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A Patient’s Guide: How To Stay Safe In a Hospital

Checklists have become more common in the operating room. Now, there’s one for patients and families, too.

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Falls are a common hospital hazard.

Propping up a patient’s hospital bed at a 30-degree angle can help prevent hospital-acquired pneumonia. Using alcohol wipes kills staph bugs, but you need bleach wipes to kill C. diff germs. High-protein snacks can help prevent bed sores.

However, most patients don’t know these things. And doctors and nurses can easily overlook these basic care practices.

Karen Curtiss makes it her mission to remind them. After her father and husband both experienced adverse events in the hospital, Curtiss says, she founded Campaign Zero to arm patients with the information they need for a safe stay. Her book, “Safe & Sound in the Hospital: Must-Have Checklists and Tools for Your Loved One’s Care,” collects scores of these simple actions and details that can make a big difference in a patient’s recovery.

Checklists have become more common for surgeons in the operating room. But according to Curtiss, she’s the only one producing checklists on hospital care for patients and families.

To make the checklists, Curtiss read everything she could get her hands on: nursing textbooks, information from the CDC, academic publications. She took her work to specialists and focus groups. And then distilled all of the information into something so simple a sixth-grader could read it.

We sat down with Curtiss, who is a member of ProPublica’s Patient Harm Community, to find out more about patient-centered checklists.


Why checklists?

Conventional wisdom says that when you go to the hospital, you take someone with you. However, nobody is prepared. There’s nothing in college that teaches you how to be an advocate. There’s nothing in your life experience. We have an army of people sitting bedside, who are ripe for education.

We put a checklist out on Campaign Zero, but I could tell from the traffic that people were finding it only after a problem had occurred. They were Googling bed sores and how to treat them, staph infections. People do not prepare to be sick. So I wrote the book.

I learned during my research that there are repeated problems that put people back into the hospital that nobody ever tells you about. For example, if you have congestive heart failure, you need to weigh yourself every single day. If you gain two pounds in a day, you have to get to a doctor right away.

But I don’t know how many people are told that. Even if you are told that when you’re discharged, many people are still on drugs and not thinking clearly. And it’s a hurried process. They need someone there with faculties intact to ask the questions, sweat the details, know what to look for and be encouraged to ask questions. The simple affirmation that it’s OK to ask questions makes people more comfortable.

Furthermore, we know checklists work. Atul Gawande, the author and surgeon, wrote in “The Checklist Manifesto” that the ideal checklist is no more than ten items.  And they are effective. It’s been proven with other checklist projects, some that are being rolled out throughout the country.

So I said OK, if checklists work for the medical community, then they can work for families. It’s a potential win-win.

 

A lot of people in ProPublica’s Patient Harm Community say that when they ask questions, providers push back. What would you say to them?

I relate to that so much. And it’s unfortunate, but it does happen.

First of all, before you choose a hospital, make sure to vet them. Some hospitals talk the talk, and others walk the walk. You can look at their Leapfrog score or their Consumer Reports rating, if you have access to it. [Editor’s Note: You can also check Medicare’s Hospital Compare.]

But that’s hindsight. If you have problems after you’ve committed to a hospital, you can always call the hospital advocate. You can call a Condition Help, also called a Condition H, if you feel like your loved one isn’t being heard, or cared for properly, and a team will respond. It’s also sometimes called a rapid response team – hospitals call it different things. But very few are transparent about the fact that you can do that.

I’ve heard of doctors quitting patients because they ask too many questions. Obviously, you find another doctor. You find another hospital. A recent study suggested 27 percent of doctors and nurses feel it’s inappropriate for patients to ask them to wash their hands. It’s because they feel chastised. Their egos are bruised.

So what should a patient do? Stick to your guns. Be humble, and play to those egos. “I know you’re the expert, but I want to protect you as much as my loved one.”

That’s why in my book I have pullout cards. Sometimes, it’s easier for people to read a note than hear people say it. That’s also why some of those cards are silly; humor can help break the ice.

A lot of items on the checklist seem to address communication.

