patient safety advocate

Celebrating the Success of the Partnership for Patients

PfP Boxed logo-1

Recently, Partnership for Patients (PfP) issued a report on its achievements. You will recall from a previous post that the PfP is a very large national quality improvement learning collaborative with two aims: to improve safety in acute care hospitals and to improve coordination of care at discharge to prevent readmissions. The PfP is a public-private partnership that seeks national change by setting clear aims, aligning and engaging multiple Federal partners and programs, aligning and engaging multiple private partners and payers, and establishing a national learning network available to all healthcare providers and facilities.

I participated as a patient advocate in the work of the PfP. My fellow patient advocates and I were invited to give input in every meeting, every phone call, every critical decision. The patient advocates imbued passion for safety into the conversation. This passion set the tone for co-operation and action among the members of the campaign. Several times I was part of a discussion which bogged down in, what seemed to me, a standoff between two camps: those who believed that a proposed policy would save lives and thus should be adopted, and those who believed that the policy was too difficult and/or costly for hospitals to execute. A patient advocate took to the airwaves, and gave her personal story of the harm that she suffered because the policy was not in place. The tone immediately changed from “this is too difficult/costly to achieve” to “we must do whatever we can to keep patients safe.” Within minutes the team moved forward, working co-operatively for patient safety. I believe the patient’s voice was a major contribution to the overall success of the campaign.

The Partnership for Patients and its over 3,700 participating hospitals were focused on making hospital care safer, more reliable, and less costly through the achievement of two goals:

  1. Making Care Safer. By the end of 2014, preventable hospital-acquired conditions would decrease by 40% compared to 2010.
  2. Improving Care Transitions. By the end of 2014, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.

As part of the PfP campaign, baseline measures were collected on nine hospital-acquired conditions (e.g., adverse drug events, pressure ulcers and surgical site infections) in 2010. At the end of the initial engagement period of the PfP, a cumulative total of 1.3 million fewer hospital-acquired conditions (HACs) were experienced by hospital patients over the 3 years (2011, 2012, 2013) relative to the number of HACs that would have occurred if rates had remained steady at the 2010 level. It is estimated that approximately 50,000 fewer patients died in the hospital as a result of the reduction in HACs, and approximately $12 billion in health care costs were saved from 2010 to 2013.

It was so gratifying to be part of this effort that keeps the patient at the center of health care quality improvement. The momentum that was created through the PfP is exciting, and I look forward to the continuation of the patient safety movement that is driven by the patient voice.

Methodist Mondays: A Debut, from Nursing Student Matthew Sobczyk

Matthew Sobczyk is a nursing student at Nebraska Methodist College and posts the first 'Methodists Mondays' blog.
Matthew Sobczyk is a nursing student at Nebraska Methodist College and posts the first ‘Methodist Mondays’ blog.

At Nebraska Methodist College, the book A Never Event (McKnight & Bennington, 2010) is required reading at the junior level of the BSN nursing program. This past semester, Evelyn McKnight and Steve Langan visited the nursing classroom with a question and answer session regarding A Never Event and HONOReform. “Survivor Stories” will feature students’ reflections on the importance of Evelyn sharing her story and the work of HONOReform on their future nursing practice in a series called ‘Methodist Mondays’.

“Education and awareness are the cornerstone of the HONOReform mission. Lauren and I are grateful to Matthew Sobczyk, a nursing student, for providing this debut Methodist Monday blog,” Evelyn says.

During Dr. McKnight’s visit, I was very impressed with the amount of passion that she had for preventing reuse of needles, and enabling safe injection practices to prevent any further outbreaks from occurring. As a student nurse, I feel that enacting safe infection practices is one of the most crucial to prevent transmission of blood borne pathogens from patient to patient. Since needles are used every day for a multitude of reasons, it is important that no needle is used more than once to prevent any possible pathogens from passing between patients. It is one of the simplest acts that we as healthcare providers can use for safe practice. Hearing Dr. McKnight tell her story made me more passionate than ever to commit to this practice.

To be a patient advocate means to not only stand up for the patient and what their wishes are about the care that they will be receiving, it also means intervening when you see unwanted harm coming to your patient or any other patient from a fellow provider. I feel that being a patient safety advocate is one of the most important qualities of a health care professional, and if you can’t stand up for your patient and be there for them then you don’t deserve to be in the profession. You have to be there for your patient in order to provide the best possible care.

Without a doubt, I can’t thank Dr. McKnight enough for coming to speak to our class and sharing her story and her experience. When I had read her book, I was beyond shocked that such a horrific experience had taken place here in Nebraska, let alone in a town not far from Omaha. I also want to thank Steve Langan for coming along and talking about the activities that HONOReform has been a part of. It truly means a lot to have taken the time to come share their personal account with us. I won’t ever forget this experience.

Happy New Year!

