October 12, 2008 | Mark Paradies

The Personal Anguish that Poor Healthcare Quality Can Cause – A Reprinted Article

This is a reprint from the Pulse newsletter that I thought readers might find interesting:

By Mary Ellen Mannix
www.PULSEofPA.org

October 13, 2001 my infant son died from a series of preventable errors in a local hospital. The numerous errors (known broken equipment, medication error, failure to rescue, ventilator induced pneumothorax, hospital acquired infections, to name just a few) he died from are now classified as “sentinel events” and would be reportable under the new PA laws passed just 6 months after he died.

The only way I have been able to learn what happened was through nearly five years of being a plaintiff. After refusing a near 7 digit figure and providers who perjured themselves on the stand, the jury found one doctor negligent but not responsible. I am one of the very few to have gotten my day in court.

PULSE of PA was established in the last year to support and educate patients, family and providers in Pennsylvania about safe, quality health care practices.

After a recent talk I gave at Harvard University, an advocate asked why I didn’t name names.

On one hand, if anyone really wants to know, it’s all public; go googling.

On the other hand, I have been working to encourage doctors to partner with their patients, and I didn’t want to scare them off. Physicians and patients need open communication. Reports like the one below in the Philadelphia Inquirer “Hospital Mistakes Go Unreported in PA” by J. Goldstein:

http://www.philly.com/inquirer/front_page/20080912_Hospitals__mistakes_are_going_unreported.html?viewAll=y

remind us that patients and physicians have no choice. If you want to save a life today, you have to speak up today. You do have to name names.

These are the people and places to go to learn what did not work so it will not be repeated. It’s not okay to wait until trainings are completed. Waiting means another newborn boy, or someone’s mom, or sister, brother, aunt, uncle, grandparent will die from a preventable error. It could be yours. It could be you.

The dilemma as to whether to print real names of my son’s providers or oblige a request from one to withhold that information for now is over.

Jim Conway, VP of the Institute for Healthcare Improvement, (not involved in my son’s case) is due respect for the experience, knowledge and compassion he brings to these discussions. He stated in a 9/12/08 article: “We cannot improve care unless we understand the problems. There can’t be safety without transparency.”

One patient’s report can be found at www.beasleyfirm.com. Click on “A Client’s Story”.

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