Communication is the number one challenge. In the 1970s, there were two or three doctors involved in a patient’s care. Now, there are up to 15. That’s good news. But the bad news is how do they communicate? Care is much more fractured because it’s specialized.

I encourage people to be a part of the shift change, which is called the hand-off. That’s when they share notes with the doctors starting their shift. It’s a huge opportunity to spot inaccurate information, fill in gaps and raise questions. Ideally, the hand off should occur bedside. If they resist, you can always ask to go to where they’re doing it. It might be in a break room.


How are providers responding to the checklists?
We’ve had a lot of support. And not just from providers. Blue Shield of California is giving the book to patients at University of California, San Francisco, who are employed by the city and county of San Francisco. Community Trust Bank in Kentucky, which has 1,000 employees, is giving everyone who has a pre-planned admission a copy of the book.


I also collaborated with Mary Foley, who’s a prominent leader in nursing innovation and head of nursing research and innovation at the UCSF, to create a companion nursing workshop. Nurses on the front line probably haven’t had up-to-date education on the basics of patient safety because they’re really busy and went to nursing school a long time ago. Plus, people can walk in with these checklists, and one look from a nurse who isn’t on board can make them feel like they were thrown under the bus. The workshop is meant to help nurses understand how engaging families and supporting safe care practices can benefit them.


What would you say is the one most important thing someone can do?

I have two: Ask people to wash their hands. The greatest hazard in hospitals is infection, and the number one thing you can do to prevent infections is hand washing. Don’t let people give you flack about it.

The second thing is to take notes. Take notes to ask questions and be organized. When the doctors and nurses come in, if you’re prepared with your questions in notes, then you use your time wisely.

Also note when medications are given, when tests are ordered and the test results. You could have tests ordered at 9 a.m., and the results might be critical for next steps. If they don’t come until 9 p.m., that’s a problem. And a detail like that can get lost.

People respect stuff that’s written down. And if the doctors and nurses know you’re on it, they will be more accountable. It’s very subtle, but it takes the drama and emotion out of it, and makes the experience more businesslike. 

Clifford Wilson

Feb. 4, 2013, 4:21 p.m.

This is an excellent source of invaluable information for everyone in need of help when dealing with the Medical System.

Nancy Stephens

Feb. 4, 2013, 5:41 p.m.

Great Info.  Much more to add, as I haven’t read this book. But patient or loved one, should also bring items with them to hospital often needed. Wipes just for face,hands for patient. Alcohol and/or bleach wipes for bed rails, sink, toilet. I always bring my own paper cups for water ,tissue. Have even brought my own pillow! Little Snacks.
ASK about your Meds, and if on IV, ask what it is , when changing it!
Med mistakes happen often. Nursing care is real limited today, such as morning wash of hands and face, brush teeth, if your bedridden..just don’t get anymore. So try to keep wipes,mouthwash and a item close by to spit in or a trash can. Cleanliness, watch /ask your Meds, and bring wipes to stay clean! Patient comfort, also infection comfort that you can’t trust anymore.  IF ON a Ventilator, loved one should find out when it gets changed/cleaned and BE there to make sure it is done.
BIG item, as these items and catheters do not get changed or cleaned often as should for patient.  Let people know you be in a certain hospital, so they can visit you or bring you something needed.

Bravo to Karen for her work that will make patients safer. another great resource is the book Never Go To The Hospital Alone. In addition to all of the hospital advice, it also provides checklist sand tools for finding a great physician and working with that physician before you go to the hospital.

No patient is ever truly safe that doesn’t take charge of their own care and forcefully but tactfully become a member of the health care team.

abinico warez

Feb. 4, 2013, 6:51 p.m.

Medical industry, by their own numbers, kills up to 200,000 patients yearly. Google ‘medical deaths’.

Stephanie Palmer

Feb. 5, 2013, 8:51 a.m.

I think people need to really look understand how bad they feel before going to the hospital.  Unless you absolutely can’t take care of yourself, there is no reason to be in a hospital. Toooooooooo many germsssss.

This is definitely a good starting point.  Since we won’t be able to convince the AMA to “insult” doctors with a checklist, a patient’s checklist to drive the conversation is a brilliant move.  Certainly, it’ll help more people than “fine anybody without medical insurance.”

