LOCKPORT – Mary Brennan-Taylor, vice president of programs at the YWCA of Niagara, is a lifelong Lockport resident and longtime advocate for women who are touched by domestic violence. But when she lost her robust and active 88-year-old mother after she was hospitalized for a simple procedure five years ago, she began a crusade to end medical error.
Her mother, Alice Brennan, had been very diligent about her health with regular checkups and a short list of four or five medications. She was admitted to be treated for gout and then went in for what was supposed to be a short stay in a rehabilitation facility, where Brennan-Taylor called her mom the “Walmart greeter,” enthusiastically making friends with all. However, 12 days later she was lethargic, gray, hallucinating and nauseated.
“My mother went in for a non-invasive treatment. There weren’t any surgical incisions. She didn’t have a catheter. She had gone to this hospital three weeks earlier for pain in her neck and shoulders and back. The emergency room doc gave her Flexiril, a muscle relaxant,” which Brennan-Taylor said her mother’s neurologist said never should have been prescribed to an 88-year-old woman. She said that her mother really hadn’t used it and disposed of it.
However, when her mother went back to the hospital to be treated for the gout, she was automatically given the drug again. Once the connection was made, Brennan-Taylor demanded the drug be halted, but by that time she had been taking it three times a day since for 17 days. It was too late, and the downward spiral continued with hospital-related infections; a fall that severely injured her back, hand and foot; psychosis; pain; and loss of appetite.
Brennan-Taylor, a former chief of district staff for Rep. John J. LaFalce; the former executive director of the Niagara County Commission on Women; and a former assistant bank vice president, used her considerable resources and research powers to get to the bottom of what was going on by going to the top – enlisting an emergency consultation with the University at Buffalo’s chief of geriatrics, Dr. Bruce Naughton.
Naughton recommended the removal of all the adverse medications – by that time it was a lengthy list – but the damage had been done. Alice had become emaciated at 108 pounds, having lost 24 pounds. Eventually, with Brennan-Taylor’s advocacy, her mother was admitted to Hospice House for end-of-life care and died Aug. 29, 2009, six weeks after it all began.
For most, the saga would have ended that day, five years ago, but Brennan-Taylor is not like most people.
Her mission as a patient safety advocate has taken her to across the country and to Washington, D.C., to speak out against medical error and for better hospital safety. She also has gone back to the UB Medical School, where they first helped her, and for the past four years she has been telling “Alice’s Story” to new medical students and making an impression so that Alice Brennan will not have died in vain.
What prompted your mother to go to the hospital?
She was on the steering committee for her 70th high school reunion and was hellbent on wanting to dance for that high school reunion. So she said she really wanted to (take care of the swelling in her knee).
At the YWCA you have a strong role in helping women, but you took on a different role when your mom died
It’s certainly not a club you’d ever want to belong to. It really has become my avocation and certainly my passion. I’ve taken on a role that has touched me deeply and that is as a patient safety advocate and trainer.
How do you educate people on what happened?
This (she holds up a lengthy document called “Alice’s Story”) is a Power Point presentation, and I do them for various audiences so they are targeted specifically.
What do you do at the University at Buffalo Medical School?
I speak to them once a month, and there have been 500 UB medical students who have gone through the lecture. I touch upon a number of issues that I think are critical in reaching this new generation of medical professionals – by putting a human face on medical error from medication error to falls to hospital-acquired infections. I begin the program by giving them a feel for who my mother was. She spent 88 years as a vital, robust, spontaneous woman. I liken her to a cross between Lucille Ball and Carol Burnett and she spent 48 days as a victim of medical error. I don’t want people to think (at age 88) she was an invalid, by any stretch of the imagination.
Did you know much about medications and hospital safety before your mother was hospitalized?
One would think because of the advocacy I do here (at the YWCA) I would also do patient advocacy, but I was blissfully unaware. Like most people, blissfully unaware of the importance of doing just simple things like asking, “May I see my mother’s charts. May I see her medical records. May I see what medications you have her on.” I didn’t ask for that. We all assume that everything is fine. I didn’t know that what I should have done is bring in Clorox wipes to wipe down the high touch surfaces in her room. I didn’t know that the privacy curtain between the bed is the greatest conductor of these germ like C-difficile (Clostridium difficile) and VRE (Vancomycin-resistant Enterococci). Who knew that stuff? I didn’t know. I was an English major, for God’s sake. When she was diagnosed with MRSA (Methicillan-resistant staphylococcus) and they said it was “no big deal,” that should have been something that sent me fleeing, but it didn’t. I just said, “OK.” C-diff is a life-threatening colitis than can and did kill my mother.
Should we be afraid to go to the hospital?
I think what my mother’s tragic experience has done is made me aware of knowing what facilities have better patient safety ratings. I would certainly ask before I was hospitalized. And I would ask, “Have you had an outbreak of C-difficile? Have you an outbreak of MRSA?” I have asked those questions. I didn’t know that before. If they won’t tell you, that’s certainly an indication that you need to go somewhere else.
Is this is something that has gotten worse?
What has shone a light on this issue was in 1999, the Institute of Medicine released a report – “To Err Is Human.” That was 10 years before my mother’s death. They predicted from looking at patient records that 98,000 patients are killed annually in medical errors. And that was just the tip of the iceberg. I am addressing preventable situations.
This is where you see a lot of anger and lawsuits. Did your mother’s case result in a lawsuit?
I don’t want to say the name of the hospital that treated my mother, because it could happen anywhere and you get into a lot of finger-pointing and a culture of blame. I never thought about a lawsuit because what would that achieve? What I did want to do is do is something that would change a very dysfunctional culture.
Since this happened you are helping to train future doctors in your mother’s name. What do you tell them?
I tell the medical students and the nursing students to go use the lowest tech part of your tool box, and that’s communicating with the patients and family members. Because family members can help you care for that patient better than anyone else. They know that person better than anyone else. They can give you health history that the patient has forgotten. They can see a change in their family member and you can rely on that.
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