Leah and her mother expressed numerous concerns about her pain to the nurses and physicians – who responded by increasing her fentanyl. When Leah became increasingly non-responsive, her mother refused additional fentanyl but a resident administered Ativan – telling Leah’s Mom that it would decrease her “anxiety”.    Exhausted, Leah’s Mom fell asleep at her bedside.  When she awoke two hours later, Leah was dead.  Her autopsy revealed that her epidural was actually delivering the medication into the interpleural space.
 
In her book Josie’s Story, Sorrel King describe the moments before her daughter Josie’s death: “Both (doctors) agreed with me and issued a verbal order that no more narcotics be given.  At 1:00 pm (the nurse) walked in with a syringe of methadone.  I asked her what she was doing and said that (the doctor) had given orders for Josie not to receive any more methadone.  ‘Don’t give it to her,’ I said as she neared Josie’s bed.  ‘The orders have been changed,’ she responded.  (The nurse) squirted the drug in Josie’s mouth.  When I looked at Josie, I stopped dead in my tracks.  Her eyes had rolled back in her head.  ‘Josie? Josie!’  I shook her.  She was not responding.”

Lenore Alexander and Sorrel King experienced the worst pain imaginable as a parent – in part, because of the failure of medical personnel to listen.  In error prevention, one of the tools for critical thinking is validate and verify:  Validate is an internal check – does this situation or the information that has been given to me make sense? Verify is an external check of the information with an independent and credible source to corroborate our thinking.  We often characterize this as being responsive to the internal smoke detector inside your brain that warns you when something isn’t right.  Information from patients and families can set off our internal smoke detector – if we are willing to listen without prejudice.  When we believe that we know better because we are the medical professionals or assume that patients are families are merely being “annoying” with their questions, comments, and concerns – we may miss important information or warning signs.

Don Berwick once described patient-centered care as:  “… transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care.” These should be our watchwords as we include patients and families as equal members of the care team.