Martin “Marty” Hatlie is a patient safety advocate with a strong interest in the roles patients and family members play as co-creators of patient safety solutions.

Marty Hatlie’s journey as a champion for patient safety and justice is deeply influenced by the value his family fairness, justice and lifelong learning. Originally from Wahpeton, North Dakota, where the closest hospital was across the border in Minnesota, Hatlie’s father was an FBI agent and then a prosecutor; his mother was a teacher; and his grandfather was the county sheriff and then a judge.

“My parents really wanted to make the world a better place, and I think they instilled that in their kids,” Hatlie said. “That still motivates me.”

This early foundation, combined with a strong academic background—a bachelor's degree in philosophy from Carleton College and a Juris Doctorate from Boston College Law School—has shaped Hatlie’s career and lifelong mission.

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The Leapfrog Group Announces Three New Board Members

September 26, 2023

The Leapfrog Group, a national watchdog organization of employers and other purchasers focused on health care safety and quality, today announced the election of three new members to its board of directors: Janet Lucas-Taylor, Senior Director Employee Benefits, Northwestern Mutual; Susan Sheridan, MIM, MBA, Founding Member, Patients for Patient Safety; and Karen van Caulil, PhD, President & CEO, Florida Alliance for Healthcare Value. 

“Leapfrog is proud to welcome these exceptional leaders to service on our Board,” said Michelle Martin, Leapfrog Board Chair. “Janet Lucas-Taylor and Karen van Caulil are among the most isionary employer voices in the country, and Susan Sheridan brings an international reputation as an activist and changemaker for patients and their families. These three new Board members have been part of Leapfrog for many years, and they are deeply respected by all of us for their ffectiveness, expertise, and talent. We are fortunate to have them join our Board, where we will count on their 

leadership to accelerate our strong growth.”

Read Full Announcement Here...

Las Vegas, Nevada

September 11, 2023

Board Certified Patient Advocate (BCPA) Rebeka Acosta, founder of A+J Patient Advocacy – a non profit provider of health navigation, advocacy, and education services across Southern Nevada – was named Independent Advocate of the Year at the 2023 Healthcare Advocate Summit, the premier event created by advocates for advocates involved in patient access, navigation, and reimbursement.

Advocates received recognition across four categories, with Acosta winning Independent Advocate of the Year for her work in pediatrics. In just the second year of the awards, Healthcare Advocate Summit welcomed over 500 advocates from numerous healthcare specializations to New Orleans for the annual event.

Independent patient advocates are professionals that guide and support individuals and their families through their journey in the healthcare system. BCPAs are advocates credentialed by the Patient Advocate Certification Board, who have passed the official certification exam therefore determining their ability and fitness to serve patients. 

Acosta, the first BCPA in Nevada, earned her certification in September 2018 as part of just the second cohort to do so in the United States. After a decade of advocating for her own children and several years supporting other families, Acosta founded A+J Patient Advocacy in 2021.

“Having 15 years of experience in healthcare administration hardly prepared me to navigate the system when my children were born with serious medical conditions. How could the average family even begin to find their way?” said Acosta. “My patient advocacy career truly began in pediatric ICU rooms, hospital cafeterias, and support group meetings.”

As one of just two BCPAs in Nevada, Acosta is honored to be recognized while shining a light on the healthcare needs of her state’s youngest residents. “Without a free-standing children’s hospital, coupled with an extreme shortage in pediatricians and pediatric specialists, even healthy children in Nevada are facing an uphill battle in the healthcare system.”

According to the Healthcare Advocate Summit, “the Advocate of the Year is an awards initiative that recognizes the contributions being made across the field by rising stars and emerging leaders working as Healthcare Advocates.” For more on the Healthcare Advocate Summit, visit www.healthcareadvocatesummit.com.

Channeling Pain Into Purpose

By Debbie Haine Vijayvergiya

Since I was a young girl, the only thing I was 100% certain of was that one day I would be a mom.

