Tapping into the human side of patient safety

During the 4th Annual Patient Safety Symposium, health care administrators, physicians, nurses and other health care professionals came from across the state to learn from some of the most respected experts in patient safety and quality improvement. Of all the amazing speakers and compelling stories shared, none better addressed the underlying motivation of the symposium than a mother’s powerful account of the loss of her only child. 

Patty Skolnik and her husband David traveled from Denver, CO, to share the story of their son, Michael, who died at age 25 as a result of preventable medical error. During a breakout session at the symposium, the Skolniks shared their story through the film “The Story of Michael Skolnik,” created by Transparent Health to educate the health care community on the importance of transparency in informed consent, the critical need for shared decision making and the power of a meaningful conversation.

Watching the film with the Skolniks added a layer of emotion to an already profoundly touching story. The couple squeezed one another’s hands as the shocking trail of errors unfolded before us. Clearly, they were reliving the tragedy that took their only child.

Before his death, Michael was studying to become a pediatric nurse and worked as an emergency medical technician. One day, as Michael was playing with his dog, he suffered a seizure. Michael was taken to the emergency room where they found he had a three-millimeter cyst in his brain.  This news was shocking and frightening for the Skolniks. They sought out a second opinion from a neurosurgeon referred to them by a friend. The neurosurgeon told the Skolniks Michael’s time was limited and he needed to go into surgery immediately. Motivated by the fear of losing Michael, the Skolniks consented; relieved that they had sought out a second opinion and believing they were saving his life.

Following Michael’s first surgery the neurosurgeon pushed for a second surgery he said needed to take place within 48 hours in order to save Michael’s life. Never did he alert the family of potential complications or alternatives. He assured them the procedure would be relatively simple and take only three hours. That night the Skolniks received a fax from their primary care physician urging them to hold off on any treatment of Michael's condition. One could only imagine their fear and disbelief when the next morning they learned that the neurosurgeon planned to proceeded with the second surgery based on consent received from Michael after they had left the hospital the night before. When Michael agreed to the surgery he was under the influence of strong narcotics and did not meet the criteria required to provide informed consent. The Skolniks pleaded with the neurosurgeon to stop preparations for Michael's surgery, holding up the fax they received from their primary care physician the night before. He refused. That day, Michael endured a six hour surgery to remove a cyst that was never even found, his life forever altered.

Members of the audience were quietly reverent as they learned that Michael died three years after the three-hour turned six hour surgery that put him in a semi-vegetative state. He spent his remaining years in bed with the cognitive ability of a third grader. He lost the ability to speak and had to be fed through a feeding tube. His parents contend that it was the surgery that they had strongly contested and his primary care physician had advised against that killed Michael. On a hot summer day in 2004 Michael’s struggle came to an end. David stood by his son’s bed when Michael looked up to him, mouthed “I love you” and then passed away.

Following the film, the Skolniks shared their closing comments. Members of the audience no longer looked at the Skolniks as speakers at a conference. They saw them as parents who had lost their son, Michael, due to a flawed health system. The tears of the caregivers in the room attested to their deeper level of responsibility to the patient after hearing Michael’s story. Many voiced that they were inspired to strive for the safest, best quality of care for every one of their patients, every time. In closing, Patty asked us to take close care in the work that we do. “Remember the patient,” she pleaded.

Since Michael’s death, Patty has fought for greater transparency in health care. As founder and director of Citizens for Patient Safety in Denver, CO, she continues to advocate for patients. In 2007 Patty and David worked with Senator Morgan Carroll of Colorado to pass the Michael Skolnik Medical Transparency Act, which requires physicians in Colorado to report education, certain business relationships, malpractice involvement and any disciplinary action or crimes. The act seeks to nurture a patient-centered approach to the delivery of health care services that starts with transparency.

“[Michael] was a magical child and he loved the medical field. We promised to leave it better than he found it,” his mother said, explaining the passion she brings to her fight for safer patient care.

Visit CitizensForPatientSafety.org to learn more about the Skolnik’s and their work to improve patient safety.

05-18-2011 10:36 (EDT)