Errors Acknowledgement Creates a Hero

Ilene Corina of PULSE has been speaking and teaching patients about their role in patient safety for more than ten years.  She issues a bi-monthly report which contains interesting tidbits and sometimes something remarkable.

The following excerpt comes from her most recent newsletter which can be viewed in at least two ways:  a testament to Mr. Aviles who has taken a leap of faith, and as a gauntlet thrown down in front of hospital administrators and others in a position to begin public acknowledgement of patient safety travesties. 

We don’t often see the terms “hero” and “transparency” in the same paragraph.  See what you think:

How Heroes Are Made
By Ilene Corina

…. There are many leaders in healthcare who acknowledge there is a problem with medication errors, infections and bad outcomes. They often talk amongst each other and lecture to rooms full of other medical professionals. But, it’s the public who must be aware of the problems associated with the care they receive so they can play a role in improving outcomes. Were there no leaders who would do this?

On June 6, 2007 I was invited to speak at the New York City Health and Hospital Corporation Community Advisory Board Annual Meeting. Each facility associated with NY City HHC has a Community Advisory Board or CAB. The CAB is made up of community leaders who work together for the improvement of the hospital for the community.

On this date, I was going to speak to the CAB members about patient safety. I’ve done this hundreds of times before, but never with the full support of a hospital or healthcare system’s leadership. On this particular evening, after everyone was well fed, I was going to tell them that people die in hospitals from medical errors, infections and other complications that shouldn’t happen. I was going to tell them that it could be them or someone they love next and I was going to tell them that the hospital leadership knows this. I would tell them true stories about people who have died in hospitals, how it could have been avoided and what they should do to participate in their own care. And, I hoped even to be able to make them laugh at some of my stories, experiences and audio-visuals.

As the early part of the evening wore on, I sat next to Mr. Alan Aviles, HHC President and CEO. I asked him if he was ready. “There will be no turning back,” I told him almost feeling sorry for him. He made a comment about full transparency and shook my hand. “Full transparency” I thought. You can’t get any more transparent than this. Mr. Aviles was introduced to his community and he was supposed to speak for five minutes. The five minutes turned into much longer. As I listened, heart pounding and palms sweating, the Chief Executive of one of the nation’s largest healthcare systems stood in front of his community members, customers of his services and told them exactly what I would have said. “Medical errors kill as many as 98,000 people a year in hospitals nationwide.” He told them the truth.

He told them about errors, infections, deaths and injuries. As my heart beat with anticipation, I watched the audience staring in awe, some with their mouths wide open, some with their faces all twisted, all listening intently. I sat at the edge of my seat waiting, waiting to see what else he would say. He continued to tell the truth.

I wasn’t sure the rest of the audience knew how courageous Mr. Aviles was that day. I am sure his staff knew. He didn’t sugar coat the problem and he spoke directly to those who use his healthcare system. This bravery to me has never been matched. Now when I go to speak with his staff or work with the patients of NY Health and Hospital Corporation, I will do so with the same respect he showed everyone that day. His patients deserve the best and he wants them to have the best. Shouldn’t we all be there to help him along? To fix a problem, we have to acknowledge a problem.

And that’s how heroes are made.

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Well put, Ilene.  Thanks for sharing this hero’s story.

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