My first pregnancy was completely normal and resulted in a healthy picture-perfect baby girl. However, things became eventful a week later when a late presentation of Group B Strep went undiagnosed and nearly killed me. The doctor, who was covering for my Obstetrician while he was away, ignored my symptoms and concerns. I called the office repeatedly over the week; I shared with the doctor and nurses that I was in so much pain that I was consuming Percocet’s like they were tic tac’s. Even then, no one ever thought that this was alarming. Instead, they chalked it up to me being a ‘tired and hormonal new mom.’  

A week to the day that I returned home with my beautiful baby girl, I arrived in the ER in complete septic shock. Thankfully, there were some truly exceptional doctors in the ER that day who saved my life. When my OB returned from vacation, he visited me in the hospital, apologizing profusely for the abysmal care I had received from his colleague. He also told me I would be dead if I stayed home another day.

My recovery was long and hampered by complications from the infection, including a blood clot resulting from the subpar PICC line courtesy of a rushing and impatient hospital staffer. My friends would often ask me if I wanted more babies after all that I had been through. I was always quick to reply, absolutely! At that point, I was convinced that I had paid my dues to the fertility gods and that nothing worse could happen to me.

The following year, I experienced my first miscarriage, which I was able to easily make peace with as I was still in recovery mode. The next year, I suffered my second miscarriage—which was a much bigger pill to swallow. After 2 weeks of bed rest, an ambulance ride, 10 hours in the ER, and compassionless care, I returned home broken. A year later I was pregnant yet again, for the fourth time in 4 years. Once I made it through my first trimester, I gave a deep sigh of relief and allowed myself to believe that everything would be ok.

Unfortunately, I wasn’t that lucky. On July 7th, 2011, my life irrevocably changed while at a routine checkup when my OB could not detect my daughter Autumn’s, heartbeat. My world came crashing down around me as I was suddenly thrust into any expectant mother’s worst nightmare. Time stopped moving for me that day— and my life has never been the same since. My doctors led me to believe that my losing Autumn was as rare as being struck by lightning. But I soon learned this wasn’t the case and that stillbirths are one of the most common adverse pregnancy outcomes, with tens of thousands of babies born still every year in this country. I learned that many of these deaths were preventable and were happening in otherwise healthy, low-risk pregnancies. Up to this point, I had always considered myself educated, yet there I was, unaware of the realities of stillbirth.

I suddenly found myself faced with the reality that this tragic maternal health issue was being seriously neglected. I never knew how risky the business of a baby having truly was. Losing Autumn was the final straw for me. After everything that I had been through, I had to act. I couldn’t sit idly by and let others suffer as we had. I was compelled to help them and found that my only path forward was to channel my pain into purpose.

And so, I set forth on my advocacy journey, sharing my story and working tirelessly for the past 11+ years to put stillbirth on the map in this country. Some of that work includes helping to develop and champion multiple pieces of legislation, such as the bipartisan Stillbirth Health Improvement and Education (SHINE) for Autumn Act, which we hope to see re-introduced into the 118th Congress, one day soon.

Advocacy was never a part of my master plan, but here I am. And while none of this work will bring Autumn back or erase the trauma I’ve experienced; it will save lives. Sadly, we will never truly know if Autumn’s death was preventable, but many of the medical errors and near misses I have endured over the years were. Far too many communication breakdowns almost cost me my life and psychologically scarred me for the rest of my days. But it didn’t have to be this way. Something must change.

Elevating parent voices is a powerful form of advocacy, whether it is for stillbirth and/or patient safety. However, the real change depends on the patient and providers’ partnership. Safe and reliable healthcare is attainable— once we start working together. To learn more about how you can create a safer and brighter future for all, go to Patients For Patient Safety US.

CHICAGO – Provider burnout and overwork is a hot topic in the wake of the COVID-19 pandemic. But patients often struggle to navigate their own care in the complex and fragmented U.S. healthcare system. 

Bradley Schwartz, founder of Greater National Advocates​, said providers need to realize many patients aren't able to advocate for themselves or make use of the information they're being given. 

"If we can acknowledge that when you become a patient, you lose power, you are freaked out, your head is spinning. And when you're sitting there nodding and nodding, that doesn't mean you understand," he said.

