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Sorry Works! Blog

Making Disclosure A Reality For Healthcare Organizations 

RN Daughter Develops Video with Hospital Where Dad Died from Medical Errors

deenaToday we have a guest column from Deena Sowa McCollum, BSN, RN. Deena shares the story of the death of her father due to medical errors and how the hospital was initially unresponsive. Deena was extremely persistent, her dogged efforts finally led her to the right person in the organization, and this tragic story has a positive conclusion that will improve care at this hospital and hopefully other hospitals. Here is Deena's story... **********************

My Dad - Joe Sowa -- grew up in a small Polish town in Texas. He worked for the VA for many years, and then opened his own small business with the help of my Mom, who he was married to for 49 years and 4 days. As the father of two girls, Daddy was not a push over...rules were enforced with consequences, but there was a lot of love in our house. I never went to bed without "I love you." When I became an adult and started my own family, I never left Daddy's house without "I love you." Every day after work I would visit my Dad in the hospital, and he would always say, "Debo (his nickname for me), you look beautiful."

Daddy had 6 grandchildren: 4 grandsons and 2 granddaughters. Those boys more than made up for him not having a son. One week before his death, he was at his grandson's college basketball game. He didn't miss their events! In fact, one of his surgeries had to be changed so he could attend his grandson's graduation -- the Valedictorian. Daddy attended the graduation in a wheel chair with continuous IV antibiotics infusing and a wound vac on his knee.

Daddy was surrounded by a large, loving family, and losing him to medical errors has left a hole in our family.

I am an RN in Texas. I have worked in many areas: Acute Care Telemetry/Progressive Care, Long Term Care/Skilled Nursing, Acute Inpatient Rehabilitation as a bedside nurse, and leadership roles. I went back to bedside nursing after 10 years in leadership. I had to better understand all the missed opportunities that occurred with my Dad.

New Year's Day 2014 was the beginning of our roller coaster ride through healthcare my family never dreamed we would endure. My Dad was admitted with infected hardware to his right knee. The sequence of events which followed were nothing short of a nightmare for my family. From January 1st to December 1st, my Dad was hospitalized over 100 days and had 15 surgeries. He survived 2 delays in care in less than a week but was unable to survive a 3rd delay in care and a misdiagnosis.

The first delay in care was the placement of a Nasogastric Tube to decompress Daddy's stomach. From the time the tube was ordered to the time it was placed was 10 hours. My Dad decompensated as a result of this delay and was transferred to the ICU.

We notified the House Supervisor and Unit Director immediately. They apologized and we were assured it wouldn't happen again. Within a week we received the first of three standard/obligatory letters via certified mail which are required by The Joint Commission that organizations send as follow up to any complaints.

The second delay in care was when Daddy had a decline in condition and the MD ordered for him to be transferred to the ICU. From the time the order was written until he actually arrived in the ICU was 5 hours. Daddy went from only needing a BiPap and observation to needing to be intubated and in multisystem failure. We notified the House Supervisor, the Unit Director and the Chief Nursing Officer. Again, apologies and promises that these were isolated incidents and would not occur again. Within a week, we received the second standard/obligatory letter via certified mail.

During one of Daddy's surgeries, we were to arrive at 7am and would be admitted and taken to O.R. He was not taken to O.R. until 9pm. We were not kept informed as to the delays, and my Dad had no food or water for almost 24 hours. We notified the House Supervisor and the Chief Nursing Officer and heard the same "sorry speech" for the 3rd time.  Daddy was put in a "fancy room" after surgery and my Mom was given a "comfortable bed" to sleep in (not the recliner she had slept in for so many nights). Within a week, we received letter #3 via certified mail.

I worked for this healthcare organization in the past as a staff RN and in leadership roles. The connections I had were beneficial. I would email the director of any unit we were on that was providing subpar care. I often never heard back. Additionally, I had the C.N.O.s email and I would email her or cc her in the emails. She would always reply. She wasn't helpful, but would reply.

The final delay in care and the misdiagnosis were over Thanksgiving weekend. It was the worst possible scenario. No leadership was present, and doctors on call for my Dad's usual doctors. He had no hope... we had no hope...

Daddy died at 7am, the Monday after Thanksgiving weekend. I emailed the C.N.O. while we waited for the funeral home to pick up my Dad's body. I reminded her who I was and refreshed her memory on our experiences over the last 11 months. Then I said, "My Dad is now dead." I requested a meeting with her a.s.a.p.

