Learning From Our Mistakes: A Key Component of Improving

Contributed by Richard Stone

Over the last few months, I have had the opportunity to see our healthcare system up close and personal as my dad, soon to be 97 years old, traversed through it with the first major health crises in his life. It started a couple years ago when he decided to rearrange the boxes in his condo’s storage bin. I came by one weekend and he wanted me to take some things, so I had to lift some extremely heavy boxes off a top shelf. When I inquired how they got up there he informed me he put them there. Interestingly, just a few weeks previously he had been complaining of abdominal pain and had been diagnosed with an inguinal hernia. When I asked at that time how in the world he had gotten a hernia he pleaded ignorance. But as I stood there in his storage area I put it all together and looked at him in disbelief. “I know how you got a hernia, you clod, you lifted these boxes all by yourself.” He was a bit sheepish when confronted with the fact that there are some things he simply shouldn’t be trying at his age.

Well, a few months ago he decided to get the hernia repaired. Something like this is now done in one day as an outpatient procedure, so I came over to support him and his wife. I kiddingly joked with his surgeon when he stopped by the pre-op area to check on him that my dad must be the oldest person he’s ever operated on for a hernia. I was wrong. He had done a repair on a woman who was 106!

Post surgery, I sat with my dad and his wife in a small curtained off area as the discharge nurse went over everything he needed to know to care for the surgical site. He had made it clear before the surgery that he often doesn’t do well with narcotic pain relievers, getting easily constipated, but who looks at charts these days? She gave him a Percocet and a prescription and sent us on our way, encouraging him to eat lots of prunes when he voiced his concern.

Sure enough, a couple days elapsed and he was severely constipated. A call to his surgeon resulted in some encouragement to eat more prunes. Another day or two passed and he was still constipated, and in a lot of discomfort, so now it was time for an emergency room visit. More admonishments to eat fruit, plus a script for a stool softener. Three days later he was back at another ER for a procedure to relieve him of bowel impaction.

I don’t know what the final tally was for all the medical bills for these aftercare visits that all could have easily been avoided—surely in the tens of thousands. All unnecessary. All preventable. But the charge nurse who originally administered the Percocet will never learn from this event. The first ER won’t either, just as the second ER won’t. They are all independent actors on a stage with sets separated by immensely high walls and lots of sound proofing.

Five weeks later my dad took a fall and broke 6 ribs. Even drove himself to the hospital. But that’s another aspect of the ongoing story of waste and mismanagement inherent in healthcare that I’ll share with you in an upcoming blog.