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One son-in-law鈥檚 pursuit to change the system

November 2, 2012

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Claire Friedman was not the mother-in-law of sitcoms and punchlines.

She was active, vibrant and loved by friends and family.

So when Bernie Weinstein walked into the hospital that day in 2002 and saw his mother-in-law restrained in a chair, he was shocked.

鈥淢y mother-in-law was a patient in the Jewish General Hospital, recovering from cancer surgery,鈥 says Bernie. 鈥淪he was a very active person, constantly walking the corridors, talking to people.鈥

That Friday evening, Bernie and wife Sandy had stopped by the hospital to check on Claire.

鈥淲hen we arrived, we found her sitting in a chair, strapped down, pretty much comatose,鈥 says Bernie. 鈥淪he鈥檇 been in good shape Thursday.鈥

The couple approached a nurse for an explanation of why Claire, who loved to be up and about, was strapped down. They were assured Claire was fine.

鈥淵our mother-in-law is over 80 years old,鈥 said the nurse. 鈥淪he has low blood pressure. This is quite normal. This happens all the time.鈥

The nurse also assured them that Claire would be fine to leave the hospital on Sunday for Mother鈥檚 Day visiting. Claire was more herself on Saturday and by Sunday she was much better.

Bernie says he remained suspicious about the matter but set his concern aside. But on a subsequent visit, another nurse pulled him aside and said his mother-in-law鈥檚 temporary stupor was caused by a medication error.

鈥淪he was given the wrong medication and they lied to us and told us it was normal,鈥 says Bernie. 鈥淚 really got upset, and I'm not a very quiet person.鈥

After several drafts 鈥 toned down in editing, by Sandy 鈥 Bernie sent off a letter to the Jewish General Hospital鈥檚 ombudsman. Soon after, Dr. Joseph Portnoy, the hospital鈥檚 director of professional services, phoned Bernie to explain the details of the error and the steps being taken to ensure it wasn鈥檛 repeated.

But what really shocked Bernie was Dr. Portnoy鈥檚 humility.

鈥淥n behalf of the staff, we are sorry,鈥 Bernie recalls him saying.听 鈥淲e鈥檙e sorry because of what happened and we鈥檙e sorry we didn鈥檛 tell you the truth.鈥

Then the doctor asked Bernie if he would be interested in sitting as a community representative on the hospital鈥檚 Quality and Risk Management Committee.

Bernie, who is now also a member of Patients for Patient Safety Canada (a patient-led program of the Canadian Patient Safety Institute, now 日本无码), has gone on to help implement a number of positive changes at the hospital.

The medication error in his mother-in-law鈥檚 care prompted inquiries with the pharmaceutical company, which then changed the appearance of the medication to be more distinct.

The case was an example of where the health provider wasn鈥檛 at fault, says Bernie. It was a technical or system error that, as it turned out, had caused other patients harm.

鈥淭he system had to be changed and that鈥檚 the sort of approach taken by the Quality and Risk Management Committee,鈥 he says.

The Jewish General also implemented a disclosure policy and Bernie became involved with the hospital鈥檚 Speak Up program.

The program is part of the three-pronged approach at the hospital to improve communications between clinicians and patients.

鈥淚t encourages patients to speak up in an open and respectful manner, whenever they don't understand what they have been told or are uncomfortable about what is happening around them,鈥 says Bernie.

The Speak Up program works with clinicians to improve their communication and stresses listening closely to what patients and their families are telling them.

鈥淚n general, when you went into the hospital as a patient you lost all your power,鈥 says Bernie. 鈥淵ou could be the biggest corporate magnate and lose all your power.

鈥淏ut having patients and their families be part of the medical team will make the entire system better.鈥

Claire died a couple of years after the incident, in January 2004, at age 81. Bernie still thinks about her often.

鈥淪he was a very special person,鈥 he says. 鈥淪he was very much loved by her children and grandchildren. She will be very well remembered.鈥

Bernie deeply appreciates the action of the Jewish General Hospital in making amends to Claire鈥檚 loved ones. The problem with the initial coverup, he said, is that it created a divide between the hospital and the patient鈥檚 family.

鈥淲e felt like they didn鈥檛 trust us,鈥 he says. 鈥淚t made us feel unimportant.鈥

The sincere apology acted to restore the trust and connections.

鈥淎n apology and explanation of what鈥檚 being done makes you feel like you鈥檙e part of the process and that something good, something positive came out of the incident.鈥

Claire鈥檚 experience in healthcare reminds us that when patients and their families are included in the medical team it makes the system safer for everyone.

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