List Archives

Fri May 25 03:27:17 BST 2007

Dear Janei,
  It sounds like this case is still distressing you because of the 
outcome for your patient. There should be a few channels  available to 
you in your hospital to follow this up. In the past with difficult cases 
I have found it useful to ask if you can present the case at a ward 
meeting and open up the issues raised for discussion amongst your 
colleagues own your own mistakes. This does need to be done very 
carefully because if it is not handled well can create a lot of 
conflict, but if people involved can see their own need for improvement 
and humbly, honestly, and critically analyze their own practice against 
evidence based research it can begin to create a positive knowledge 
based culture that is patient focused. If the problem is with more 
senior management and having raised the issues with them you are still 
unsatisfied and feel that patients are at risk, it may be useful to 
refer the case on to your hospital's adverse events committee (or the 
equivalent). This is a committee that is designed to review adverse 
events or near misses to determine if there are breakdowns in the system 
that should be addressed and more importantly they have the authority to 
address them in the most appropriate manner. You may not always hear the 
outcome of this committee but having done this myself, I have noticed 
that in the ensuing months practice changes are sometimes implemented 
that assist with addressing the problem. Be aware that there is 
sometimes a price to pay for being a whistle blower and before you take 
any action speak to a trusted wise colleague to determine the best 
course of action.
Kind regards,
Chris

Janei D. Brockhausen wrote:
> HI Dr Mattox,
>    I am disappointed there has not been more discussion, and no real
> thoughts on how to best approach this with the hospital. I can't say I'm
> surprised, but I am disappointed. It's disheartening to think I am on 
> staff
> there and this may just be swept under the carpet. No one to teach the 
> right
> way. I think the ( this is janei speaking only) that the head nurse (call
> was to the Head nurse of the ED)should carry some of the 
> responsibility as
> she knew the situation and did not act to secure the patient in the ED 
> and
> make sure treatment was ensured.
>   Yes, sometimes the enemy is ourselves.
> I appreciate all you have tried to do, maybe I can find a way to teach
> triage in a more reliable manner. I may have to do a super job of 
> selling an
> information board on peanut allergies/all allergies/anaphylaxis and the
> potential severity/immediacy.
> Again, appreciated.
> janei
>
>
>
> On 5/23/07, KMATTOX at aol.com <KMATTOX at aol.com> wrote:
>>
>>
>> In a message dated 5/23/2007 12:07:34 P.M. Central Daylight Time,
>> tch at sun.ac.za writes:
>>
>>
>> 6)  As to the DUTY to the persons involved: none unless the law of 
>> the USA
>> allows  otherwise or unless you are the patient's usual treating
>> physician. The
>> most  you can do is forward this information to the patient or their
>> lawyer.
>> However, I would suggest they get a local Emergency Physician and an
>> Allergologist as expert witness rather than (an esteemed) trauma
>> surgeon.  :)
>>
>>
>> I am not sure that the solution should be a legal one, although there 
>> are
>> some JCAHO and regulatory system issues here.    One reason that  I 
>> choose
>> to
>> air this publicly is that this hospital is one known to everyone on  
>> this
>> list
>> server, and may be one that is a major hospital for members of this  
>> list
>> server.   A patient who had come to this hospital before with  peanut
>> allergy, who
>> was in severe trouble was brought by an appropriately  identified health
>> care
>> worker with an in-route phone call made to the  registration desk of the
>> emergency department of a hospital with a trauma center  designation.
>> When the
>> patient arrived they were put into a long  line, put through a long
>> interview
>> and eligibility screen and made to wait,  while having strider and 
>> looking
>> bad.
>> When questioned the  hospital (administration and registration) tried to
>> cover up, tried to change  the story, and tried to indemnify the 
>> hospital
>> and its
>> staff.   We  each have a responsibility to assure that such system
>> problems
>> are  addressed.    Who knows, this might be my own hospital or your  own
>> hospital.   I do have its name.   I did some calling  around and this 
>> kind
>> of
>> activity is more common than most of us would not like  to admit.
>> DESPITE EMTALA.
>>
>>
>> I am almost ashamed that I gave my impassioned post about access to 
>> health
>> care last week.   Now I am embarrassed to find that we have met the  
>> enemy
>> and
>> it is us.
>>
>> k
>>
>>
>>
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-- 

Chris Wilson

Lecturer

School of Nursing and Midwifery

Flinders University

Phone 82013354

Mob 0414253393

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EC - Unrecognized severe Peanut Alergy by triage clerk in MAJOR EC