UB Brings a New Dimension to Patient Safety
Published August 31, 2011
When Mary Brennan-Taylor lost her mother to a series of preventable medical errors two years ago, she wasn’t interested in suing the hospital where the mistakes had been made.
She was interested in changing the culture.
Today, Brennan-Taylor—a highly regarded Consumers Union patient advocate—is bringing that culture change directly to UB medical students through an innovative educational program that teaches them how medical errors impact patients and their families.
This summer Brennan-Taylor was appointed adjunct research instructor of family medicine, a volunteer faculty appointment.
On Aug. 22, she gave a presentation on what happened to her mother to a class of third-year medical students. By the end of the fall semester, she will have told her story to the entire medical school class of 2013.
All of Brennan-Taylor’s presentations are being introduced by Ranjit Singh, MD, associate director of the UB Patient Safety Research Center, who talks to students about his related clinical research.
The center is located in the Department of Family Medicine, where Singh also serves as a clinical associate professor.
“It adds a very human dimension to our discussion about medical errors. It helps the students realize that it’s not just statistics that we are talking about—it’s somebody’s mom.”
Last semester, Brennan-Taylor also lectured to and coached nursing students as part of an innovative patient-safety course in the UB School of Nursing.
Her goal is to develop a patient-safety guide or tool kit for consumers. Toward this end she is collaborating with the UB Patient Safety Research Center on a pilot project aimed at identifying and studying avoidable adverse events in order to understand what went wrong and how patients and caregivers could have intervened.
“UB is ahead of the curve on this,” says Brennan-Taylor. “Instead of circling the wagons, they are asking, ‘How can we be better doctors and nurses?’”
In July 2009, Alice Brennan, a vibrant, 88-year-old woman who lived independently, went into the hospital for a common, non-life threatening medical problem. Six weeks later, she died from multiple hospital-acquired infections and from polypharmacy, the use of numerous medications, often more than are clinically indicated.
“It was a health care system failure,” says Brennan-Taylor. “My mother was put on medications that I now know should never be given to elderly patients. It was a deadly cocktail. Then she contracted, not one, not two, but three hospital-acquired infections: MRSA, C. diff and VRE.
“There should have been some alerts from the pharmacy. There should have been some infection-control procedures. I never thought that a doctor or nurse intended to harm my mother, but there was an utter breakdown in the system,” she says.
After her mother’s death, Brennan-Taylor began searching for answers. She found that, unfortunately, her experience was far from rare.
She learned that as many as one in three hospitalized patients will experience some form of medical error. According to a recently released report from the Office of the Inspector General, 180,000 Medicare patients die as a result of medical error every year.
“That’s just unacceptable,” Brennan-Taylor states.
From her family’s tragedy, Brennan-Taylor developed a passion for making sure that what they experienced becomes an extremely rare event.
“I felt that I would be remiss if I didn’t reach out,” she says.
“Mary Brennan-Taylor came to being a patient safety advocate the hard way, after her mother died from a health care-acquired infection,” says Lisa McGiffert, director of the Consumers Union Safe Patient Project.
“She transformed her grief into action, collaborating with a unique University at Buffalo program that educates future doctors and nurses about the human impact of medical harm and the actions they can take to prevent such harm.”