Editors: 

Laura Batz Townsend & Rachel Armbruster

© 2022 Louise H. Batz Patient Safety Foundation. All Rights Reserved.

The Batz Guide for Bedside Advocacy is truly a collaborative work. The authors have knowledge and great ideas, but alone they are just ideas. We have worked together as a team over the past eighteen months to bring these outstanding individuals together to create a tool that bridges the communication gap between doctors, nurses, hospital administrators, patients and family members in a hospital setting. Together we can generate a safe hospital experience for our loved ones.

Protecting the Patient First

Foreword

My mom passed away in 2009—unnecessarily, unnaturally, because of a medical error. Every single day since then, I’ve wondered, “What could I have done differently? What do I wish I’d known that could have helped save her life?”

We have five doctors in our family, so whenever someone we loved was in the hospital, we always felt we had the knowledge we needed. In 2009, when my mom was in the hospital, I was sure I knew the right questions to ask. I felt like a knowledgeable and active member of her healthcare team—but clearly, I was not.

In the year since Mom’s death, our family has collaborated with fellow doctors, nurses, hospital administrators, patients, and families to put together The Batz Guide. Our goal is to create a guide that will allow you – user of this guide – and a hospital’s medical staff to work together as a team.

My mom’s death did not lie on the shoulders of one person; it was a system failure. Until we all work together, these mistakes will keep happening. And as budget and reimbursement constraints begin to affect staffing in the entire world, the mistakes could reach epidemic proportions.

Because we know that medical terminology is often times very difficult to understand, this guide is meant to help you ask potentially life-saving questions in a language you and your doctors and nurses can all understand. It will allow you to work with doctors and nurses as a team. What happened to my mom was easily avoidable, and it would have been SO simple to correct, if only I’d had a guide to help me through her stay.

“Use the Batz guide!” is like saying “Don’t forget to put your seatbelt on!” We’re all going to drive our cars, and we now know the risks of not wearing our seat belt. If we didn’t we wouldn’t be able to get to work or go on vacations to see our loved ones, but we know the risks of not wearing our seat belt. Doctors and nurses save lives and perform miracles every day, but their work, too, carries risks. Like that seatbelt, this guide’s purpose is simple: to keep you and your loved ones safe.

Laura Batz Townsend
Co-Founder Louise H. Batz Patient Safety Foundation

This book is a tool to help you organize your healthcare information, and can be further utilized to make the procedures or hospital stays as safe as possible.

Disclaimer: This guide was written to educate and inform readers about the specific information and skills they need to be active participants in their medical care. It is intended to be a catalyst for patients and their advocates to cultivate mutually respectful relationships with healthcare providers, to learn to ask the right questions, and to communicate effectively about treatment options. It is informational in nature and is notintended as a substitute for the professional advice of a physician, attorney or other advisor.

Look for the STAR for helpful tips, facts, recommendations and resources

Organize your questions and concerns as soon as you learn about an upcoming procedure. This packet will be useful during pre-procedure appointments, during your time in the hospital, at home post-procedure or hospital stay. It will also help you during post-procedure doctors’ visits. We encourage you to include personal questions based on feelings or concerns and utilize the questions provided.

We recommend you keep all of these documents together in a binder and bring it with you to your appointments. Include important phone numbers, information about medications, and test results. If you do not understand an answer you receive, ask that the answer be given in a different, more understandable way.

Don’t hesitate to ask questions and take notes. Ask your healthcare team to slow down if the appointment is moving too quickly. Be sure you understand and agree with the treatment plan. Feel free to ask for more time to consider different options and a second or even third opinion, as long as it will not compromise treatment.

A medical error: The failure of a planned action either because it was not executed or because it was incorrectly executed for the achieved goal (IOM, 1999).

A system failure: Medical errors often resulting from inadequate organization of medical care.

Current medication use:
Please list all prescription medication, vitamins and over the counter medicines in the Medication Log table on page 15.

Share this guide with all your doctors.

Share this guide with all your doctors.

About your procedure

Some examples of medical practices or procedures: investigation, surgery, endoscopy, colonoscopy, labor, stent placement, intravenous chemotherapy administration, mole removal, ambulatory surgery, short stay.

Ask your doctors about the most important complications, such as:
Blood clots, anaesthetic complications and infections.

• If you take any anticoagulant medication, such as aspirin or heparin, consult your doctor before your procedure.
• If you take medication because you have diabetes, consult your doctor before your procedure.

If you have more than one procedure, print out this page again and have your doctor or nurse fill in a separate page for each.

You have a legal right to access all your records. Ask your doctor or nurse how to get access to them.

Here are records we suggest you keep in your binder:

• Copy of medication records (prescriptions and non-prescriptions) must be in your hands at all times!
• Copy of discharge summary after the procedure; these papers explain what to do when you are sent home.
• Copies of all pathology reports.
• Copies of any second opinions.
• Copies of all imaging (MRI, CT) reports from before and after the procedure.
• Copies of pertinent films (x-rays, MRI, CT).
• Legal documents including, but not limited to, Power of Attorney, Do Not Resuscitate Orders, Living Will, etc.