And if it can, in fact, be circulated through the insurance companies without being dumbed down or marginalized, you might have actually literally saved lives.

Make sure to mention that when someone asks how your week was…

Donna Crowder

Feb. 6, 2013, 1:33 p.m.

The article was excellent and I can’t wait to read the book. As a RN & someone who has had many family members & friends hospitalized, this information is needed immensely to educate not only caregivers but patients themselves! We need to get more people involved and have more patient advocates who are willing to help in this push for better patient care without fear of repercussions from staff. Nancy, I agree with your comments, as well as those of others.  I too could add so much more!! This is a subject that I am very passionate about! If anyone needs a pro patient advocate on their team, hospitals, nursing homes, attorneys, Education Departments, etc, I am your person to help
push this forward! I have 19 yrs experience as a RN and would love a position such as this! Keep up the awesome public/patient education!

The link to patient zero program seems to be broken.

Also, you suggest using the leapfrog group scores but don’t point out that most hospitals refuse to participate.  Here’s a list of hospitals within 50 miles of where I live http://www.leapfroggroup.org/cp?frmbmd=cp_listings&find_by=zip&zip=56377&radius=50&cols=oa

Also, this article should point out that over 95% of all hospital mistakes are beyond the control of the patient.  The biggest killers are surgical errors, medication errors, lack of hand washing and slip ups in communication https://www.impartial-review.com/stories/survey-nearly-one-in-three-americans-report-medical-mistakes-364  The patient has not control over any of these whatsoever except for asking medical staff to wash your hands if you awake.  As noted in the above link, research has shown that doesn’t work in most cases.

There is no motivation within most health care systems to listen to what patients say.  Instead, there is a profit motivte.  As the NHS has recently discovered when it moved some aspects of its system to for-profit, the result was that hundreds of people died http://www.bbc.co.uk/news/health-21275826 -  just like they do in the US every day.

For example, most physicians know how to treat diabetes but you’re seven times as likely to have it go untreated in the US as you are in Spain.  https://www.impartial-review.com/stories/ten-leading-government-and-corporate-causes-of-death  In other countries, medical errors and medical system failures are not the leading cause of death as they are in the US because health care professional make more money if they provide greater benefits to their patients.  The US system provides disincentives for quality care.

Blair Hickman

Feb. 8, 2013, 12:06 p.m.

Donna - thanks for your comments. If you have a moment, we’d love your input on our provider questionnaire: http://www.propublica.org/article/providers-share-your-observations-on-patient-safety

One of the most important thing involving a hospital stay is to always have a patient advocate with your family member if they are having surgery, elderly, or confused.  Even a young adult needs someone in their room postoperative when they are unable to montior their own care.  What medications were they taking at home and are they getting them in the hospital?  If they are getting a medication at the same time each day and suddenly get one that does not appear to be the same thing,  ask questions,  If their IV is running out ring their buzzer and if necessary go to the nursing station.  If you have questions for their health care provider and they merely stick their head in the door (as some tend to do), ask them to please step into the room and get the information you need.  Aspetic technique is impotant- washing hands, handling equipment, etc.

Karen Curtiss

Feb. 8, 2013, 5:26 p.m.

First of all, kudos to ProPublica for all they do to support patient safety. I hope you’ll join their Facebook page and follow them on Twitter because they are constantly covering the issues in an in-depth way.  So often I see the headlines screaming about problems in health care without offering solutions—and yes, we patients and our families can actually make a difference in outcomes!  I’ve really enjoyed reading all of your comments and I am happy to say that most of the cracks in hospital care you’ve identified in this thread of conversation are covered in my guide for families, Safe & Sound in the Hospital: Must-Have Checklists and Tools for Your Loved One’s Care (http://www.SafeAndSoundBooks.com).  This site has additional info (FAQs), and blogs with more checklists for patients and their family-member advocates will be up soon! Please check in with http://www.CampaignZERO.org from time-to-time, too, as we try to keep that site fresh with new info as well. We are always happy to hear about patient safety solutions… so write us any time with your ideas!

