Nancy’s call to action came in 2012 when she lost her husband, Glenn, as a result of a series of medical errors. Nancy is not a medical professional. So, when she entered the ER with her husband, she trusted the doctors to help her husband, and expected that he would be given the best care. In the end, Nancy’s faith was misplaced as mistake after mistake resulted in the loss of her husband. This horrible experience has fueled both Nancy and her daughter, Melissa, to become advocates for the disclosure of medical errors.
Nancy’s story speaks to the Patient Voice Principles of Safety and Accountability.
On a Friday evening in 2012 I took my husband, Glenn Clarkson, to the emergency department of our nearby rural hospital. He had been badly burned while assisting with a controlled grass burn, which did not proceed as planned.
At that hospital he experienced a series of medical errors, including a delay in transfer to a burn center. By the time he was finally transferred the next morning there was little hope for his recovery. He died twelve days later. I would like to share what happened in hopes that our experience can educate other healthcare workers and hospital administrators.
When we arrived at the emergency department, a nurse told me that Glenn would most likely be transferred to the burn center. I told her I wanted him where he would get the best care. I knew nothing about severe burns and assumed I could trust the hospital to do what was best for my husband. After the ER doctor arrived and assessed the situation he told me he didn’t feel the burns were bad enough for a transfer, and admitted Glenn to ICU. The doctor made this decision despite Glenn having second and third-degree burns over 30% of his body (and exceeding the criteria for transfer). I did not know this doctor, but chose to trust him, thinking that Glenn’s condition must not be as bad as it seemed. No physician discussed anything with me at that point or any time during Glenn’s stay at that hospital.
Lesson for physicians: Discuss treatment options with patients and their families, even if they are in a state of disbelief or confusion.
I stayed the night with my husband in ICU. I could tell his condition was worsening and knew that the ICU nurse was trying to get the ER doctor to transfer. Through testimony three years later I learned that she had also contacted the doctor on call, but he chose not to get involved. In addition, the house supervisor had called the administrator on duty, but she said she would not be able to influence the decision of the ER doctor.
Lesson for supervisors and administrators: When one of your hospital staff expresses concern about the status of a patient, take this concern seriously. Have a procedure for mobilizing another physician or team to assess the situation, even if it is in the middle of the night on a weekend.
While in the ICU Glenn was not given proper fluids, not given adequate pain medication, and given medications that caused his condition to worsen. Not until after a shift change the next morning did transfer take place. By this time Glenn was severely dehydrated and in renal failure.
Two days after skin graft surgery, I made the painful decision to have him removed from life supports.
Later when I tried to talk to the hospital about Glenn’s care, we received only silence. Based on this experience, my daughter, Melissa Clarkson, and I have become advocates for disclosure of medical errors.