Unite for Safe Care - patients, advocates, health workers and leaders, together globally - working to ensure patient and health worker safety in every nation on earth.
The Problem
VTE is estimated to be the second most common medical complication, the second most common cause of excess length of hospital stay (LOS), and the third most common cause of excess mortality. Standardized early recognition protocols are inexpensive, readily available, and effective methods to prevent VTE.
The Cost
Medical costs for
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Each APSS is developed by a workgroup comprised of patient safety experts, healthcare technology professionals, hospital leaders, and patient advocates. The Foundation is proud to connect as many stakeholders as possible to focus on how these challenges can best be addressed. The Foundation’s Board of Directors also contribute and review the APSS prior to their annual dissemination.
We believe that progress cannot be achieved by sitting on the sidelines; we must take ACTION together. Like-minded individuals are the driving force that makes our mission to reach ZERO preventable deaths not just conceivable, but achievable.
In 2015, our family nightmare began when my daughter, Shalynne, showed up at the hospital in Las Vegas, Nevada.
My eldest daughter, Shalynne, decided to move out to Las Vegas to be closer with our family and to finish nursing school to become an RN. Soon after driving 23 hours straight, from Kansas City, she started complaining about the redness and pain spreading throughout her leg. Within days of her arrival, while I was on a business trip in Phoenix, Shalynne’s pain became so severe that she went to the local ER.
Shalynne was African American, had sickle cell trait, was on birth control, and had just completed a long drive from Kansas City to Las Vegas on an injured knee that was healing. Her symptoms and risk factors were classic of a rare, life-threatening condition called deep vein thrombosis. Also known as DVT, the condition occurs when a blood clot forms in the body; DVT is deadly if left untreated, but survival rates are excellent — about 95 to 97% — with adequate medical care.
Walking into the hospital, Shalynne was not sure if she had healthcare or not. Immediately, upon arrival, the intake receptionist asked if she had insurance. She replied, “no”. She was told it was going to be very expensive and if she left now it would not cost anything. The pain was so intense that she stayed. At their suggestion, my husband called Tricare, military insurance, to see if we could add her to our plan. Shalynne would not qualify, one of the reasons being that they do not cover our children between the ages of 21 to 23 unless they are in college full time.
Shalynne had just arrived and classes hadn’t started so she didn’t qualify. I received a call from Shalynne asking what to do and if I could call to try and get her on our plan. I told my daughter to not worry about the costs; just be seen and we would take care of the bill later. Once in the back, the hospital took her temperature and blood pressure, but when Shalynne mentioned that she did not think she had medical insurance to the hospital staff, the staff was of little help. Even after begging for additional diagnostic testing, they told her to get insurance and see a specialist, since, as an emergency room, they were not a doctor’s office. I received another call from Shalynne crying, “Mommy they’re not helping me”.
They did not satisfy even the bare minimum requirements for a patient presenting as Shalynne did, essentially telling Shalynne to go home. In other words, the hospital showed a lack of patient engagement, denying her proper care.
Shalynne did what they told her and applied for insurance and began researching specialists. Unfortunately, Shalynne had to fly back to Kansas City to finalize her move. Shortly after she landed, she went into cardiac arrest because of the blood clot that had travelled from her leg to her lungs.
I remember receiving the call from her father telling me of Shalynne’s condition. I was in utter disbelief. My daughter was so young with no known medical conditions that would cause an early death. My flight to Kansas City was almost excruciating. Upon walking into her hospital room, the severity of Shalynne’s condition was inescapable. All I could do was hold her hand and beg her to fight to live. My sister, an RN who lives in Kansas City, was appalled to hear how Shalynne had not been screened and kept weeping that they should have caught this.
With each hour that passed it became apparent I was going to lose my daughter. The pain is indescribable. When it was time to turn off life support, I climbed into bed with my daughter and held her. I wasn’t going to let her go through this by herself. My daughter died in my arms as I told her how much I loved her. My last words to Shalynne were, “You will not have died in vain”
Because Shalynne couldn’t show proof of insurance, she couldn’t obtain adequate treatment. Without access to medical treatment, Shalynne died an untimely death. All of her dreams and aspirations died with her.
