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A true story of the hell patients and their families go through when patient safety programs fail.

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"In 1991, my wife experienced brain damage/permanent short term memory loss, following a hysterectomy and an emergency colostomy (due to a cutting of her colon during the hysterectomy). At the start of recovery in her room, she experienced an overdose on morphine delivered through the PCA pump IV drip. The code team responded right away when a student nurse heard what she described as an elephant snoring in Diane's room, and it took over 21 minutes to intubate her; too late for the brain to survive intact.

While Diane was in the hospital, I started asking logical questions, and received some nice, polite answers. I starting asking tougher questions, and was turned over to a senior Risk Manager. He was very difficult, gruff, condescending, arrogant, healthy ego, loved to argue. I initiated all conversations/meetings over the next 21 months. They were primarily superficial with much speculation stated; one involved the physicians, never anyone from management though I requested it.

The risk manager's wife was his key associate. She was a nurse, sweet and empathetic. It was clearly good cop, bad cop. I think the risk manager was not functioning any different or better than his training, hospital and insurance company directives, value system, personality and/or personal incentives would let him function. I think the idea of a health care system revolving around the patient was foreign to him. It was hard to envision him standing up to the hospital board, CEO/COO and/or doctors and telling them they could/should not treat patients/family members that way.

I asked for a copy of the medical record. For $94 I was told I could get a copy at the medical records department. I did...Read the rest of this compelling story.