Carol Hemmelgarn, patient advocate, headlines Patient Safety Awareness Week

Carol Hemmelgarn, patient advocate, headlines Patient Safety Awareness Week

Storytelling is an essential element in patient safety, said Carole Hemmelgarn, patient advocate and safety specialist.

“That’s how our patients communicate with us,” she said. “When you have patients who have questions, you should embrace them. They are your ally.”

Hemmelgarn was a keynote speaker on March 15 during National Patient Safety Awareness Week. She used a real-life example of breakdowns in communication that resulted in harm to a patient.

These types of stories are important for care providers to hear in order to establish respectful, caring and honest partnerships with patients and families, said Christine Carrico, RN, MSN, CPHQ, director, Patient Safety and Accreditation.

“We are trying to open all lines of communication with our staff and our families so that we can be transparent,” she said. “Telling stories is how we learn, and Carole’s story is very powerful.”

Hemmelgarn stressed the importance of face-to-face communication in preventing medical errors, citing studies that conclude that only about 7 percent of a message is effectively absorbed through non-verbal communication.

“But when there’s vocal communication and facial communication, it goes up to 55 percent,” she said. “Still, we know we are not talking as much as we should since the electronic medical record. We don’t find our patients in the medical records. We find them in the beds.”

There are many reasons why communications between patients and clinicians fail, she said, including culture, ethnicity, language, age, lack of language, hierarchy, busy-ness, lethargy, outside interference and distractions.

“We have to break down those barriers,” Hemmelgarn said. “We really need to listen a lot more. We can learn so much more from our patients if we just listen.”

She told the story of “Sally,” a 9-year-old girl whose condition deteriorated rapidly after she was admitted to a hospital in Colorado with leukemia.

The resident on duty prescribed medication for anxiety. When Sally complained of abdominal pain, the resident attributed it to Sally’s mental distress. The resident ignored Sally’s mother when she said her daughter was not an anxious child.

“Labels only belong on jars. They do not belong on patients,” Hemmelgarn said. “We get locked into a diagnosis.”

Sally continued to worsen.  Her mother complained to nurses and the resident, but no one called an attending physician.

After hours with no improvement in her condition, Sally’s parents demanded to see an attending physician, who rushed Sally into surgery. But it was too late.

At the end of the story, Hemmelgarn revealed that Sally was actually her own daughter, Alyssa. She died of sepsis that resulted from an untreated hospital-acquired infection.

Alyssa’s death and her mother’s struggle to obtain honest answers from the hospital sparked her career as an advocate for patients and patient safety.

“We need to bring mindfulness back into health care,” she said. “The patient comes first, last and everything in between.”