It is important to keep copies of your medical records for future reference.

To keep in mind before your procedure

• Try to be always accompanied by some member of the family or love one.
• Make sure the medical team knows about your living will, do not resuscitate orders, power of attorney.
• Make sure your family and friends know about your wishes, needs and decisions regarding medical subjects.
• If you remain hospitalized after your procedure, plan the visits of family and friends.
• Ask your doctor about infection risks, possibilities of blood cloths or if you will be at risk for falls.
• Know the level of medical attention that you will need after the procedure (intensive care, medium care, cardiac care, general ward, ambulatory)
• Ask if the health care center provides spiritual care of your preference.
• Ask if you have the possibility to share a room with another patient.
• Remember to plan what needs to be done at home while you are in the hospital and after you are being discharged, whom will go with you to the procedure, what you need afterwards, taking care of pets, plants etc.

If you have more than one procedure, print out this page again and have your doctor or nurse fill in a separate page for each.

To take into account on the day of the procedure

• Make sure you know exactly what procedure will be done and how long it will take.
• Make sure you know which part of your body will be affected by the procedure.
• Make sure you know if they will mark the body parts beforehand that will be affected by the procedure.
• Make sure you know what type of anesthesia will be used during the procedure.
• Make sure you know about most frequent side effects, risks and complications that you should know about and watch.
• Ask about the pain levels, how they will manage them and about the side effects of pain medication.
• Inform your health care team about respiratory problems you might have due to your weight, neck size, snoring history, sleep apnea or narcolepsy.

To take into account for after your procedure:

• Ask if you will be going home with drainage tubes, pumps, central or peripheral lines.
• Ask about how your surgical wounds will be taken care off (should you have them).
• Make sure you know if you need special requirements in your home such as oxygen, intravenous medication etc.

When looking at or evaluating your hospital or healthcare environment it is important to ask questions that will help protect you from acquiring an infection you didn’t come into the hospital with. Hospitals call these HAIs which stands for Healthcare Associated Infections. Talk with your doctor about facility’s infection rates so that you have good understanding of what your facility is doing to promote hospital safety.

Allergy: Medication allergy is group of symptoms caused by a reaction of the immune system upon administration of the drug (medication).

Vitamin: Group of organic substances that are essential for normal nutrition and growth. They are necessary in every diet, in small quantities, because they cannot be synthesized by the body.

Herbal Supplement: Herbal supplements are not medicines. They are non-food substances that are commercialized to promise to give you a better health.

Dose (quantity you take): A quantity of a medicine or drug taken or recommended to be taken at a particular time.

Medication: A substance used for medical treatment, known as medicine or drug.

Procedure: A procedure can be any surgical procedure, diagnostic intervention or treatment. After some procedures the patient requires an overnight stay – or longer – in the hospital to be observed or receive treatment; after other procedures the patient does not need to stay in the hospital. For example: colonoscopy, skin biopsy, endoscopy, chemotherapy etc.

Intensive Care: Special treatment for severely ill patients, who need constant monitoring.

Intermediate Care: Special treatment for ill patients, who require an intermediate level of medical care. Between intensive care and basic care.

Monitoring at a distance of heart activity: Permits monitoring of electrical heart activity by doctors during a longer period of time. The electric signals control the heart beats and are registered so physicians can see if there are any heart problems.

Anesthesia: Artificially induced condition before the surgical intervention through administration of gasses or injection of medicines that block the feeling and pain.

Vital Levels: Your heart beat, breathing rate, temperature, and blood pressure. Your doctor or nurse may watch, measure, or monitor your vital signs to check your level of physical condition and functioning.

Pulse Oximetry: Pulse oximetry is a noninvasive way to monitor the oxygen saturation level of the patient. The most common method consists of putting a sensor on a sensitive body part of the patient, generally the ear. In case of a child, the foot.

Cardio Respiratory Monitor: A machine that is used to monitor the breathing and heartbeat of a patient with the objective to inform the care givers about potential problems that could threaten the patient’s life.

Types of surgery: 
A surgery is considered clean: when the tissue to be intervened is not inflamed, when surgical asepsis is not broken, when there is no prior trauma nor traumatic operation, when there is no involvement of the respiratory, digestive or genitourinary tract.
A surgery is considered dirty (requiring empirical antimicrobial treatment): when there is infection, when a viscus is perforated, when a traumatic wound exists for over 4 hours without being treated.

• Try to be always accompanied by some member of the family or love one.
• If you have any trouble or concern that is not being attended by the nurse, try to contact the nurse supervisor or the doctor.
• Be aware of the members of the team/ staff that will be attending you.
• Ask about shift changes and be aware of nurses’ hand off (in general, nurses will stop by every one or two hours).
• If you wish, your relative or loved one may be present during hand offs in order to listen to nurses’ evaluation.

In every shift, your relatives could help to write down medications, vital signs or any relevant information.

• Ask about monitors or machines if you are plugged in, especially about their function.
• If you do not need continuous monitoring ask how your vitals should be checked. In different intensity of care (ICU, General Ward) you need a different frequency of control.