But patients now have access to more information about their health and care. That makes communication and relationships even more important, said Christine Von Raesfeld, founder and CEO of People with Empathy

"Most of the information that is valuable, that is correct, is behind paywalls. So as patients, what we're getting at is the breakdown, the free version from whoever we trust to give that information to us," she said. 

Encouraging patients to access their health records and check them for accuracy is key. But records are often filled with medical jargon, said Greg O'Neill, director of patient and family health education at Wilmington, Del.-based ChristianaCare. 

"I don't know if you've ever looked at an entire patient chart from an extended medical stay: reams and reams and reams and reams of data. [...] We have a plethora of data, you bet," he said. "How much of it is accurate? How much of it is understandable to the average person? We have a lot of work to do in that space. We need to really prioritize information and present what is important to people as they're trying to manage their health."

Now is not soon enough: Patients, families and the general public have much to gain from the US National Patient Safety Board Act

Summary

In this blog, Olivia Lounsbury, Committee Lead for Patients for Patient Safety US's National Patient Safety Oversight committee, looks at a new Bill calling for the creation of a US National Patient Safety Board (NPSB). She outlines why the NPSB is needed and demonstrates the importance of engaging patients and families in its design and processes. Olivia also look at existing healthcare safety organisations in other countries, highlighting the opportunity that the NSPB has to benefit from their approaches.

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Would A “Patient-Centered” Sepsis Measure Have Saved This Man’s Arms And Legs?

Michael L. Millenson

Contributor

I write critically about U.S. health care

A recent JAMA article proposing a different way of assessing hospitals’ sepsis care was filled with technical arguments, but for me contained a powerful “between the lines” message. I read it and immediately thought, “Could this have saved Brad from having parts of both arms and legs amputated?”

Sepsis, known colloquially as “blood poisoning,” is distressingly common and deeply awful. It’s a life-threatening condition that can happen when the body overreacts to an infection, leading to tissue damage, organ failure and even death. At least 1.7 million Americans contract sepsis each year, and 350,000­ – about one in five – die, according to the Centers for Disease Control and Prevention. Amputations to save a sepsis patient’s limbs or life happen on average an astonishing 38 times each day, according to the Sepsis Alliance, and the condition’s inpatient and follow-up costs make it the single most expensive medical condition.

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The Journal of Health Design:

Identifying family caregivers as preventive medicine: An essential component of comprehensive primary care

Many patients are also family caregivers, who care for an ill or disabled family member or friend. Most do not “self-identify” as caregivers. Over time, caregiving can have significant effects on caregivers, as they often put their own health last. Primary care is an ideal place to identify caregivers through screening for caregiving status as part of patient history. This practice allows for the triaging of caregivers to appropriate supports and services, and as such is a form of preventive medicine.

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Health and Human Services (HHS) Secretary Xavier Becerra startled a recent meeting of senior health system leaders by declaring in opening remarks that a plane crash had just killed all 200 passengers. He immediately added that this hadn’t really happened; he’d said it only to illustrate the toll taken by medical error.

The Nov. 14 meeting at which Becerra spoke signaled a renewed commitment by HHS to preventing patient harm as it launched an “Action Alliance to Advance Patient Safety.” The Alliance aims to recruit the nation’s largest health systems as participants.

“We’re losing pretty much an airline full of Americans every day to medical error, but we don’t think about it,” said Becerra. (The department’s fiscal 2022-2026 strategic plan actually estimated the death toll at roughly 550 daily, which would be a very large airliner.) “But the worst part about it is that it’s avoidable.”

Our very own Soojin Jun, Co-Founder of PFPS US, has received this award for 2022 Rising Star Award from the University of Illinois Chicago, College of Pharmacy.

Class of 2013: In recognition of a distinguished young alumnus in the profession of parmacy.

One of our many Champions, Keri Anne Connaughty, has been working with both Republican and Democratic representatives in her state of Wisconsin on a bill proposal: "Patient's Right to Know" (Transparency).

Plans are to move efforts forward into the next session: January 2023.