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From "dad for a day"
I just brought my wife home from the hospital. She finally exhausted
herself crying and went to sleep. The drive home took longer than
usual because every now and then I had to stop by the road and once
in the shopping center parking lot because her crying had escalated
into screaming and the people in cars next to us were looking. Anyway,
my wife was in one of those fancy "birthing" rooms that
look like rich people's bedrooms where the newborns sleep in those
carts next to the moms. My wife was exhausted and the baby was sleeping
so the nurses left them alone and I went home but when she woke up
our little girl was not alive anymore. No one had been watching her.
I don't know what actually happened because everyone was crazy when
I arrived. I just got finished putting the wallpaper up in her room
and that's why I wasn't there with my family when I should have been.
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From a patient:
"I accidentally hit the utensil drying rack by my kitchen sink
and a knife popped out and sliced open my arm before I knew what happened.
They stitched me up in the emergency room and then sent me to a floor
to recover because I had lost a lot of blood and needed a transfusion.
I went to sleep but woke up in the intensive care unit all hooked
up to monitor screens. They told me that I must have passed out because
a nurses' aide found me in a pool of blood. My incision had come undone.
I'd probably be dead right now if the aide hadn't found me." |
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A physician in Kentucky writes:
"The hardest thing about telling the family of a patient who
died unnecessarily due to a medical or patient safety error is admitting
our own involvement in the cause. I heard about your "hidden
patient" articles at a California Medical Association meeting.
I looked back and realized that three of the errors where I had admitted
fault had less to do with what was determined by the plaintiff's attorney
to be my "under-assessment" of the patient's mental condition
and more to do with the fact that had staff been closer to the patients,
i.e. "visible", they would have been saved from themselves
instead of the staff having to unsuccessfully attempt to save them.
Thanks. I wish I had thought of this myself." |
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From "Dahlia Rose", sister
of the first patient, daughter of the next:
"At first they thought he was just wetting the bed all the time
and they were getting tired of having to change the bed, and then
they were complaining to my sister about the IV. Then when I came
in later I noticed that the IV hadn't even been put in correctly so
it was leaking all over the bed. My brother wasn't just 'hidden' from
the sight of the nurses; he was 'hidden' from their care as well.
"The same thing about my mother: no one was
there to care. At first I didn't realize why she was getting worse
but no one seemed to notice. On the morning of the third day I finally
noticed that no one had brushed her teeth or given her a bath. She
isn't getting any care and everyone is bitching and moaning about
us because we're demanding. They finally came in a brushed her teeth
and discovered that she had three days of pills lodged in her throat."
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From "Maryanne" and "Wendy",
Idaho, 'floor nurses':
"Here's one for you: don't tell the name of the hospital but
they just fired one of our nurses for something that wasn't her fault.
Her patient pulled out his tracheostomy tube and by the time we got
the monitor alert from the monitor station we got to him and he was
[exact comment deleted] blood was coming out of his tracheostomy incision
and he was gurgling and gasping and now he's dead." (updated
7/12/07) |
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From "Kristy" and "Joe":
"Me and my brother were taking turns staying with Mommy during
her recovery from a histerectomy operation. When she wanted something
like food or water the nurses let us help ourselves. In fact, they
pretty much left us alone to take care of her ourselves. They were
very grateful and kind. Several times neither of us could be with
her but the last time was the last time. She died while we were gone.
