Donna Helen Crisp’s Story: Medical Errors & the Call to Accountability as Experienced by A Nurse Ethicist and An Author

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Donna Helen Crisp JD, MSN, RN, PMHCNS-BC Assistant Professor School of Nursing University of NC at Chapel Hill
Donna Helen Crisp
JD, MSN, RN, PMHCNS-BC
Former Assistant Professor
School of Nursing
University of NC at Chapel Hill

A problem not acknowledged is a problem that cannot be studied or resolved. Many patients get worse, or die, without knowing what went wrong,” says Donna Helen Crisp, Nurse Ethicist and author of Anatomy of Medical Errors: The Patient in Room 2.

Never before has it become so critically important and possible to become active participants in every aspect of our healthcare. From insurance coverage to provider and treatment options, we have the opportunity to take charge of our health and demand that the healthcare industry, as a whole, address our questions, concerns, and rights to involvement with dignity and respect…and it all begins with the responsibility to become an informed, vocal healthcare consumer now.

Because as Donna Helen Crisp describes from her own experience..it’s a matter of life and death.

DHC-Book Cover May 2016 (4) (1)

 

I almost died from medical errors
By Donna Helen Crisp
Nurse Ethicist and Author

Upon entering a large teaching hospital for surgery one hot summer morning, I expected to go home the next morning, to rest and recover before going back to work the following week. Unfortunately, fate had a different plan for me. My surgeons unknowingly damaged my bowel and everything changed. I woke up with excruciating pain late that night, when my small intestine burst open in two places. While everyone thought I would die, somehow I survived multiple medical errors. I have no memory of pain, or the events of the next three weeks.

As daybreak arrived, I was still in acute pain, as residents wrote orders for me to eat breakfast and be discharged. While no one was supervising the new doctors that morning, or coordinating my care, I was slowly dying. It took about forty hours before anyone realized how sick I was.

By the time I had a CT scan and was taken for emergency surgery, it was early the next day. Things got worse, when a student nurse anesthetist incorrectly placed a breathing tube down my throat, causing me to aspirate. A gallon of barium dye infiltrated my lungs. In addition to the infection I had from my leaking bowel, I developed raging new infections, including sepsis. I spent the next three weeks in a coma and endured three more surgeries.

When I was finally taken off the ventilator, I woke up to unknown surroundings, with no idea where I was or what had happened to me. Still psychotic from the drugs, I vowed to write a book. As a nurse who became a patient, and a nursing professor who had taught medical ethics, I knew my perspective would be unique. The hospital refused to tell me anything, so I spent eight years discovering the truth and writing my memoir.

Eventually, I went home, with a large hole in my abdomen, hooked up to a draining machine for two more months. I had no idea how to put my life back together. Unable to move, bathe, dress, or prepare food, my initial recovery focused on regaining enough strength to walk and attend to my usual daily activities. Fourteen months later, I had to undergo a major repair surgery.

During the years it took to write my book, I was amazed to learn how unsafe hospitals can be. Even though I had trained, worked, and taught students in hospitals, I had no idea how many patients die from healthcare-associated infections (HAIs) each year in hospitals. Recent findings indicate that HAIs affect up to 10 percent of hospitalized patients in the United States each year, causing approximately 1.7 million HAIs, which result in 99,000 deaths. [Read the CDC article Preventing Healthcare-Associated Infections.]

I was shocked to learn that medical errors is not included on the annual list of major death causes compiled by the Centers for Disease Control and Prevention (CDC). Why? Because the CDC creates its annual list based on information from death certificates, which are filled out by physicians (and others), who use the International Classification of Disease (ICD) code for each cause of death – and there are no ICD codes for human and system factors. This means that when hospital patients die from preventable errors and adverse events, their deaths are not linked to the real causes of their demise. Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. BMJ.

During my month-long hospitalization, I suffered from: inadequate care from inexperienced doctors who lacked adequate knowledge and assessment skills; uncoordinated care; deadly infections and unsafe practice; medical staff with poor critical-thinking abilities and poor communication; and some nurses and physicians who saw me as an object instead of a suffering human being.

While heart disease and cancer are the two leading causes of death in this country, an estimated 250,000 and 500,000 (or more) patients die every year from medical errors, which constitute the third leading cause of death in the USA. Unfortunately, it is currently impossible to get a more accurate estimate, since many hospitals (and physicians) do not disclose errors. Nor are all states required to report facility HAI statistics. [Check this CDC list to see if your state requires hospitals to submit HAI data to the National Healthcare Safety Network (NHSN).]

I was incredulous that the hospital never told me anything, not one word – as though I did not exist, and had never been a patient there for a month. Certainly, no one ever apologized for what happened to me. This silence gave me the moral courage to write my book, to help others understand how one failed moment in surgery, can cause unquantifiable suffering and enduring hardship for patients and their loved ones. [Read Anatomy of Medical Errors: The Patient in Room 2.]

People who know my story ask me what can be done to prevent medical errors. I say there is little one individual can do. Vulnerable patients cannot diagnose themselves, prescribe correct medications, observe their surgeries, coordinate their own care, or disclose errors when things go wrong. However, healthcare systems and insurance companies can evolve to value patient safety more than profit. Hospitals can operate with transparency so that errors can be identified, understood, and minimized. Patients can learn to be more aware and participatory in their health care.

We need to ask lots of questions, especially when we (or people we love) enter a hospital. We need to know more about the informed consent we sign before surgery. We need to maintain current advance directives (living will and health care power of attorney). We need to get second opinions. We need to know which medications we are given. We need to have someone with us at all times (if possible) to be our advocate and witness.

Medical errors are ubiquitous. For the medical paradigm to change, those who work in health care – including hospital administrators, risk managers, attorneys, insurance companies, physicians, and nurses – must summon the integrity and courage to put patients first – before ego and money – and stop denying or covering up medical errors.

We consumers of health care must become better critical thinkers and more proactive about our bodies. We must stop trusting blindly that everything is as it should be. We must not wait for corporate profiteers to change their goals. We need to become our own consumer advocates and protectors. Now.

 

Donna Helen’s story demonstrates the PVI Principles of Accountability, Dignity, Empowerment, Information, and Safety. Learn more about Donna Helen Crisp and follow her on Twitter.

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