Accountability Isn't Optional When it Comes to People's Lives.

If you missed my previous blog post about my recent hospitalization, then I encourage you to go back and give it a read. This post serves as part two of  my up-close-and-personal experience with communication failures in the hospital. Luckily, the situations described in these two posts don’t involve time-sensitive emergencies (TSEs). When communication failures occur in TSEs, the impact can be devastating. Rather, these examples provide evidence that miscommunication is part of the everyday routine in healthcare. This communication crisis is real, and it impacts real people every day.

In case you missed my previous post, let me recap: I was out of town on a business trip and ended up being hospitalized for a day. Luckily, it was just one day; every additional day a patient stays in the hospital, the odds of a full and speedy recovery decrease. But the experience that would follow was so bad, I was half surprised a lady with crazy hair didn't walk up to me on admission and say "may the odds be forever in your favor!" (That's funny if you've seen the Hunger Games. If not, you seriously need to go to the movies now and then ... but hey, no judgment).

The nurse who admitted me was like Nurse Ratchet from “One Flew Over the Cuckoo’s Nest.” She told me about a million times that I needed to ask for help before trying to get out of bed. As if warning me a dozen times wasn't enough, she put a fashionable, bright yellow arm band on me, stating that I was a fall risk. I understand why: though I’m 38 years old and healthy, the fact that they were giving me pain medication after my surgery puts me in that higher-than-normal risk.

But then my day got even better: I got color coded socks. Usually, the "normal" kids get gray socks … but I was special. I had the privilege of sporting bright yellow socks to match my band. The REALLY naughty kids had to wear red socks which means they can't be out of bed at all.

So when my 98-year-old roommate arrived, guess what colored socks he had on? Yep, red. He looked like Dorothy from the “Wizard of Oz.” I'm surprised they didn't force him to get a tattoo saying “FALL RISK”  on his forehead. But I digress. Fast forward to the witching hour in the hospital ... all of a sudden I hear this horrible noise! See, when you're wearing red socks, they add a loud and annoying bed alarm that goes off when the patient (in this case my roommate) tries to get up without assistance. If I were sleeping, this for sure would have woken me up ... yet somehow it didn't wake up the nurses.

Being the good Samaritan that I am, I hit my call light to let them know that Dorothy was trying to go back to Kansas. They assured me that a nurse would be right down. After a few minutes, I hear the man trying to get up again. I hit the call light again, and informed them once more that this guy needs help. Through the noise and chaos, I hear the same voice of the lady who answered the call light yell across the unit: “Room 302, bed number two needs some help!” The words I heard echoed back from the other side of the unit are ones I'll never forget:"That's not my patient."

This same scene proceeded to happen three more times. I was beginning to feel like Bill Murray in Groundhog Day. “If they get it right just once, then maybe it will be over,” I thought to myself. But the second time it happened, a voice said, "It's not my job" and the third time, "Someone else will have to do it, I'm busy."

Imagine for a second that you were the wife, son, or parent of the fall risk patient who needed help. Imagine that that patient managed to get up and out of the bed by himself, but then upon taking his first step, he fell and severely injured himself, worsening his condition and putting his chances of recovery in jeopardy. Now, imagine knowing that just moments earlier, you had heard the nurses arguing like this over whose responsibility he wasn’t. How enraged might you be?

Healthcare is in bad shape, and it's not something that a president can fix. It's not something that voting left or right will solve. The best that an outside governing body can do is create more rules and brighter socks and another page to sign. The real issue is a failure in leadership, and leadership can’t happen without clear, consistent, and effective communication. Without communication, there is no accountability, and accountability isn't optional when it comes to people’s lives.