She had internal bleeding and they just found her dead. No one knows
how long she had been dead but that's not the point is it? The nurse
said they thought we were still watching her. Now my dad is mad at
us (he has to work on a ship) and we're all freaked out about what
happened." |
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From "Twice
Abused":
“…I had had traumatic brain
injury and had been rushed to the hospital by an ambulance after my
roommate just happened to come in and find me unconscious after I
had been beaten, raped and left for dead. I woke up in a hospital
bed and no one was there and I totally [expletive deleted.] I pushed
every [expletive deleted] button on their high-tech remote thing and
then I started screaming. All I could think of was that the bastard
who had done that to me was going to come in and finish the job. So
what felt like hours later a girl, and I do mean “a girl”
in a white outfit with white shoes comes in and says she’s sorry
but the nurses are all busy but am I okay? I don’t remember what
happened after that but I must have blacked out. I was told later
I yelled something horrible to that little poor girl and she ran out
of the room to get a nurse…I woke up in the intensive care unit.” |
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From "Mandie" in
Oregon:
"Our local hospital just unveiled their new design for the $500
million medical center that they will begin building next year. They
posted the floor plans in the hallway next to the main lobby. I saw
them on my last visit to the existing hospital where my brother died
from a cause they don't know about yet. He was only 35 years old and
they found him dead in his room but no one was there so that is why
they still don't know why he died. I looked at the drawings on the
wall and now I know what my friend (who is a nurse in the hospital)
meant when she said that I should tell you about what happened. All
the rooms looked to me like they were for hidden patients. My friend
says future hospitals will be built with no hidden patient, but we
don't know why they are still going to build this one when they know
there is a problem with hidden patients." |
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From a family member in Bethesda,
MA:
"I took both my elderly mom and dad to what is known as one of
the best hospitals in the world. They got into a car accident. My
best friend is a nurse who said it was the safest hospital so I should
be comforted. On my second visit I walked into my mother's room where
I noticed my mom was sleeping just like she always does; on her back,
her mouth wide open, mid-snore. I smiled and went up to her. Just
when I noticed she was not starting to snore again the door crashed
open and nurses piled into her room, doctors and other people too.
It was then that I noticed the monitor was like on TV, you know, lines
and numbers and stuff. She died. While the nurses tried to console
me they also noted that my father had died only hours before I had
arrived. They told me it had been "hell day." There had
been two patients having heart attacks at the same time. The other
guy got the nearest crash cart. My dad got the crash cart brought
over from the other unit, but there had been only one nurse and a
respiratory therapist available at the time. My mom and dad would
have been better off if they had stayed in the ambulance. |
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From Manny, RN in Canada:
"I just got hired in a hospital that is nationally recognized
as the safest hospital. They even got recognized by some award and
have front-page articles posted in the main waiting room. There's
only one problem. All of the patients are hidden down long corridors.
The [name of national mainstream journal] article even said on the
third page that the nurses have to walk their butts off. Now I am
so tired by the end of the shift I can't imagine how any patient gets
any care at all except at the beginning of our shifts. The patient
care corridors are as long as bowling alleys! |
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From 'Nurse Ratchet' in
Washington State:
"These high-tech vendors really know their client. It's not
us, the nurses. It's the CEOs who never step foot onto a patient
care unit unless they are touring a vendor. Instead of giving us
nurses raises this year, or bonuses, they put in a very fancy dancy
expensive monitoring system that connects patient room video monitors
and tele-monitors to the big city hospital 40 miles away. We now
have a red phone right at the nursing station that rings with annoying
persistence so that we can respond to some video-doc whose remote
monitoring staff told her the patient turned over in her sleep.
Here's what I think of your "No hidden patient" hospital.
It's the only kind of hospital that should be allowed. After all,
what's a hospital for if it isn't for being absolutely "right
there", like immediately, when a patient needs us? I got into
nursing to take care of patients, not telephones.
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From
"Winona" patient:
"I don't know what you're going to do with all these hospitals
that are being built with private, one-person rooms. My roommate woke
up agitated and disoriented after her hip replacement surgery. She
got up out of her bed and started walking around the room. If I hadn't
called the nurse my roommate would have had a serious, probably irreparable
accident. If she had been in a room all by herself..." |
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From "Mrs. T.",
California, wife of the deceased:
"My husband died when a nurse helped him to the toilet but then
left him there. When she returned later he was lying on the floor
in the bathroom where he had had a heart attack." |
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An
aside: Listen to a 3-Minute digivideo about what Dr. Larry
Bedard M.D., 35-year veteran Emergency Department Physician
and twice President of the American College of Emergency
Physicians, has to say about "hidden patients"
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Double-click
on PLAY button to start |
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Dr.