I met with the C.N.O. and the Director of Performance Improvement a week after my Dad's death. I reviewed all our issues. I explained the missed opportunities were system wide.  Daddy was on 11 different nursing units. These were trends. I told them I could be their biggest cheerleader or their worst nightmare. I want better care at Methodist Hospital! They agreed to work with me.

I heard nothing, a month later I emailed them touching base. "Where are we?" I received a vague response.

I emailed them every month for 6 months. Nothing materialized!

On the anniversary of my Dad's death, I sent letters to the CEO, CFO, CNO and Board of Directors for the organization. I used letter head with a picture of Daddy and myself at the top. In the letter I shared with them that it was the anniversary of my Dad's death in their facility. I reminded them of their promise to me the year before to use our experiences to ensure better care at Methodist and had heard nothing. I ended the letter with, "I hope each of you never experience what we experienced at Methodist Hospital and that your concerns are not disregarded as ours were."

Within a week I received a certified letter from the C.N.O. She misspelled my name 3 times throughout the letter and she was very defensive. At the end she said I would be hearing from the Patient Safety Officer for the Organization. I didn't hold my breath. The next day I received a call from the Patient Safety Officer, Janet Mirza. After 14 months of persistence, SHE was the game changer for their organization. Janet told me in our first conversation, "I am like a dog with a bone, I don't let things go." I was cautiously optimistic. She held to her word. After a few visits, Janet shared with me what she would like to do. Have me tell my Dad's story in the form of a compassionate care video to be used in many venues (Med Exec meetings, New Nurse Orientation, Nurses week and many others). I was thrilled!!

Throughout the making of the compassionate care video, Janet was consistent in her words and actions. She delivered what she promised. She was tearful during the taping of the video. She always had a hug for me. A hug that was genuine, empathetic. When the making of the video was complete, I asked her a favor: "Janet, if this hospital is ever open to have a patient advocate on their Patient Safety Committee, would you please allow me that opportunity." She got tears in her eyes and said, "I was going to ask you before you left if you would be willing to consider that?"

I am not "done" fighting for what is right for my Dad. I have been turned down my more lawyers than I care to count. BUT Janet made me a different person. She gave me hope.

I'm sorry does work!

Sincerely,

- Deena Sowa McCollum, BSN, RN

 

Final note: the video is in final stages of completion, not finished yet. She had a professional come do the video with multiple cameras going and so he is "meshing them together" to make the best video.

 

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Thanks for sharing your story, Deena. Lots of "teachable moments" in Deena's story:

  1. Don't keep saying "sorry" for the same mistakes and problems - fix the problems instead!
  2. When you agree to work with a patient or family after something goes wrong, really work with them! Stay connected. Whenever you close a conversation, meeting, or even an e-mail, set the time/date for the next meeting or conversation. Always keep the ball rolling. And, yes, I appreciate that hospital and nursing home executives are busy people and a few weeks or a month (or even longer) between conversations may not seem a long time to you, but it's an eternity to patients and families. Stay connected, and never let patients/families feel abandoned - or they may find a new friend!
  3. Look for creative solutions. We are so conditioned in med-mal to think every case must be an angry fight over money, when most families simply want to hear "I'm sorry" and see a genuine effort to learn from the event - and this learning may include an active role for the patient/family. Deena's story is a prime example of developing creative solutions/resolutions with a family.
  4. Remember to make an interview of the patient or family part of your review process. At the minimum, interviewing someone and getting their side of the story can be an incredibly empathetic act. People who experience tragedies want to be heard! Interviewing patients/families can also teach you a lot about the care your organization is providing.
  5. You can re-build a lot of trust and re-establish relationships with patients/families by listening, taking complaints seriously, and sticking to your word. If you can't make a promised deadline with a patient or family, give them a phone call or e-mail and say, "I'm sorry, this has been a crazy week, I have not had a chance to complete what I promised, I believe I will have it completed by next Tuesday, thank you for your patience."
  6. Take the time to spell a person's name correctly!  And when addressing someone in person try to make sure you know how to correctly pronounce their name.  If you don't know, ask: "How do I pronounce your name?"  Misspelling or mispronouncing a person's name at a sensitive time adds insult to injury.
  7. Post-event, patients and families should not have to continually complain -- as Deena did -- to be heard. After a while, consumers will take their complaints elsewhere (lawyer, regulator, media, or social media). Does your organization have a disclosure program in place to hear patients and families the first time they complain?
  8. Whenever something goes wrong, Deena is absolutely right - the patient/family can be your best friend or worst enemy. The choice is yours. Is your staff and leadership prepared to make the right choice?
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