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Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY September 2015 Webinar

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Page 1: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

Case Studies in Patient SafetyThe Silence of the Hospital:

Linda Kenney and Medically Induced Trauma Support Services

CONSUMERS ADVANCING PATIENT SAFETYSeptember 2015 Webinar

Page 2: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

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Welcome

• Lisa Morrise,Program Coordinator, Consumers Advancing Patient Safety

Page 3: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

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Learning Objectives

• Create awareness about the emotional impact that medical errors and adverse medical events have on patients/families and clinicians/providers.

• Describe what patients and families want following medical errors and adverse medical events that cause harm.

• Explore the presence or absence of support services that exist in respective institutions

• Identify and discuss the barriers that prevent utilization of these supports

Page 4: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

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Agenda

1. Helen Haskell – An Overview of the book Case Studies in Patient Safety.2. Linda Kenney – Share, briefly, the story from the book, “The Silence of the

Hospital,” including the lingering medical consequences of this and later operations

3. Linda Kenney – Development and Mission of MITSS– Purpose: To create awareness, promote open and honest communication,

and to provide services to patients, families, and clinicians affected by medically induced trauma.

– Vision: Our vision is for all those involved in a medically induced trauma to have access to support services. We envision a more compassionate, people-centered healthcare system.

4. Linda Kenney and Frederick (Rick) van Pelt, MD, – Optimum Supports for Physicians and Patients

5. Helen Haskell, Linda Kenney and Rick van Pelt, MD – Questions / Discussion

Page 5: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

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Case Studies in Patient Safety

Page 6: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

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The Patient Story• Patient stories in the book highlight real issues

in Patient Safety.• Many patients have taken their stories and

developed effective advocacy that benefits patients and providers as well as supports Patient Safety efforts.

• Introduction of Linda Kenney

Page 7: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

November 18, 1999

Page 8: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

We all have stories…

Page 9: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

• Emotional impact• Constant Questions• Follow up with Orthopedic surgeon• Calling the hospital

First Six Months

9

Page 10: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

• Transparent communication in real time• An Apology or an acknowledgement• Organizational response to prevent recurrence• Support (unique for each individual)

What Patients and Families Want Following Adverse Medical Events

Page 11: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

2002 – Medically Induced Trauma Support Services (MITSS), Inc.

Mission:To Support Healing and Restore Hope to patients, families, and clinicians following adverse medical events.

Creation of MITSS

Page 12: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

• A non-profit organization founded in June 2002 by a patient who experienced an adverse event.• Local (headquartered in Chestnut Hill,

MA), national, and international reach.

About MITSS

Page 13: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

• Medically induced trauma is the emotional toll that results when something goes wrong during medical and/or surgical care. It may or may not be due to an error, but is an undesirable outcome due to some aspect of diagnosis or treatment. Most importantly, these events can significantly affect the emotional well being of the patient, family member(s), and/or clinician involved.

MIWhat is medically induced trauma?

Page 14: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY
Page 15: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY
Page 16: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY
Page 17: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

• 2002 - Found out my ankle shifted and couldn’t get the ankle replacement without another surgery.

• 2002 – Had surgery to realign my ankle• 2007 – Rt Ankle replacement

– 3 weeks later ended up with a SSI (Surgical Site Infection) – MRSA• 3 months in bed with open wound and a PICC line• Skin graft surgery to close wound• On PO Antibiotics on and off for 18 months• Another surgery to remove hardware that was infected.• Another PICC line for 6 months

• 2011 – surgical site hernia repair(where the chest tubes where placed)• 2014 – Removal of ankle replacement (because of breakdown) to do a Total Ankle

Fusion• 2014 – 2015 constant pain in swelling in ankle• 2015 – Surgery to fix the non union of the ankle fusion• 2015 – Emergent Hernia repair• 2015 – Need to get a custom foot brace for right ankle

Ongoing Medical Issues…

Page 18: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

Rick van Pelt, MD, MBA

Page 19: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

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Discussion

a. What barriers do you feel exist to providing full disclosure following medical error?

b. How do full disclosure programs overcome the barriers to transparency that exist on both sides?

c. What could be done to alleviate the adverse effects of providers who are involved in medical error? Is having an employee support program enough?

d. Other questions?

Page 20: Case Studies in Patient Safety The Silence of the Hospital: Linda Kenney and Medically Induced Trauma Support Services CONSUMERS ADVANCING PATIENT SAFETY

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News• October 22 – Ilene Corina – Turning Personal Tragedy into

Advocacy – Meeting the Needs of Vulnerable Populations

• On the CAPS Website (patientsafety.org)– Find links to prior events– Information about the IOM Diagnostic Errors report

• Please take the survey for patient advocates and HENS:

https:/www.surveymonkey.compatientandfamilyadvocates

https://www.surveymonkey.com/r/hospitalengagementnetworks

https://www.surveymonkey.com/r/patientandfamilyadvocates
https://www.surveymonkey.com/r/patientandfamilyadvocates
https://www.surveymonkey.com/r/patientandfamilyadvocates
https://www.surveymonkey.com/r/hospitalengagementnetworks

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