PROCESS FAILURES

You would think that acquiring hospital bacteria would be a thing of the past – acquiring 4 during your hospitalization is insane – totally out of control. Is VMC taking “short cuts” with patient safety?

The first thing I think of with VMC is Dirty Hospital…

If VMC staff members are washing their hands - what other ways are infections/bacteria transmitted to other patients? Could it be the instruments not being sterilized properly? Could it be cross-contamination when multiple procedures are performed by surgeons? Could it be how the surgery center is cleaned between procedures?

It’s in the medical records that another patient acquired the same bacteria after my son did:

What is documented in Mark’s medical records is the fact that the Lab called the nurse and reported another patient acquiring Pseudomonas and Burkholderia on December 27. The Lab wants Dr. Wynne Chen to call them. Dr. Wynne Chen calls the Lab back and discusses. The nurse has this documented in her Focus Note; Dr. Wynne Chen does not put this discussion in his Focus Note nor discusses with me (I’m sure this is in his email).

A whistleblower also came forward because instruments were not being sterilized properly (and the records were falsified).

I asked the State of Washington Department of Health (DOH) [per their audit report of VMC] the following questions – of course I received no response.

Since a whistleblower came forward because instruments were not being sterilized properly (and the records were falsified) did you check the below:

How are the Miller, Macintosh and other blades for intubation sterilized? What about the forceps and other surgery equipment being sterilized properly?

When was the last patient seen at VMC that had cystic fibrosis and what procedures and equipment were used during their hospitalization?  Was this patient seen for a procedure before Mark (because of these certain types of bacteria)? If so, how was the sterilization of this equipment accomplished and logged? How did the patient after Mark acquire the same bacteria? What procedures did they have done?

Did the DOH auditor witness surgeons performing surgeries to ensure they re-gloved when performing multiple procedures (especially with someone that has acquired bacteria during hospitalization)?

Did the VMC IC Surveillance System (per 42 CFR 482.42 requirements) fail because these issues were never disclosed or documented in a required log?

All the DOH said in their report is that VMC employees wash their hands…

There is no process for long term care.

December 11: Since I have been “collecting” foreign object debris (FOD) in Mark’s bed during his stay in the ICU I decide to start counting and labeling what I find today. During this day I find 18 pieces of FOD in the bed: everything from medication caplets, syringe plastic needle covers, plastic packages, alcohol wipes, dirty bathing wipes and a syringe filled with blood. I set the syringe filled with blood in an obvious location so Joyce, the nurse, will see it. Today is no exception; this has gone on Mark’s entire hospital stay at VMC.

December 5: Mark now has Stage 2 bedsores. This should have been prevented early on. From the CNAs that specialize in hospice that I have talked to rotating a patient every hour is a requirement. At the VMC ICU, the patient is lucky to be rotated once each 2 - 4 hours. Of course, VMC says they couldn’t do that because of Mark’s condition and his size – that is a non-starter for a hospital. 

December 11: The skin on Mark’s feet, hands and legs is cracking and peeling off in large sheets. This should have been prevented early on (no long term care plan ~ but simple nursing practices).

FedEx or VMC issue?

December 31: TPN is stopped; Dr. Frank Thomas feels this is causing the liver enzymes to be elevated; says that Mark will be fine without nutrition for a couple of days until they place the new naso/duodenal tube that will go into his stomach and past the pancreas (into the small intestine). This new tube is on order.

January 1: The naso/duodenal tube is in route (via FedEx).

January 3: We are still waiting for the naso/duodenal tube to arrive. Apparently there is a problem with Fed Ex and the holiday schedule (which does not make sense). The Nutritionist says she will to look into this today. Dr. William Park says this is priority #1.

January 4: Apparently, the naso/duodenal tube never arrived from Fed Ex and they are going to use a tube they already have here (which says they never ordered it). Within a couple of minutes of me calling the South Clinic office Dr. Frank Thomas calls me back and explains that the other feeding tube never arrived (this is unbelievable since Fed Ex delivers 24 x 7, 365 days a year – see www.fedex.com ). What did the tracking numbers say?

Can a patient actually get another lab to perform a test?

January 4: Mark gets a liver biopsy today. I request that we get a second opinion from the University of Washington (UW). By January 16, those results are not back and Dr. Wynne Chen says this may be something they overlooked (sending the biopsy to the UW). I find out on March 12 that VMC sent the biopsy over on January 11.

Initial process; get the patients drugs right

November 10: All meds listed on the first day in the hospital are wrong. I tied in with the 3^rd floor nurse to review Mark’s meds with me, she has an old list. This should have been discussed in the ER with me when I arrived last night. I have to “pull” the info from VMC versus them “pushing” the question to me. Apparently the “tie-in” doesn’t happen (the nurse logged these into the computer) and for days the doctor dictation is wrong.