I am Dr. Diane Perez. Every day, families place their trust in our health care system and the lives of loved ones.
While millions of healthcare professionals provide exceptional care, preventable harm remains one of the biggest challenges.
According to Safe patient movementthree million people die each year from preventable harm.
Today we’re talking to Dr. Michael Ramsay, CEO of the Patient Safety Movement Foundation, about how accountability, transparency and knowledge can help save lives.
But first, the story of a young boy whose death from undiagnosed and untreated sepsis inspired a crusade to raise awareness and change emergency care.
Ciaran Staunton, Rory’s father
Rory played basketball at Skoda Jam. Cut your elbow on the gym floor, train on that machine, and it was Tuesday. And Rory was dead at 6 o’clock on Sunday. How can a little boy go to the morgue in five days from being criticized in the school gym playing basketball?
Orlaith Staunton, Rory’s mother
Rory is a very gentle child; deals with people a lot.
Ciaran Staunton, Rory’s father
He was a foot taller than everyone else and a broader young man. But when all the new kids came in, he looked at them.
Orlaith Staunton, Rory’s mother
I think that with his age he became a leader. We trusted many people. We believed that if it falls, the school will take care of it, they will clean the cut, but no. We believed that our pediatrician would identify the symptoms if he was sick, but he was not, the doctor dismissed him. The next morning he was no better, and there he began to turn yellow, and the tip of his nose turned black. We ran alone; we ran back to the hospital with him. A doctor came to talk to me and he told me that your son is very sick. And then they brought him to the intensive care unit. It was Friday night and he was dead Sunday evening. I don’t even know how to describe her loss. There was a voice in my life that I loved that disappeared.
Ciaran Staunton, Rory’s father
Well, we spend the rest of our days with it. We’ve spent the last four years bringing it back to life, and after we’re dead, we’re going to bring it back to life.
Orlaith Staunton, Rory’s mother
The important thing was that no one knew the symptoms of sepsis and no one knew that he had sepsis.
Ciaran Staunton, Rory’s father
We have never heard the word sepsis. But then we find out that 50% of Americans have never heard of it. Now we know that it is the biggest killer of children in the world. When we went online and searched for sepsis, there was nothing. My wife went to the CDC. There was nothing in the CDC about sepsis. Yes, a quarter of a million Americans were killed here. We pitched our story to the New York Times and… It was the most widely circulated article in the New York Times. And a few weeks later, we got a direct message from a woman in Florida. And he said: I want to thank you for saving our son’s life. And he says, my son was in the hospital in Florida, the doctors didn’t know what happened to him, we knew he was very sick. And in a panic, I was talking to my sister and she said that I read a story in the New York paper about a boy who died. Could it be sepsis? It was sepsis. And that woman wrote to us; I’m sitting here with my son by my pool in Florida. My 11 year old son and I owe you and your family. And our daughter, Kathleen, said, Well, isn’t it a shame that someone didn’t do this for Rory?
Orlaith Staunton, Rory’s mother
I’m so grateful for the notes we get from people, but I really wish I knew the science and wasn’t in this situation.
Ciaran Staunton, Rory’s father
Rory’s death was completely preventable. We came to Washington, knocked on many doors and had our first hearing. It was broadcast live on C-SPAN on Sepsis. We developed a language called the Roy Regulation.
Orlaith Staunton, Rory’s mother
Ensures all hospitals have mandatory sepsis protocols.
Ciaran Staunton, Rory’s father
Roy’s rules save New Yorkers 5,000 to 8,000 annually. However, this is only in one state. There are 49 other states.
Orlaith Staunton, Rory’s mother
It is very bitter because I could not save my son’s life, but I know that we are saving another life. The frustration is that they have to find out about this from us, that we were their source of information.
Ciaran Staunton, Rory’s father
We have an empty bed. We are sitting at the table in the evening. Three seats are full. There is an empty seat.
Joining me now is Dr. Mark Ramsay. What a sad story.
Michael AE Ramsay, MD, FRCAExecutive Director of the Patient Safety Movement Foundation
Diane, thanks so much for the invite. This is an important topic.
Dr. Ramsay, in your opinion, what are the most common ways patients receive medical care?
Michael AE Ramsay, MD, FRCAExecutive Director of the Patient Safety Movement Foundation
The list is unfortunately very long, but some of the most common are medication errors, diagnostic errors, hospital-acquired infections, misdiagnoses, and things we need to address.
But because doctors, nurses, and health workers are usually overloaded with so many tasks, they don’t have amazing memories, they definitely pay attention to specific things, but there’s so much going on with patients that they make mistakes they shouldn’t.
And we can help them avoid making those mistakes because there are systems in place to help with that.
At what point in health care are patients most vulnerable? When it comes to admissions, surgeries, medication changes, discharges, follow-up?
Well, what is immediately apparent are things that have been devastating to patients, such as wrong site surgery, wrong surgery, wrong medication, hospital-acquired infections.
But the fact is, as you just started there, it’s right against pre-admission because they’ve misdiagnosed sepsis, they don’t realize that this kid in the emergency room is septic.
And sepsis, when you develop sepsis, you’re basically talking hours before you actually get sick with sepsis and die.
And we still, in this day and age, we still see patients being sent home from emergency rooms where sepsis is misdiagnosed or not diagnosed.
What message do you give to parents when their child fails at school? What may appear as a minor scratch. What do we do with this? And if the child has a fever, how can we raise our voice with the doctor to say please do more, this is not normal.
I think you should raise your concerns and if the doctor won’t listen to you or just doesn’t see it, ask to speak to someone more senior.
If families want to take a proactive step to reduce the risk of preventable harm, what should that step be, Dr. Ramsay?
Michael AE Ramsay, MD, FRCAExecutive Director of the Patient Safety Movement Foundation
We in the medical profession need to change. We have to find solutions and I think number one is to listen to the voice of the patient.
You know, you go to the doctor and most of the time they’re on the computer, they’re taking the information from the computer or typing into the computer what you’re saying and they’re not listening to you.
And you, as a patient, if you go in, you’re nervous. You are worried that you might have something terrible and you don’t really listen to the clinical explanations.
So you can do several things. First, if you have to go to the hospital because you are worried or whenever you go and bring someone with you, a trusted friend or relative of yours who can listen to the answers, can remember what the doctor said, can talk to you in advance, highlight some of the main problems that really worry you, and be there in case of emergency during your visit. the doctor
Dr. Ramsey, thank you so much for this interview and I hope the audience enjoyed it as much as I did.
Michael AE Ramsay, MD, FRCAExecutive Director of the Patient Safety Movement Foundation
Diane, thank you so much for the interview.
