Stan's Story

“Who is this Stan fellow, Curmudge?”

“He is one of the reasons that we are going to talk about patient safety, Jaded Julie. Another reason is that we have recently been discussing standard work, and improved patient safety is one of the main benefits of standard work in a hospital.”

“I’m listening, Curmudge. Tell me about Stan.”

“Shortly after his retirement, Stan, a very close friend from my college days, suffered a stroke. While he was recovering in the hospital, he sustained a tragic fall that injured his brain much more than the stroke had. Stan, always a gentle giant, now cannot speak a coherent sentence. Although he is cared for by his devoted wife, this is not the way Stan planned to spend his ‘golden years.’

Here are some of the details as provided by Stan’s wife: Stan experienced a severe stroke early one evening a few years ago, and his wife rushed him to the hospital a few minutes away. She anticipated that Stan would be treated with thrombolytics within the ‘golden three hours.’ (However, I never did learn whether the stroke was ischemic or hemorrhagic.) Stan was first seen by a physician in the ED two hours after they had arrived; he apparently did nothing. At 2:00 a.m., a cardiologist appeared, and he pronounced that it was ‘too late’ for treatment with t-PA (or whatever). So Stan was admitted to the ICU.

While in the ICU, Stan fell and crushed the bones around one of his eyes. The eyeball was out of the socket, and 15 stitches were required to close the cut. After performing the necessary repairs, the physician checked the sight in Stan’s eye by holding up three fingers and asking Stan to count them. At that point, Stan was in no condition to count anything.

When Stan’s wife left the hospital the night of his fall, the rails of the bed were up and an alarm was in place. Stan’s condition would have prevented his lowering the rail by himself, and the alarm should have alerted the nurse had he done so. Yet the nurse in the ICU said that the rail was down when Stan fell (of course it was, but who lowered it?). Stan was her only patient. And so the risk management and legal issues began. Ultimately, Stan and his wife had to accept what they considered a very inadequate settlement from the hospital.

The final outcome is as I described at the beginning of our conversation. Stan’s wife is his constant caregiver. Stan recognizes me but not the names or anything about many of our close college friends. He can say ‘hello’ and ‘good-by,’ but his long sentences are quite incomprehensible. We try to see Stan and his wife whenever we visit the far away city where they live, but reminiscing about our college days is pretty difficult.”

“Curmudge, that is so sad. And it appears to have been preventable. I guess that explains why you are a patient safety zealot.”

“Julie, everyone should be a patient safety zealot, but it’s inevitable when tragedy strikes close to home.”

Affinity’s Kaizen Curmudgeon