Recently the media was feeding off of the finger pointing going on between nurses, doctors, CDC and EMR vendors at Texas Presbyterian Hospital regarding the first U.S. Ebola patient. Unfortunately the first patent was misdiagnosed ultimately resulting (or playing a part) in his death and chaos. So, who is to blame? Nurses? Doctors? EMR vendor? EMR Implementation? CDC? Patient? At the end of the day, it is everyone. Protocol , processes and information slipped through the cracks with this patient because everyone relied on their ‘Process” and “System”. Unfortunately, this happens all the time in hospitals…it just doesn’t hit the media like it did this time with the international fear of Ebola.
I can speak personally to a family situation where a member of my family contracted MRSA four times from the same hospital facility. Four times because doctors and nurses did not follow protocol. MRSA caution notes were placed on hospital room doors, yet ignored. Caregivers did not suit up properly, different equipment ( blood pressure cuffs, stethoscopes, etc) was transferred between rooms without being disinfected and rooms were not being thoroughly cleaned. I was there and witnessed it; However, the situation led to a valuable lesson learned….Every patient must have a patient advocate present at all times. It could be a family member or a family friend. Someone who can remind doctors and nurses to suit up. Someone who can double check medicines, family histories, and potential medication allergies. Someone who can help answer questions that patents often forget could be important to their healthcare needs. Someone who questions every procedure and interaction.
People make mistakes. Doctors and nurses are doing the best they can on tight schedules and with new systems but errors do occur. Patient advocates can help prevent errors. No one cares more for a patient than a friend or family member. At the end of the day, every patient must have a patient advocate..it could be a matter of life or death.