Larry Bedard is currently a Delegate of the California Medical
Association
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From "Jack", patient:
"I'll tell what got my blood boiling in a hospital where they
are supposed to have taken care of my heart. I'm a truck driver and
my wife is a lab technologist. She told me to write so here I am writing.
I was 5 states away from home and my chest started hurting, constricting,
so I follow the 'H' signs and end up in this hospital where they saved
me and I am grateful. But then they put me in a room and the nurse
comes in and asks if I have any family who would like to join me and
watch over me for my own safety and comfort. They even have this family
area type place in the room for someone. My wife couldn't come and
my kids are grown up so I had to tough it out on my own. What really
got me was hearing the other family members outside in the corridor
calling the nurse or talking to the doctors. I think if this ever
happens to me again I am going to demand that they put my bed in the
corridor where someone can take care of me." |
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From "Janet", daughter
"I know my mom was ready to go but not the way she went. She
was a DNR patient [do not resuscitate] but DNR means 'don't try to
revive her when the monitor starts beeping.' DNR does NOT mean letting
her gurgle and spit up blood for four hours until she drowns in her
own fluids. The problem as I see it is that they put her in a nice,
quiet, private room that was so far away from the nursing station
that no one bothered to check on her because of her "DNR status."
I'm going to file a complaint with our state department of health
so you can add that one to your "DHS Reports" collection.
But I am going to feel guilty for the rest of my life for having assumed
that the hospital would do better than I to make her final journey
as painless as possible." |
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From "Tom" patient safety
statistician
"We're following the 100,000 lives
campaign and realize that it's all "downstream" patient
death aversion. This no-hidden-patient idea is as "upstream"
as patient safety can get. I think we've been assuming that we have
to live (or die) with the existing hospital design that architects
are building but we shouldn't have to. Isn't no-hidden-patient some
kind of a wake-up call for hospital designing? I'd think there are
a whole lot more lives to be saved than just 100,000 per year if every
patient can be seen...." |
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From "Me" nurse
"If you came to our hospital you'd
feel sorry for any patient who was placed in rooms 322-328. You'd
also feel sorry for the patients in rooms 308-314. That's just one
floor. We have twelve floors and they're all alike, except the intensive
care floor. The physicians sometimes admit a patient to an ICU, CCU
and TCU, even when they don't have a medical problem that would warrant
being placed in one of the intensive, critical or telemetry units.
Registry and traveling nurses usually get stuck with what we call
the 'end unit' rooms on the regular floors. For the care the patients
get they might as well call the rooms 'end stage' rooms." |
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From "Beck", Washington,
nurse supervisor:
"We have to hire a lot of traveling and registry nurses who not
only have to be oriented to the way we work but also have to be observed
much closer than our core staff. The only problem is that the core
staff is busy enough with their own patient load to be babysitting
the 'newbies'. We've had more incidences than I want to admit regarding
difficulties in finding the per-diems because at least they get lost
somewhere on the unit or in the hospital, and at worst they find places
to take long smoking breaks or just hide out. One of the per-diems
was missing for so long I figured she'd up and quit, but I ran into
her in the parking lot at the end of my shift. It turns out she had
taken the elevator to another patient care unit after her lunch and
had put in a full day's work on the wrong floor! I think all of this
will be eliminated when hospitals are built on the "No Hidden
Patient" layout plan. You probably don't want to brag about "No
hidden nurses" however. Some of them want to hide!" |
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From "Tanya", Alabama,
daughter of the patient:
"My father was in a corner room and the nurses were always so
busy I had to stand outside of the room to wave down the nurse. They
finally moved him across from the nurses' station so I would go home." |
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From "Scott", Washington,
patient:
"The hospital told me that they just got a new call system that
I was told was the problem but one nurse told me that even when they
fix it nothing will help the nurses because they are already maxed
out." |
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From "Amelia", California,
nurse on a pediatric unit:
"I got a knee injury that got worse so slowly over the last 20
years I had to have a knee replacement. It was from walking up and
down long nursing unit corridors. Even so, now I have to stand at
the other side of the nurses' station counter because I still can't
do all the stand-up, sit-down, stand-up, sit-down that nurses have
to do all day long." |
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From "Ron",
Arizona, Hospital Chief Executive Officer of a 100 bed hospital:
"I have a stack of incident reports that have to be sent to
the insurance company and Department of Health. About 30 of them
are about problems that could have been averted if the hospital
had been built even to today's standards. One of the patients didn't
die but is now in an LTACH [long term acute care hospital] because
she [74 year old woman] got her head twisted up in an IV tube. Please
don't use my name or my hospital. Thank you."
