The Power of Introducing Patient Stories to Eliminate Preventable Patient Deaths

Kevin McQueen, MHA, RRT-ACCS, CPPS, Director of Respiratory Care & Sleep Diagnostics at the University of Colorado Health in Colorado Springs (Previously Director of Patient Safety at Tri-City Medical Center)

Each death is a tragedy. The devastation it reaps on families, loved ones and the clinicians that cared for them lasts a lifetime. Tens of thousands of people in the most dire circumstances are rushed to hospitals every day for urgent medical attention, whether it be to treat a heart attack or stroke, a traumatic injury caused by an accident or the progression of a life-threatening disease – it’s inevitable that some won’t make it.

What surprises most people is that it’s actually deaths caused by preventable medical errors that are the third-leading cause of deaths in this country. That’s over 200,000 people a year who entered a hospital to be treated for a problem that normally wouldn’t prove fatal and then dying due to an error that could have been prevented if the proper patient safety processes were in place. This doesn’t even take into account the thousands that are harmed and survive with challenges they have to live with the rest of their lives.

I remember attending the World Patient Safety Science & Technology Summit in 2013 and the most common comment heard from attendees is how much they were inspired to action after hearing real-life stories of families who lost a loved one due to a preventable medical error. Patients and their families were intertwined into every part of the Summit, and they even have a place as panel members to bring the patient’s voice to the center of the conversation. Each session opened with a short video that tells the story of a patient who has been significantly harmed by one or more medical errors. If the patient died, it’s often a family member in the video who describes the personal impact of losing a loved one in this manner. Following that, depending on the topic at hand, patient safety experts and advocates are brought in to explain the weaknesses in the process or system that led to the patient harm or death and what can be done to prevent it from happening in the future. These solutions are the genesis of the Actionable Patient Safety Solutions to avoid these preventable deaths.

It’s important to point out that these videos don’t just feature elderly patients or people with compromised systems who are particularly vulnerable to a fatal “medical mishap” during care. One notable story shares the life of Alicia Cole – a young, healthy, working actress in Hollywood, who went in for what should have been routine fibroid surgery. She ended up nearly dying of multiple hospital-acquired surgical-site infections, requiring $2 million worth of surgeries, treatments, and physical therapy, permanently altering her personal life and career. Another story shared the tragic death of 11-year-old, Leah. Her mom, Lenore Alexander, saw her make it through surgery and later Leah was found ‘dead in bed’ because her respiration wasn’t being monitored after receiving strong opioid pain medications following surgery.

In health care, clinicians are driven by two things: their emotions and data (i.e., evidenced-based information). These stories touch on both areas. They show how failure to do the right thing harms people—a real person with a network of real people who love them and depend on them. The stories further motivate staff by helping them understand the “why” of the new processes that are put in place to protect patients.

Like others, I left the Summit determined to create a culture of safety and an action plan that is strong enough to get through the inevitable obstacles that we may encounter. Tri-City Medical Center in San Diego, California decided to begin their efforts by bringing Alicia Cole, one of the people PSMF highlighted in a patient story video, to speak to their hospital staff. They also shared Leah’s story. In a room of 100 people, there wasn’t a dry eye in the room. It literally shook everyone to the core. The Tri-City Patient Safety team then went to work to keep the momentum going and create a whole culture change. They made a public commitment to zero, put new processes in place, did team huddles, gave patient safety symposiums and educational classes. They made sure patient safety ideas were encouraged and supported and no one was afraid of speaking up on misses and close calls. They even incorporated posters that requested patients to ask questions and become a part of their care team.

Tri-City’s NICU unit has celebrated over six years straight free of central-line associated blood stream infections (CLABSI). The NICU central line infection prevention team has been sharing how they did it with clinicians around the world so that other institutions can achieve being CLABSI-free in the coming years.

They also saw a tremendous reduction in their falls. They found a way to reduce variability. They put processes in place to deter anyone from breaking the patient safety processes and created a system focused on what is best for the patient. Participation was mandatory, not optional. They became an example of how zero is possible.

This example can serve as a model for clinicians looking for a place to begin and a way to motivate colleagues to implement patient safety processes at their hospital and make a commitment to zero preventable deaths. Sharing patient stories can engage coworkers in a way that isn’t possible by just giving them data. The stories will give them a real sense of purpose and supercharge their patient safety efforts and deepen their understanding of the importance of the patient safety processes that are in place. It will help them decide to prevent these avoidable tragedies from ever happening under their watch.

As human beings, we can sometimes be really stubborn about change. But in healthcare precious lives are at risk so the one thing that cannot change is the Hippocratic oath-first do no harm-a culture centered on patient safety. The best medicine is innovation. But, medical providers are trained to do things a certain way, and it’s often hard to get them to change their practice. Change takes constant effort so by presenting these patient stories of tragedy and loss, it helps clinicians overcome the systemic apathy and resistance to change. They begin to realize that unless things change, the next statistic could be their child, parent or loved one.