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Surviving A Hospital Stay With Luck and Pluck

A grad-school colleague once described his hobby – military history – as stories of luck and pluck stitched end-to-end.  Stories replete with derring-do and narrow escapes.  Suffering losses bravely while hoping for the occasional happy ending.

I feel much the same way about hospital customer service anecdotes (except there’s more unnecessary deaths and even fewer happy endings.) Still, I can’t help regaling you with another adventure through healthcare's minefields.

A friend’s father recently sought treatment for a leg infected with what appeared to be a nasty staph infection. A late-Saturday ER visit resulted in his admission and the first of what was supposed to be multiple doses of IV antibiotics.

Now this is a well-regarded hospital with a spanking new facility, a member of one of the industry’s most highly-regarded national systems. So far so good, right?

At 4:30 P.M. the next day, as the attending physician reviewed the chart, she wondered why no antibiotics had been administered after the initial dose in the ER. “No orders” she was told. So she wrote an order.

The nurse dutifully hung the IV bag yet failed to check that antibiotics were actually reaching their intended destination. They weren’t. In fact, some doohickie wasn’t connected to some other whatchamacallit, an error that wasn’t noticed until the next morning, nearly 36 hours after the ER visit.

I advised a call to the CFOs office and an utter refusal to pay for the hours wasted, antibiotics not given and another life jeopardized.

I realize that one anecdote is just that – one anecdote. I’m sure this hospital has elaborate patient safety protocols. I’m sure ‘near misses’ are rigorously investigated. I’m sure everyone talks the language of process improvement - PDCA. CPOE. EMR. Six Sigma.

And I’m sure, if Risk Management permits it, that hospital leadership would call these careless oversights wholly unrepresentative of a wonderful organization filled with wonderful people doing their wonderful best.

I’m sure. Well, pretty sure.  Though if I ever find myself on the receiving end of an antibiotic IV, I'm checking the doohickies and praying for luck and pluck in equal mega-dose proportions.

Follow me (Steve Davis, Health Care Strategist) on Twitter @whatifwhynot

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