The problems that I had experienced firsthand were twofold: first, my daughter could not present proof of insurance and second, all patients deserve treatment regardless of insurance status.
For over a year I was immobilized with unbearable grief. Eventually, my tragic loss motivated me to make a difference. During my research, I read that over 40,000 people a year die due to a lack of healthcare. It was at this point that I knew I could not continue with a comfortable existence. My eyes were opened and I would not close them again. I became an advocate for improved healthcare access, even launching a campaign for Congress in my home state of Nevada during the 2018 midterm elections. My journey on the campaign trail is featured in the Netflix documentary “Knock Down the House.”
Today, I continue to fight for improved access to medical care for those without health care coverage. I am a fierce supporter of Medicare for All and have worked tirelessly to improve health care access for the 29% of Americans who are underinsured, including 27.5 million Americans without any insurance, so that no one has to endure the pain our family has.
The last normal day of Michael’s life began like any other. He was sitting on the couch playing with the family’s new puppy. Suddenly, he inexplicably passed out. When Michael regained consciousness, the 22-year-old EMT and nursing student knew he had to get to the emergency room right away.
At the time, a doctor suggested that Michael had probably had a seizure, a side effect of Wellbutrin, an antidepressant he had been taking for smoking cessation. But a CT scan later revealed a three-millimeter dot in his brain. The Skolnik’s believe that the neurosurgeon made a quick and deadly rush to judgment. He had warned that Michael was lucky to have survived his initial seizure and that he needed surgery immediately.
“He said, it’s a very simple operation,” Patty recalls the doctor saying. “You don’t even go in the brain. All I do is go in and excise the cyst.” The Skolnik’s say the doctor claimed to have performed many such surgeries, but he later admitted in a legal deposition that Michael’s procedure had only been his second.
Whatever the case, no cyst was removed or revealed. An exhausting three-hour operation ended six hours later, and Michael was never the same again. Other physicians have since told the Skolnik’s that at most, a shunt should have been placed in Michael’s brain and that the elusive dot was likely benign. The seizure, some doctors say, was likely a bad reaction to the Wellbutrin.
The neurosurgeon, who would later establish a […now closed…] medical practice at Western Plains Neurosurgery in Scottsbluff, Nebraska, has been unavailable for comment to the press. He reportedly still lives in the Denver area and plans to open a new practice in Glenwood Springs, according to a Western Plains receptionist.
The Skolnik’s become visibly angry when they describe the way the neurosurgeon announced Michael’s prognosis after the ill-fated surgery. “He pulled back his hat and says ‘I’ve had the worst year,’” David recalls angrily. “We were a family that made decisions together. This changed who we are. It was our life forever with Michael. Now, it’s still our life, but without Michael.”
The family’s 32-month nightmare included multiple surgeries, systemic infections, deep vein thrombosis, pulmonary embolism, DIC and sepsis. Michael suffered from paralysis, psychosis, respiratory arrest and an endocrine-system failure that caused him to gain more than 100 pounds. He was partially blinded and unable to speak. He was fed through a tube in his stomach.
On June 4, 2004, Michael looked into his father’s eyes, mouthed “I love you” and died.
It’s April 1, 1986. Seven-year old Michael Skolnik is up to his usual tricks, but this time, he is armed with a convenient little alibi called April Fool’s Day. The mischievous child is slowly creeping up behind his unsuspecting mother… when all of a sudden, crack! A perfect shot, over and easy. A broken egg scrambled on Patty’s face.
“He just thought that was the funniest thing he had ever done,” Patty recalls, as a glow quickly covers the same face. “My first reaction was, ‘What have you done?’ But then, you had to laugh because Michael just made you laugh. He was such a character.” The laughs come as easy as the tears when Patty talks about her only child. “Your life is forever changed and you hope there is something after death so you can believe you will see your child again,” Patty says. She remembers Michael’s realization, at 13, that he did not believe in God.