Welcome back to the HONOReform blog, aka “Survivor Stories,” for our second full year of publication. We thank everyone who has had a role in making our blog a growing success—contributors and readers and everyone who has suggested to friends that they should check out our blog and pass it on to others.
And we encourage you to please continue to support our efforts.
Here at HONOReform, community-building is a key to emphasizing safe injection practices and doing all we can to educate the public and reeducate providers on the absolute necessity of injection safety.
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Drug Diversion, a Broken Healthcare System

Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.
Lauren Lollini is a patient safety advocate who has been integral in changing laws to keep patients safe as well as a member of the Drug Diversion Prevention Committee.

If you are a regular member to this blog you will have heard me say these things before, so I apologize for the repetition, but it appears I may not be saying it loud enough. So I am thankful to have the support of fellow patient safety advocates, healthcare workers who understand the broken system as well as a series of talented reporters to help articulate the point.

Our healthcare system is broken, let me say that again, it is broken and not the way the majority of Americans might think after reading that statement. It isn’t about the Affordable Care Act, in fact, just the opposite. It is underneath the polished floors and inside the magnificent facilities. It is behind the scenes, what happens when most people are not watching.
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How my 6 year old found the CDC website

Lauren Lollini and her 6 year old daughter Lucy
Lauren and her 6 year old daughter Lucy

When I was infected with Hepatitis C, my daughter had just turned one. The devastation of such a horrendous diagnosis coupled with the new person who was now in my life was almost stranger than fiction. Now more than five years later, after a wild ride and a journey still in process, I have started to open up to my daughter and talk a bit about the drug diversion which caused my disease.

I know, I know, Lucy is only six and the idea of drug diversion seems a pretty intense subject for a first grader. But every so often she asks me to tell the story and I know which one she means. And as it is a very long story with many twists and turns, I always ask, which part?
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Sharing stories, transforming ourselves

Evelyn McKnight, president of HONOReform
Evelyn McKnight, president of HONOReform

In my work as a patient safety advocate, I have had the great good fortune of meeting many people who share with others their tragic story of how they were affected by unsafe healthcare. Like my family, their families were hit with a Mack truck on the road of life when they went to the doctor seeking better health, but came away with a worse medical condition because of unsafe healthcare. Telling the story may be gut-wrenching – it can be like living a nightmare all over. But through sharing their stories, these brave men and women are able to transform their experience into something useful, rather than simply a horrible personal trauma. Read more

A special thanks to our colleague, Sharon Bradley

Sharon Bradley, RN CIC, of the Pennsylvania Patient Safety Authority.
Sharon Bradley, RN CIC, of the Pennsylvania Patient Safety Authority.

We are just two of many citizens and patient advocates who remain concerned about the safety of our nation’s many outpatient clinics—and ambulatory surgery facilities, in particular. Perhaps, it is because trips to these type of healthcare settings resulted in the Hepatitis C virus for both of us.

Since the founding of HONOReform in 2007, there has been a migration of care from the hospital to the outpatient setting. Very few of us do not know someone who described their surgery or procedure, which appeared quite complicated, yet they were released the same day.
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When Journalists Make a Difference by Lauren Lollini

Lauren is one of many Coloradans infected with Hepatitis C from a hospital outbreak in 2009.
Lauren is one of many Coloradans infected with Hepatitis C from a hospital outbreak in 2009.

Once again the journalist got it right; and not just right, dead center, hitting the issue squarely between the eyes. I am referring to the 4/15/14 (4/16/14 print) USA Today article by Peter Eisler highlighting the dilemma of addicted healthcare workers and drug diversion. http://www.usatoday.com/story/news/nation/2014/04/15/doctors-addicted-drugs-health-care-diversion/7588401/
Not only does Eisler get to the heart of the matter stating that addicted healthcare workers often go unnoticed enabling them to wreak havoc not on themselves but the patients they treat, but he makes it clear that the system is broken and far too many episodes of drug diversion are happening all around us. Truly the highlight of the article is his focus on the solutions.

Ah, such a relief to not just hear the cold facts but to have an emphasis on what we can do fix these problems. While the incidence of addiction in healthcare settings is roughly about what it is in society as a whole, the chance to do harm is far greater as the article so aptly points out. Addicted healthcare workers may not even know they are causing problems or get the help they require. Eisler states, “Much of the damage goes unnoticed or undocumented; systems to detect, report and address drug problems in health care settings are haphazard and limited.”
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Let me talk a little bit about Patty Skolnik by Lauren Lollini

Patty Skolnik, Founder, Citizens for Patient Safety
Patty Skolnik, Founder, Citizens for Patient Safety

It has been five years since I have heard those life changing words, “You have Hepatitis C…” so the irony and gratitude to be meeting with Patty Skolnik was not lost on me.  Patty is a warm and caring woman who took me under her wing shortly after my decision to reach out and become a patient safety advocate.  I remember our first meeting like it was yesterday, converging on Capitol Hill to speak out about healthcare and tort reform and to tell stories of healthcare tragedies in order to raise awareness.  We sat in each meeting and as Patty spoke about her son Michael, who had died in 2004 following an unnecessary surgical procedure due to complications related to medical errors, I knew I had found a kindred spirit; someone with passion and energy and the need to change a broken system.

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