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From "Sam", RN, Missouri,
gero-psych unit nurse:
"I am feeling guilty because all the [nurse call] lights lit
up at once and there was no way that we could determine which patient
needed more immediate care, but because we couldn't actually see the
patients from the central station we didn't know and one of my patients
could have died because I almost didn't make it in time to help her.
When I finally arrived she was leaning over the edge of the bed but
she was too weak to pull herself back up. She had dropped a magazine
on the floor. She has permanent brain injury now." |
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Mrs. "O'D", New
York, patient (second visit following open heart surgery):
"I just got home and the nursing staff was so nice but I never
knew if they were on break or just avoiding me most of the time because
I couldn't see them. I always felt surprised when they finally came
in to my room. They were always so helpful but they left too soon." |
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From "Elonya", Utah,
patient:
"I had a plate put in my back and I know I woke up for awhile
in the recovery room because I vaguely recall my doctor talking to
me about something but when I actually woke up in my room I had forgotten
and I panicked because no one was there and the glass door was closed
and there was a window on the hallway but no one was there. Since
I was in a hospital a few times before (I'm a mother of 4) I grabbed
the remote to call a nurse but when I pushed a button the television
came on instead!" |
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From "Cardiologist",
Mississippi, 350-bed hospital:
"Whenever I come to a nursing station I have to search for a
nurse and undoubtedly the nurse I want to find is with a patient in
another room. I often have to do my own 'nurse search' since they
are always so understaffed and overworked I feel bad asking anyone
to help me." |
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From "Joseph", California,
patient:
"What I can't stand is that when the nurses change shifts they
go somewhere and meet for I think fifteen minutes or longer and then
what happened was the guy next door started yelling about his stomach
pain because I think it was he couldn't get a nurse. And then a new
nurse that I've never seen before comes in the room when the other
one never even told me she was leaving." |
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From "Rock", Healthcare
analyst
"The Institute of Medicine reports
that 100,000 patients die every year because of medical or patient
safety error. We figure that if all the hospitals were designed so
that all patients could be visible at all times, my team guesses (SWAG)
that we could reduce patient deaths by at least
15,000 hospitalized patients a year from that 100k number. We also
think that we could reduce life-threatening accidents of approximately
1.2 million patients a year, mitigate substandard care of approximately
12 million patients a year, and make the hospital experience for approximately
60 million patients a year a whole lot better. |
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From "Kupper" a floor
nurse from Idaho
"I've only been a nurse for two years. I am used to patients
dying if they're old and it's their time to go. I am even used to
patients who die because they were in some horrible accident, or they
had an aneurysm, and waking up from an operation to discover they
are no longer among the "living" living is worse than death
itself. But I'm leaving the hospital and becoming a physician's office
nurse. I just saw my last patients die because they aren't staffing
the floors with enough nurses anymore. You think "hidden"
is a problem? Add "what patient?" to your list because that
was the straw that broke the camel's back for me: They may as well
call those rooms at the end of the hallway "the morgue"
since that's what they became today. Not one, but TWO patients. Dead.
The charge nurse discovered them at the end of the shift. Bye."
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From "Patricia",
Tennessee, staff intern:
"I have given up. I am a second year intern with an interior
design firm. The planners are brushing me off because I'm not a "clinical
person" and they say that by the time our replacement hospital
opens it will be so high-tech that every patient in every room will
be visibly monitored at the nursing station with two-way televideo.
