The poor health care system caused my husband’s death

On Tuesday, the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, and the Center for Healthcare Research and Quality took an important step: They launched Core Elements of Hospital Diagnostic Excellence, a new initiative to help reduce the number. of Americans die or become permanently disabled each year from a diagnostic error. In 2023, that happened to about 800,000 Americans.

My family is one of many who have suffered from this. I am sharing our story with the encouragement of the CDC.

In 2012, I had no idea that the biggest threat my husband faced in the hospital was not the brain bleed we came to treat – but one of the most common complications after of surgery, venous thromboembolism (VTE). This deadly blood clot was growing on my husband, and no one on his care team knew about it. In a few days, it would reach his lungs and kill him. Simple measures, such as risk assessment and monitoring, could have been taken. However, these guaranteed preventive measures were not taken.

Before 2012, phrases like “delayed diagnosis,” “missed diagnosis,” “patient safety,” or “VTE” had never crossed my lips. Now, they roll off my tongue almost every day.

Since my beloved husband, Yogiraj Charles Bates, passed away from VTE, it has been a fact of life for me to help patients and healthcare professionals listen, learn and work together to improve outcomes and patient safety. Hospitals and patient and family advocates encourage family members like me to share our experiences because they say it can save lives.

Yogiraj’s mere fall on the bench caused a brain bleed, which required surgery. The neurologists successfully treated the wound, and at first, we were hopeful of a full recovery. In his usual cheerful way, Yogiraj returned to philosophy (he was a teacher) within hours of the surgery. But after a few days, even though he was walking regularly, Yogiraj’s symptoms of numbness in his chest and legs, shortness of breath and fever caused concern.

Although the doctors were kind and attentive, they failed to recognize Yogiraj’s symptoms as signs of a blood clot, and they did not communicate well. We saw the staff still relying on the neurosurgery team, the team that was paying attention to his brain bleeding but not this common post-surgery complication, VTE. We did not know that he was not receiving blood wound medication due to the risk of bleeding. No doctor told us this; we didn’t know how to ask.

Yogiraj would have survived if we had not combined kindness with professional and quality care. I stayed in the hospital with him for the entire 12 days of hospitalization, and every time we talked about the symptoms, the care team listened, but I had to push harder. I hesitated to ask many questions, thinking that the doctors knew best. Now, I realize how important it is for families to work with the medical team on behalf of their loved ones and stay informed.

Since Yogiraj’s death, I have spent hundreds of hours and joined millions of others to introduce system changes to promote education among hospital leadership, health care professionals, patients, families and caregivers leading to in the protection of patients and families within the profession. he really wants to help, not hurt. Health care providers are very concerned when harm occurs to their patients. Many see the same issues over and over again because lessons learned often do not change treatment options. When the studies do not change to a better state, the effective treatment decreases, and the risks to the patients increase. However, when medical teams use well-learned tools and knowledge to link symptoms to cause, lives are saved, and unnecessary suffering for health care providers and patients’ families is reduced.

A care team may not lose its patient – a father, son, brother, uncle, husband, teacher, and many more – if patient protection efforts get money that shows results and medical malpractice costs.

A 2023 study by the Johns Hopkins Armstrong Institute for Diagnostic Excellence found that approximately 795,000 Americans die or are permanently disabled each year as a result of diagnostic errors, which which would make the broader economy very high.

To move forward, we must increase awareness and education among health care providers and improve communication across the care team, including patients, families and caregivers. Most importantly, I believe that the loss our family suffered could have been prevented if there had been clear, direct, daily communication between the health care professionals treating my husband, our family and the patient himself.

I believe that the CDC Core Elements of Hospital Diagnostic Excellence can be an excellent resource for improving patient safety, creating processes and procedures to support the decisions of health care providers, tracking progress, and promoting a culture of learning from a miss, a delay or a delay. misdiagnosis in health care settings.

Losing Yogiraj has motivated me to continue to get better diagnostic and medical care, not only because of our family’s suffering but because we envision a future where no family or medical provider suffers a loss. it is like this. Improving diagnostic systems is about building a safer, more responsive health system that protects all our loved ones, including the brave people dedicated to caring for the sick and vulnerable. It is a responsibility we all share for our families and the future of health care.

Vonda Vaden Bates has been a patient advocate since her husband’s death in 2012. She is also the CEO and senior advisor of the 10th Dot organization, an organization founded by Yogiraj.


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