My best friend had surgery to repair a broken leg at our U OF WISCONSIN HOSPITAL.
He acquired interstitial pnemonia in surgery. .(identified within days)
and died within 5 terrible months.
Sounds like a medical error killed him..? Other medical journals have sugested he should have been elevated during surgery.
How and where is this identified and reported to correct medical practices and to alert the public.
The LEAPFROG GROUP gave the UW hospital a C, lower 30%
of those rated.
I would give then a F.

Thank you for the information. I can relate to some of it. Went into the hospital Oct 26th 1012 with a massive heart attack, then caught pneumonia, then a bladder and kidney infection, then internal bleeding. To make a long story short, I left the hospital on 1/10/2013 . If I never see the inside of a hospital again it would be too soon.

This is a very good article.  My career has landed me at the safest hospital in Western New York as judged by Consumer Reports.  Getting to that point was no small trick, it is a constant, never ending journey to zero preventable errors.  All staff has had hours of error prevention training, and it is all based on the patient’s perspective.  When a patient comes to the hospital, they want three basic things; don’t hurt me, heal me and be nice to me ( in that order ).  For further reading on the subject, I recommend reading “Why Hospitals Should Fly” , it is really about the implementation of checklists, how and why they work.  We all need to be concerned about the safety of healthcare.

Very insightful information. I have been in health care for over 2 decades at various levels of responsibilities. From my early nursing school days, I was constantly reminded of the fact that, as a RN, I was the patient’s advocate. During my master’s program, I heard the same message. I do not understand why there is now a separate role in the health care industry specifically called a patient advocate, except to say we have failed our patients.
I also recommend the book Mark K. did called “Why Hospitals Should Fly” as well as Dr. Atul Gwande’s books. Communication is always one of the issues in any patient care encounter. This goes both ways. Physicians and some nurses, as well as other health care workers, are not used to being questioned about the care they give to a patient. This may lead to a feeling of being attacked when the provider has good intentions. Repeat this scenario multiple times a day for the health care professional. This can create a difficult environment to work in and may cause some of the break down in communication even before a conversation can begin. Please understand I am not making excuses for the health care professional. I am merely bring up an observation that I have not really seen addressed in literature. It is good to ask questions when you don’t understand. It is better to ask questions in a manner where the health care professional believes you are trying to work with them and not against them or challenging their expertise or their desire to help the patient.

Good article, reminds me of David Goldhill’s Catastrophic Care: How American Healthcare Killed My Father. His father died of an infection that he picked up at the hospital. Apparently, it is quite common in American hospitals, about 100,000 deaths per year.

I like the way Propublica keeps following up on articles. I would like to see all of the Propublica Health writers read Steven Brill’s “Bitter Pill” article for Time Magazine and follow up on all the issues he raises. I haven’t read an article from Time or any other mainstream publication in decades, but this is real journalism. Time is letting people read it online without subscription. http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/  I hope this forum allows links because this is one of the most important articles written on healthcare in years. It raises many issues about medical lobbyists (many times larger than military industral complex), Mastercharges and how hospitals determine rates, how most nonprofit hospitals make more profit than for profit hospitals. I hope Propublica writers read the article and follow up on all the issues it raises.

Teresa Goodell,RN,PhD

Feb. 25, 2013, 6:56 p.m.

There are a couple of problems with the evidence backing up the information presented above. First, the evidence for nutritional interventions in preventing pressure ulcers is weak and inconclusive. Although everyone should be fed, of course, the Mayo Clinic source linked above also contains erroneous information, e.g. about patient repositioning for prevention of pressure ulcer. Latest evidence shows that every 3 hours if frequent enough (two hours was never based in actual research; it was mere ritual.)

Second, the evidence for checklists in acute care settings shows that they fall short of the promise we once thought they held for improving safety. Read this metaanalysis http://www.biomedcentral.com/1472-6963/11/211  to find out more.

This article is part of an ongoing investigation:
Patient Safety

Patient Safety: Exploring Quality of Care in the U.S.

More than 1 million patients suffer harm each year while being treated in the U.S. health care system. Even more receive substandard care or costly overtreatment.

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