That's their answer to your no hidden patient idea. Before I was an
interior designer I was a ward clerk in a [name of city and state]
hospital where they had two-way visible communication on one 'overflow
intensive care unit' like what they are talking about here but the
monitor tech never even looked at the television screens unless the
[name of monitor company] telemetry monitor started beeping. Then
she'd glance up at the television monitor of whichever room the patient
was in. Only then would the nursing staff get notified. I saw it with
my own eyes more times than I can remember. What's the point of technology
if all it does is let you watch the patient die before your eyes so
you can run and try to save them?" |
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From
"Chino", medical student,
California
"Do you have any words
of wisdom for us new grads who will undoubtedly be working in hidden-patient
hospitals because that's what's out there and we have no choice?"
Response from Jeff Hardy:
For the time being just knowing that there are hidden patients might
be enough of a "yellow flag" in the back of your mind
while you are on floor duty. Practice failure avoidance and check
on these patients as often as you are able. Wear comfortable shoes.
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From
"Paul and my buds", architects:
"Just have "No hidden
patient hospitals?" What do you suggest we do with all the hospitals
that have what you call hidden-patient rooms?" |
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From "Caroline",
California, nurse on med/surg unit:
"The problem with hidden patient rooms and hidden patients is
that whenever I am in any of the patient rooms, hidden or not hidden,
all the other patients in my charge become hidden. There is no way
we will be able to convert our units from 'corridor-based' to 'ICU-type'
because our hospital is hurting financially. But now I'm wondering
what is going to happen when the regulators demand new patient care
wings to be 'no hidden patient' designs. At least we can dream!" |
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From "Gwen", Colorado,
mother:
"My 10-year old son was riding his bicycle
when a car hit him. They put him in the "critical care unit"
for the first two days which was good. I was with him when he awoke
from surgery, and I stayed with him most of the time, helping the
nurses change the head bandages every hour or so. But when they moved
him to another unit -- they called it a 'step-down' unit -- he went
to sleep so I took the opportunity to grab a bite to eat in the cafeteria.
While I was eating I heard an overhead page "code blue"
and then my son's room number. I panicked, ran out of the dining room
and up two flights of stairs and into my son's room. The back of his
head bandage had come undone and he was bleeding everywhere. If the
nurse's aide hadn't come into the room to check his water pitcher
he would be dead by now. As it is he has a much longer recovery ahead
of him." |
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From "Jackie", Idaho,
Administrator:
"What I'd like to know is why you are the only person in the
USA who is talking about this nohiddenpatient concept. I heard about
you and then I googled 'no hidden patient' and just your site and
your articles pop up. It seems to me it's pretty obvious a solution
to a compendium of problems I hear about every single day. I'm only
the administrator of a 150-bed hospital. Surely the CEOs of large
hospitals comprehend the magnitude of the hidden-patient problem.
You don't have to answer this question because I already know the
answer, at least I think I do. We all have to live with the existing
hospitals, all $1 zillion of them, for better or worse, but if we
face the hidden-patient fact there is no way in God's green earth
that we're going to be able to fix this one at all. Good luck." |
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From "Connie", Vermont,
medical records coder:
"When a patient falls or has another kind of an accident they
(physicians and nurses) often don't put it in the record. I just hear
about it informally and have to just code what I read in the record.
But it bothers me that I can't do anything about it or say anything
or I'm sure I'd get fired." |
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From "Jackie",
unknown state, expert witness:
"I am a healthcare statistician for [a university medical center],
and an expert witness in legal actions against hospitals for, your
word "apothicomial" errors [hospital design or healthcare
system failures that either share the medical or clinical error
blame, or are wholly responsible for the cause of a patient, staff
or visitor accident]."
Response from Jeff Hardy:
At best this one's a "hot button" for me. At worst it's
a sore subject that is alluding our attempts to get to the bottom
of the hidden-patient problem. I can tell you that
there isn't yet a way to gather reliable enough data for the statistics
you want.
For example, we recently heard of an instance where
a patient had died and there appeared to be no unusual occurrences
or documentation in the record to cause any suspicion that the patient
could have been saved. We still don't know. But a few weeks later
a housekeeper came forward and told us what had really happened.