“What if you die and you find out there is a God, what do you think God will feel?” Patty quizzed her son at the time. “Well, if God is supposed to be all forgiving, he’ll forgive me for not believing in him,” the young teen retorted.
The exchange has resonated with Patty for more than a decade. “I thought that was pretty profound for a 13-year-old,”she says smiling.“Somehow, some way, I feel Michael is right there behind me pushing me along.”
Yogiraj Charles Bates died from a hospital acquired venous thromboembolism (HA-VTE), the most common cause of hospital-related death in the United States. He was and continues to be revered for his extraordinary mind and loving nature by people around the world. His contributions as an author, entrepreneur, father, sage, master trainer and an unrelenting advocate for the human spirit will have a positive influence for many generations to come. Yogiraj’s story begins with a fall from his meditation seat. We laughed at this odd occurrence, that is, once we felt assured he was unaffected by the impact. Several weeks later we learned otherwise. The fall was serious. I can still remember the moment the on-call neurosurgeon gave us this news. He swiftly pulled back the ED curtain with his backpack still tightly affixed to his shoulders. Out of breath, from what I imagined was a hurried bike ride, the neurosurgeon expressed his surprise that Yogiraj appeared well. He turned our attention to an image, pointed to Yogiraj’s head and stated, “Your head is half full of blood. In cases such as these, I would typically rush a patient into surgery, but you appear well enough to hold off until morning.” Although, rather in shock by this alarming news, we felt comforted by his confident assurance. The neurosurgeon confidently acknowledged his team handled cases such as Yogiraj’s every day and despite our unfamiliarity with Subdural Hematoma surgery, we remained optimistic it would bear a successful outcome. At first, the operation appeared to go well. Yogiraj emerged from the recovery room as I marveled at his tenacity to regard everything as a learning opportunity. I reported to our community that Yogiraj, although extremely parched due to a long surgery, was musing over the many benefits of liquid. This was a telling sign my husband’s cognitive function was sound. What appeared to be progress and standard recovery quickly shifted to incessant issues and pain. The day following surgery, we expressed our concerns, but were told his symptoms were normal. Our uneasiness continued as Yogiraj was phased from ICU to the hospital’s residential rehabilitation center. Each transfer, eight locations in the span of thirteen days, we would reiterate to each new care team his mounting issues. These symptoms included shortness of breath, chest pain, spells of uncharacteristic anxiety, low pulse oximetry, weakness on the left side, and pain in his lower left leg. Although we attentively made sure each team was familiar with his various symptoms, a diagnosis was never discussed. The hospital staff was kind and also attentive. We assumed they were doing their best. We were particularly grateful for the first physical therapist, who provided us with a strap so that I could walk alongside him. I still smile when I think back and remember my 5’4 frame steadying his 6’2 stature. Side by side, 24/7, 100% of our attention was focused on Yogiraj’s rehabilitation. Everything else remained on pause. He was determined to leave the hospital better than he had arrived. Family and friends would visit and bring food, while people around the world followed his efforts towards recovery. Unfortunately, his positive attitude and continued perseverance weren’t enough to avert the underlying issues. His symptoms had escalated. On Father’s Day, the 12th day following his initial surgery, the first code blue was called. That morning I woke up to my husband in the middle of a tonic clonic seizure. He was rushed from Rehab to the ED, and several hours later admitted to a Cardiac unit. The next morning we would see several physicians come and go. After a couple of tests it was decided, he would either return to Rehab or be discharged and return home. We remained hopeful and took their words to heart. Yet we continued to be hyper-attentive. We knew something was not right. The second and last code blue was called when Yogiraj underwent an ordered EKG test. His son Ananda had just visited for lunch and although Yogiraj still needed oxygen his spirit was light. It always was when he was with family. During the EKG, he suddenly looked over at me with widening eyes and said, “It’s happening again.” I knew exactly what this meant. I cried for help and the formerly silent room instantly shifted into manic chaos. A chaplain arrived at our side before they could even rush Yogiraj to the ICU. I can still remember the initial strike of panic when the clergyman introduced himself to me. Naively, I convinced myself his presence was nothing more than a kind gesture to provide assistance. I proceeded to give him my phone and asked if he would contact our son Evan, who was waiting nearby. I ran alongside