Two years ago, while on vacation, my wife punctured her hand with a BBQ skewer. So she went to the nearest ER.

She was triaged and escorted to a treatment room. Then sat there for 45 minutes because the desk never told the doctor she was waiting, even though the ER had a computerized patient tracking system. A COMMUNICATIONS FAILURE.

While standing at the treatment room door, trying to remind the staff she was there, she overheard doctors talking about other patients’ clinical information. A HIPPA (CONFIDENTIALITY) VIOLATION.

A tetanus shot was ordered by the doctor, but it took another 45 minutes for the nurse to show up. A SYSTEMS PROBLEM.

When asked if she had washed her hand, the nurse said she always washed her hands after each patient, and then proceeded to wash her hands. Really? A PATIENT SAFETY ISSUE.

I sent an email to the CEO and got a “form letter” response addressed to the wrong last name. A PUBLIC RELATIONS PROBLEM.

Two weeks later when she touched the punctured area a splinter popped out. When this information was emailed to the ER the email response was “A splinter?! After reading the note and talking to the physician, I was under the impression that the wound was from a “barbeque skewer”. I guess it was not really clarified in the note whether it was metal or wood. I suppose I was just thinking that it was metal.” A CHARTING OMMISSION & A MEDICAL ERROR. AND A DUMB STATEMENT TO PUT IN WRITING!

If this happened to you, what would you have done? Most people just ignore these situations. That is how systems breakdowns become permanent operating procedures.

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