The patient had not been on a monitor but was only three patient
rooms down from the nursing station. An elderly nurse was in the
process of responding to the patient's "nurse call" when
she reportedly slipped on wet flooring in the hallway. Although
she was not harmed the shock unnerved her, she forgot where she
was headed and instead went to the bathroom to wash and adjust her
wardrobe. Had the patient not been hidden from view she might have
been saved. The housekeeper was in tears, saying the problem was
her fault, but the nurse didn't see the orange safety cones on the
floor until too late. The cones, and the dying patient, were not
visible from inside the nursing station."
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From "Maryann",
RN, 200-bed replacement hospital:
"I have been a nurse representative in our replacement hospital
planning group for over a year. I knew something was 'wrong with the
picture'. After I read an article on "NO Hidden Patient"
in [Patient Safety and Quality Review Magazine] I 'got it.' But the
rest of the team didn't. So I finally just looked at them and said
'what part of NO HIDDEN PATIENT
don't you understand?!'... They finally 'got it' because most
of the people in the room have teenage kids and had heard that one
before!" |
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From "Sheila" (and "Tom",
Milwaukee)
"Hey, I kinda like being hidden! Last summer I was in the hospital
after I had major dehydration after hiking in the desert. My boyfriend
snuck into my room and now I'm pregnant with our first child! We're
going to get married though. Can you help us with a name? (we don't
know if it is a boy or girl yet). Neither of us like the name 'Hidden',
but then again..." |
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From "Bart",
a CEO of a 3-hospital system with 7 connecting medical offices:
"While you're waiting for the statistics on 'no hidden patient'
(good luck; I don't know where you could possibly get them), you should
realize that hospital boards, owners and executives are interested
in the safest patient care in the world. After hearing about the 'no
hidden patient' concept we realized that our reputation will be assurred
when our communities get wind of the 'no hidden patient' designs of
their new (2011) medical center. We're going for 'Magnet' status,
so please let us know what we need to do to become a 'Living Care
Design' facility as well." |
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"Randall",
CEO, 3-hospital network with total of 800 beds:
"Our
new hospital has been opened for a year and we have reduced patient
safety errors and patient falls by 80%. The nursing staff love the
new medical/surgical and specialty units that all have alcoves outside
of every two patient's rooms. The patients rave about how nice the
hospital looks. Our planning staff, including the architects, just
convened a "One-Year Evaluation" where we all celebrated
being given "Magnate" hospital status from the American
Nursing Association. I don't think you need to be all no-hidden-patient
rooms if you have the wonderful nursing staff that we do."
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"Nurse
Love", RN, Nebraska, 200 bed acute care hospital:
"I
know you've already got loads of emails about patients waking up disoriented
and not being able to see a nurse because they were hidden from anyone
seeing them wake up. I have something that is not a negative but a
positive that just happened today on my shift and I've got to tell
someone. I was checking up on a woman who had had surgery for an abdominal
aortic aneurysm. I was in her room quite fortuitously when she finally
woke up. She looked at me and with the most wonderful look in her
eyes I had never seen in my 25 years of nursing, she said "Am
I alive?" I was so immediately choked up that all I could do
was nod my head. After a few moments trying to get herself oriented
she said, "I was told I only had a ten percent chance of surviving."
I could hardly breath. Then, still looking at me she said, "Maybe
I am in heaven and you are an angel." I held her hand. "That's
the first time anyone ever called me an angel." I think you should
tell anyone who doesn't think that no-hidden-patient layout isn't
worth it that the cost of the hospital is a finite amount but being
with a patient at their time of need is priceless."
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"Gordon",
MD:
"I am an expert witness
on medical error and patient safety error cases. I'm in the court
cafeteria and I'm looking out at the new hospital where all the steel
has already gone up.
I consulted to the planning committee in their "patient safety"
focus but they (and I) completely missed the No Hidden Patient opportunity
because it wasn't in the radar of our imaginations.
I can tell you that at least 70% of the rooms are hidden. I consulted
to the planning committee but we missed that one.
Now I have an awful feeling that all I have been doing is helping
the victims or families of victims who have filed lawsuits against
physicians and hospitals, when in fact I could have been helping avoid
wrongful death in the first place.
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