Yogiraj as he was rushed to ICU. This is when I first heard the words Pulmonary Embolism. These words, completely foreign to me at the time, were quickly overshadowed by the following eight words. The doctor and overseer of his resuscitation efforts said, “This doesn’t usually go well. He could die.” A mere thirty minutes later, I watched Yogiraj Charles Bates take his last breath. Shock and disbelief pervasively continued to follow for months. The reality of his sudden death hit once I received the autopsy report. It was at that time Pulmonary Embolism (PE) became a term for me. This term, married with my husband’s medical records, became my meticulous (devoted) study for months. It was what prompted my future concerns. My husband’s symptoms had lined up to the most common U.S. preventable hospital death, HA-VTE. With the need for more answers, I contacted friends in the medical field and tried to piece together what delayed his diagnosis until it was too late. I knew that understanding what had gone wrong would not change the circumstances that followed. I would never again wake up to Yogiraj’s beams of love. However, maybe my comprehension and experience had the power and potential to prevent future deaths and could save other families from despair. After analyzing several peer-reviewed studies alongside my husband’s medical records, I contacted the hospital. My first conversation didn’t go well. At the start, I left a message at the patient representative’s office and received a call back from the manager. I said I wanted to know what questions the hospital was asking surrounding my husband’s experience. It felt important to express to the hospital staff member that I was solely seeking understanding, rather than pointing fingers to blame. The response back shocked me. The manager said, “People die in the hospital every day.” I could not hold back my immediate gut response and said, “Not like this, I hope. Not like this.” There was silence, followed by the manager’s agreement to vet for more details and call me back. That promised call never came. Months went by as my interest escalated and research continued. I wrote dozens of draft letters which introduced my desire to simply understand and transcend blame. It had become clear that HA-VTE was a systemic issue and my husband’s experience was happening in hospitals across the nation. Over a year later, I sent a letter and requested two meetings. One meeting with an officer of the hospital and the second with physicians. It gave me peace to finally feel closer to answers once my requested meetings had been set. I offered to send my questions ahead of time in support of any preparation they may need. Our family was eager to learn and share our experience and hoped our approach could benefit others. The first meeting was disheartening. The officer on the phone casually spoke, making attempts to be chatty rather than getting to the root purpose of the call. I am familiar with the cultural notion to start a serious conversation lightly. It’s a technique I’ve used myself. However, my husband had died and I couldn’t help but wonder why the administrator made no effort to set a tone that acknowledged this significance. In that same conversation, I was told the physicians were “busy saving lives,” so our in-person meeting could not include them. I pushed back, but their approach was the only avenue forward. Only administrators would be present. As promised, I sent my questions in the week before the meeting. Several days later, the meeting was canceled. The administrator responded by email and stated my questions had changed the agenda. I was confused by this statement, but my reply accepted the fact that our objectives were not aligned. The hospital hasn’t contacted me since. In my attempts to better understand the hospital perspective, I can imagine the associated challenges to manage the complexities and risks after an adverse event. Yet I cannot help but feel the moment my husband took his final breath as Yogiraj Charles Bates, II, he suddenly turned from being a cared-for patient to a managed risk. For those who knew him, nothing could change who this great man was. Like any another delayed diagnosis death resulting in a hospital-associated death, his deserved a robust investigation – one that included the observations of the family who cared for him alongside the medical team. The real risk for a hospital is not taking time to know the person after an adverse event. If this hospital administration had heard our experience, and that of the dozens of nurses, doctors, and other staff members who cared for him, it may have been more difficult to treat this person like a risk. Yogiraj was a master teacher. In telling his story, my hope is that his life and death will reach and teach as many individuals as possible about HA-VTE, and that his experience will ultimately improve patient safety.
As Told By
Vonda Vaden Bates
Vonda Vaden Bates is an alliance builder and leadership coach. For over 30 years Vonda has guided professionals to succeed […] Read More
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Venous Thromboembolism
