I feel sick and sad this morning

Footnote to my story in November called “Why don’t auckland hospitals work smarter rather than harder.” and the previous one The Hospital is the best place to be when you are sick, or is it?

My friend passed away this morning after an agonising battle with cancer. One has to wonder how much easier it would have been for her if she had received the treatment she was entitled to at the times she was turned away due to strikes and staff shortages. I’m sure she would still be with us today if she was able to receive the treatments and surgeries she was scheduled for.

Her husband is one of those nice old school Kiwi guys who listens to what he is told and didn’t want to rock the boat. He refused to fight through the management or the media to get the treatment his wife needed because he felt that was not the way you behave. Now he has lost his wife and soul mate too soon. We had to respect his right to be true to himself, but I’m not sure we have to accept the system that put him in that position.

My advice, if you are in a situation like that, where lives can be saved or prolonged and the bureaucratic penguins and the system is holding stolidly fast to this is where the line starts and if you’re not there anymore when you get to the end of the line, will the next patient shuffle forward, make a noise like someone’s life depends on it, especially if it does. People who go to the media miraculously get the treatment they need and sometimes before its too late.
We Kiwis need to stop being PC and accepting the bs that comes from our health industry. Note its not the wonderful hospital staff, they are put in an invidious position by the administrators, by the beurocrats and by the politicians who sleep sound at night and whose close ones are probably not getting turned away because “a registrar is off sick and the shift couldn’t run”. They are the ones who have to lie to the patients and their families when cost cutting measures, old fashioned systems full of lost paper files and ancient systems, and cost cutting means many people don’t get their surgeries, live or die in pain.

This person’s story is over. We won’t be going to the media or fighting because it is not what her husbands wanted. I respect that and much as it burns me, I will not add to his grief or risk creating feelings of guilt to him to make matters worse. He came from a generation who said yes sir, I know you are doing your best and genuinely trusted that. She may still have died, in fact probably would have, but she might have had a few more years and she certainly wouldn’t have suffered the degrees of agony of that she did over the last 4 months. We don’t do that to animals.

If you find yourself in a situation like this, make a noise, get your loved ones help, let the media know and as a country we have to get our government and administrators to invest in the new technologies that in the long run will cost less and save more lives.

Why don’t Auckland Hospitals Work Smarter Instead of Harder

 

 

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76 Deaths, surgical mistakes in New Zealand Hospitals

As one of the old blues songs goes, ‘I laugh just to keep from crying’.  This morning the headlines are out there nationally and internationally. MSN tells the story that in the YEAR ended July 2008, 76 people died out of a total of 258 incidents, that is those that we now about, in New Zealand hospitals.

The story says that the Ministry of Health’s Quality Improvement Committee went on to say that each of these deaths and incidents were avoidable.

The NZ Herald had the story on the front page of the printed edition, but semi buried on the net. They quoted the Health and Disability Commissioner Ron Paterson as saying that it was not a surprise and the story continued to say that ‘Reporting is voluntary and District Health Boards do not know how many incidents are unreported.

Incidents included people’s teeth being accidentally removed, 2 patients being given 10 times the needed dose of medicines, in at least one case, morphine, another patient was booked in, anaesthetised and sent to the operating theatre for an eye surgery they had already had 2 weeks prior. Mistaken identity is another common thread.

Does this come as a surprise to you? It doesn’t to me.

I wrote about these sorts of issues in this blog in February last year. I also presented one of the solutions that has been used in hospitals in the US for many years, at least 15 years ago when Welch Allyn (a well respected technology provider to the health industry) first brought out 2D bar code scanners with the ability to read complex bar codes on patient wrist bands and patient record folders, containing a huge amount of patient information, without requiring access to the hospital’s computer systems. All they would have needed was a number of scanners and a handheld computer such as a Windows CE device (which could also contain a database of things like drug interaction data, i.e. don’t use this drug in combination with that one.

Back in the late 80’s we were already able to come up with a solution that would keep track of patient records folders (which always seem to go missing when you visit the hospital) and are able to identify not only exactly what they are in hospital for, but also things like allergies (especially to drugs such as penicyllin) and any other relevant information such as blood type, currently prescribed drugs (both by their GP and in the hospital and much more.

I presented these concepts and more to Auckland Hospital and the Waitemata DHB. The solution was simple and low cost, but they chose the lower cost option of doing nothing.

So they saved some money and chose to ignore solutions which 20 years ago were strting to be installed in some hospitals in the US. How many lives could have been saved in those years?  I shudder to think. Of course there are also many living victims, who have had to have surgery repeated to remove items accidentally left in their bodies, or many of the other incidents. What about the family of those who died?

So I have a couple of questions:

• When everyone in the industry new these things have always happened in the industry, why was nothing done about it?
• Why is it voluntary to report incidents? Why isn’t it mandatory?
• How many more incidents actually occured that weren’t reported?
• What are they going to do about it?

You can read the damning report for yourself by downloading this pdf.

If you don’t want to, check out a few of these incidents from the report:

• Several mental health patients who committed suicide when they should have been under close supervision, or who were discharged and then killed themselves.
• A patient who died because of confusion over resuscitation status
• A patient who’s tests suggested cancer which was overlooked
• Accidental removal of a breathing tube from a ventilated patient
• Accidental bowel perforation during gallbladder surgery resulting in fatal multi organ failure
• Death of a mother from post partum hemorrhage due to a number of  ‘errors’

The list goes on for 84 pages and these are only those which were voluntarily reported!

So is the hospital the best place to be when you are sick? You decide.

Are there solutions? Yes there are and there have been for many years. I introduced some of them over 15 years ago and my ideas weren’t new, they were already being introduced into US hospitals at the time.

Are they going to do something about it? I hope so. My concepts don’t solve all the problems, but they could have saved several of these poor people and their families. Who is going to take responsiblity for this? I put it to you that the cost of the solutions is far less than the consequences of not using them at least 76 times over.

If you ask me, the government needs to step in now and do something about it. In many cases there are very simple technologies that will if implemented save many lives, but will also introduce sgnificant cost savings through eliminating some of the inefficiencies that waste time and money.

While this blog is starting to get a good following, I would love to get more readers and encouraging me to keep writing. If you feel that my blog is interesting I would be very grateful if you would vote for me in the category of best blog at the NetGuide Web Awards. Note that the form starts each site with www whereas my blog doesn’t and is of course https://luigicappel.wordpress.com.

Thanks so much for your support:)