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Dr. Andrew Agwunobi

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The Patient's Role in Hospital Safety

Posted: 08/20/2013 11:08 am

Most hospitals are working hard to create a "safety culture" (a term coined by the nuclear industry after the Chernobyl disaster in 1986) to attain the levels of safety of commercial airlines and nuclear power plants. But patients must also make efforts to protect themselves, for two reasons. First, consistent safety is still years away (e.g., in May 2013, the non-profit safety group Leapfrog awarded 31 percent of hospitals an "A" grade for safety, 25 percent a "B" grade, 37 percent a "C" grade and 7 percent a "D" or "F" grade). Second, sharing in ownership of safety by those who are at risk is a critical component of safety cultures. For airports, this is summed up by the frequent overhead announcement, "If you see something, say something." For nuclear power plants, it is the International Nuclear Safety Advisory Group (INSAG) principle that safety relies on "a questioning attitude... plus communication." For hospital patients, I would sum it up with two words: "Be assertive."

I wish I could say I learned the lesson about the necessity for patients to be assertive from my career as a hospital CEO, but I actually learned it from my wife, Elizabeth, the day she gave birth to our first daughter. When her contractions started, Elizabeth was admitted to the birthing unit of our local hospital. About 30 minutes after the nurse tucked her in, Elizabeth asked me to feel her forehead, saying, "I just had chills, I must have a fever." I felt her head but couldn't tell, so we called the nurse. The nurse took a thermometer off the wall and measured Elizabeth's temperature. "98.6 degrees," she said, showing the thermometer to my wife. "You're fine. You're probably just cold -- I'll get you an extra blanket."

Half an hour later, Elizabeth said, "Andy, I'm still feeling chills, I'm sure it's a fever. Call the nurse again." I called the nurse. "Still 98.6 degrees," she said cheerfully, "another blanket?" Elizabeth declined and thanked her, but was obviously still anxious. An hour later, same thing: chills, nurse (less cheerful this time), normal temperature.

Finally, my wife sat up and said, "Call the nurse right now. And tell her to change the thermometer." I called the nurse. She sighed, found a different thermometer, and repeated the temperature measurement. It was 104 degrees -- a high fever.

I can't remember the details of what followed. It was a blur. But I always think of it as lights flashing; alarm bells ringing; the obstetrician being paged overhead "stat;" hundreds of people rushing in with tubing, syringes and bags of intravenous fluid; nurses inserting plastic tubes into Elizabeth's arms and hanging bags of fluid on poles; my wife (actually her whole bed) being wheeled out; and finally, me left in silence amidst a room littered with empty sterile-gauze wrappers.

Within an hour, my wife underwent an emergency cesarean section. High fever in a pregnant woman is often associated with infection in the baby, and the longer the baby remains untreated in the mother, the higher the risk the baby will suffer permanent damage or death. After my daughter was born, the doctors placed both her and Elizabeth on intravenous antibiotics, and both of them stayed in the hospital for about five days. Fortunately, tests didn't identify any infection, and neither suffered lasting harm.

It turns out the thermometer was broken -- stuck at 98.6 degrees. It made us realize that even in the 21st century, simple but potentially devastating malfunctions do still occur in hospitals despite all the technology, protocols, education, checks and safeguards.

But mostly, it made us realize that sometimes all that stands between safety and sorrow is a patient's assertiveness. And being assertive is not the norm for patients. Most people in our situation would not have been as pushy as we were (or should I say, as Elizabeth was), because it was hard even for us -- and both Elizabeth and I are doctors. I am a pediatrician and Elizabeth is an internal medicine physician.

The conclusion that most patients are not assertive is more than just anecdotal. The willingness of patients to challenge health care professionals has been studied: a 2008 British Medical Journal study of 80 post-surgery patients confirmed that patients are reluctant to ask questions that could be viewed as challenging clinical abilities. Incidentally, the study also showed -- as in our case -- that women are more likely to be assertive than men.

Being assertive is not about being "the patient from hell." It is about filling your role as the safety net of the safety culture. Whether it's asking that a thermometer be checked or making sure that the surgeon has marked the correct leg for amputation, being assertive is often the last guard rail before being hurt.

Be assertive and help yourself, the next patient and the hospital industry be safe.

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