recognize risks, take steps to protect yourself, and improve your communication with your healthcare team.

In the hospital, you are most at risk for infections, falls, and medical errors. However, these risks can be minimized if you understand basic safety practices and insist that everyone involved in your care practice the protocols in place for your protection.

In this chapter, you will learn more about the most common risks and what you can do to protect yourself and your loved ones from avoidable errors. You will also learn more about the importance of reporting medical errors.

The simple precautions shared in this chapter can keep you healthier and safer. Here are a few additional safeguards you may also consider:

  • Avoid scheduling elective surgery over the summer. Fatalities at teaching hospitals spike in July, when many doctors-in-training begin their residencies. Most of these fatalities are due to medication errors.
  • Do not schedule elective surgery on Fridays, weekends, nights, or holidays. During these times, staffing is lighter and test results take longer. The safest time to have surgery? The second or third slot in the morning, Monday through Thursday.
  • If you can choose your hospital, find out the infection rates at your local hospitals by checking the Hospital Compare website.
  • Ask if you are at risk for blood clots. If so, precautions such as blood thinners and compression stockings may protect you from a potentially serious complication.

The stories that follow give you more insight into how you can protect yourself or your loved one against the most common risks in the hospital.

No surgery is risk-free. According to the World Health Organization, more than half of the adverse effects suffered by people hospitalized in industrialized countries relate to surgical care—and half of those harmful incidents could have been prevented.

If you are considering an elective surgery, such as a cosmetic procedure, you should have plenty of time to consider all your options and thoroughly check out your surgical team (including the anesthesiologist). In other situations, such as worsening disease or an orthopedic problem, for example, you may have time to do some homework before committing to a procedure and a surgeon.

Your insurance company may dictate the hospital and surgeons you consider. It may also affect whether your surgery can be done in a hospital, office, or same-day surgical center

In looking at a list of surgeons, you may notice the initials F.A.C.S. after some names. This stands for Fellow of the American College of Surgeon and it indicates the person’s surgical skills have been reviewed by other surgeons.

The Agency for Healthcare Quality and Research has developed these questions to help you choose a surgeon with safety in mind:

  1. What are my non-surgical options?
  2. What different types of surgery are options?
  3. Are you Board Certified in the appropriate specialty?
  4. How many of this type of surgery have you performed?
  5. What is your complication rate?
  6. Will you personally be performing my surgery or will you be supervising another doctor?
  7. Do you send samples to multiple pathology labs?
  8. What would you consider my biggest risks?
  9. What would you consider reasonable expectations on my part?
  10. What will my post-operative care be?
  11. Where do you recommend I go for a second opinion?
  12. Do you use a surgical safety checklist when you operate?
  13. If lasers or electrocautery devices will be used, what measures are in place to prevent a fire?

The World Health Organization developed a 19-point Surgical Safety Checklist to help surgical teams operate with greater safety. Many U.S. hospitals use some version of this safety checklist.

As a patient, you cannot control what happens in the operating room or surgical center. However, you can become informed so you are the best possible partner in your healthcare, pre-operatively and post-operatively. The stories that follow give some insight into risks and safeguards related to surgery and the steps you can take to keep yourself and loved ones protected.

Good news. You are leaving the hospital? Now what?

If you are going home, you now take on a new level of responsibility for your wellbeing. You may have to involve family, friends, and caregivers to help you through your next phase of recovery.

Hospitals are under pressure to move patients out of their care “quicker and sicker.” They need to make room for other patients, and insurers push them to minimize hospital stays according to billable limits.

Research by the Joint Commission on Accreditation of Healthcare Organizations reveals the upside and downside of the hospital discharge process.

The upside is that thorough communication and follow-up improves patient’s health, prevents readmissions, and minimizes healthcare costs.

The downside is that too many patients—especially age 65 and older—leave the hospital only to be readmitted within 30 days. This is most often due to medication errors, insufficient follow-up and post-discharge infections. In other words, people end up back in the hospital due to preventable harm.

A safe discharge process starts in the hospital. Essentially, your discharge is a meeting with instructions based on your condition and personal needs. A case manager, social worker or nurse, with input from the doctor overseeing your care, typically leads the discussion about your continuing care and follow-up.

Get a friend or family member to participate in the discharge discussion so no important information is missed. Errors in medication and infections send as many as 18 percent of Medicare patients back to the hospital. You don’t want to participate in that statistic.

An effective discharge discussion includes:

  • A clear statement of your diagnosis: Why were you hospitalized?
  • Determination of whether you are ready to go home or need to transition to another facility such as a rehabilitation center.
  • Explanation of diet and medications—new, modified, and continuing.
  • Identification of any warning signs of problems, such as infections, and how to respond.
  • Identification of whether your caregiver(s) need training and support.
  • Identification of medically necessary equipment needed, such as a wheelchair or oxygen.
  • Referrals to home care agencies or support organizations in your community.
  • Necessary follow-up tests and appointments.
  • A 24-hour telephone number for care information.

You may also be given educational materials, such as fact sheets, about your illness and care.

One of the most important steps you can take in making your return home safer is to reconcile your medications. That means comparing a list of any prescriptions you took prior to hospitalization with new prescriptions. Check for duplications, omissions, or drugs that are contraindicated—ask your pharmacist if a new drug is compatible with an existing medication. Also, verify if doses have changed or if how you take the drug has changed.

To protect the recently hospitalized from preventable harm such as falls and infections, a caregiver may need help building confidence and competence in new skills, such as wound care, how to manage feeding tubes and catheters, and the safe way to transfer someone from bed to chair or wheelchair. A visiting nurse or therapist is often your best resource to learn, rehearse and master unfamiliar, hands-on care.

The stories that follow provide more insight into the discharge process and how to protect yourself and your loved ones after a hospitalization.

There are patient advocacy groups and networks for almost every disease and chronic condition. Here are some of the larger organizations that provide a sense of community, information, and educational materials to patients and their families.

These organizations provide information, education, and emotional support to caregivers and may have directories to resources available in your community.

These organizations provide information and educational materials for both healthcare providers and consumers.

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