After surgery or sedation, patient’s vital signs should be checked every 15 minutes until they are awake. If they are not stable, (i.e. blood pressure is low) they need to be checked more often than that.

• Ask staff if there is something that you should help with or watch for.
• Check your intravenous lines: liquid flow, obstructions and fixation.

Staff will ask your identity many times. This is a procedure to reassure your identity for every step of your care plan.

DO NOT take any medication that you had at home while you are in the hospital.

Do you have any other question or concerns about your care after the procedure?
This is the time to really be an advocate for your loved one. No one knows your loved one better than you, and you will be the best person to identify concerns that should be addressed by the medical team.
Never be afraid to ask a question.

Ensure your providers are using a fresh pair of gloves when they interact with you or your equipment. For example, they should change gloves right before inserting an IV so that they aren’t carrying any pathogens over from another patient or an unclean surface.

If on a pain pump DO NOT push the pain pump button or give the patient any medications from home – it may cause breathing problems. A change in your loved one’s behavior may be an early sign indicating over sedation, and is often missed because we think they are comfortably asleep.

To keep you safe, the nurse may have to wake you up in order to:

• Evaluate level of pain, alertness, vital signs, and/or check the rate and quality of respirations every 2-4 hours. More frequent assessments may be necessary (even at night) if you have one or more of these risk factors:
  • obesity
  • sleep apnea
  • chronic lung disease
  • use of a BiPAP/CPAP machine
  • are over the age of 60 years
• Monitor you more frequently during the first 24 hours of pain pump use, even at night. This might include monitoring with a pulse oximeter machine.
• Obtain an accurate assessment of your level of sedation, even at night.

• Watch if the patient responds normally or if he/she is too sleepy to answer or too sleepy in general. In this case get the nurse (not the nurse assistant) to check the patients status.
• Be aware about your love one’s fall risk and make sure the floor is clear of electrical cords, long IV tubing, extra furniture, water, paper or any other item that could cause a fall.

Warning: Falls tend to happen when the patient is getting up to go to the bathroom.

• Watch if staff wash or sanitize their hands. Remind them to wash their hands before they come to evaluate you or your loved one.
• Be aware of your loved one’s thrombosis or clots risk. If he/she has risk to develop clots, ask the doctor which preventive actions or treatments have been started.
• Be aware of your loved one’s pressure ulcer or bedsores risk. If he/she has risk to develop bedsores, ask the staff if you may collaborate to prevent them.

Encourage the patient to welcome repositioning. Sustained pressure on some areas of skin is what reduces circulation and causes bedsores.

• Call the nurse if:
  • The skin around intravenous incision is red or swelling.
  • If your loved one is trying to get up alone and he/she has fall risk.

The patient or her/his relative may avoid medication adverse events by asking some simple questions: what is this? “It does not look like to any other medication I’ve been taking”. Or “I’ve already taken this medication one hour ago” “Did the doctor order to take it again?”

• Verify that the nurse checked the identification bracelet before giving her/him any medication, extracting blood or taking him/her to any diagnosis exam or treatment.
• Verify that the patient is receiving the right medication.

Ask the pharmacy how these medicine combinations react with each other and double check to make sure they are safe for the patient.

This table can be completed by the patient, a family member or a close friend. These pages provide extra space to help you track the progress of your or your loved one’s in-hospital stay. Keep notes each time a doctor, nurse, therapist or any member of the hospital staff visits the room.

Doctors: The medical hierarchy

1. Medical director
2. Head of department
3. Attending physician
4. Physician on call
5. Resident in training
6. Intern (medical student)

Nurses: The medical hierarchy

1. Chief nurse
2. Staff or bedside nurse
3. Nurse in training
4. Assistive personnel

Medical director: Highest medical authority in the health care center. Administrative tasks.

Chief of medical services: Senior physician who fulfills both medical and administrative tasks.

Attending physician: Physician of a certain specialty responsible for the patients care, generally only during the day.

Chief on call: Physician chief responsible for the shift during the day or the night.

Physician on call: Physician on call and responsible for the patient’s situation during the day or the night.

Resident in training: A physician who is training in a specialized field.

Intern: Medical student who helps coordinate the care of various patients.

Chief nurse: Nurse responsible for all the nurses in the health care center.

Nurse manager: The most senior nursing staff member for a particular hospital unit.

Staff nurse or bedside nurse: Nurse who is responsible for the patients on a specific ward or service in the health care center.

Nurse in training: Nurse assistant who helps with the clinical work and making the patient comfortable, and works under supervision of the nurses.

Assistive personnel: Person who is in charge of helping with non-medical patient activities.

Emergency unit: A unit where a team of critical care specialists is present who’s function is to take care of patients in a medical emergency.

Chaplain: The individual who has been ordained/endorsed by a religious body and recognized by the hospital to render pastoral/spiritual care.

Advocacy/Support: To support for the patient is a fundamental part of nursing. However, evidence and empirical data is rare. Nurses, in general, consider this attitude only necessary for vulnerable patients. Advocacy and support should be reinforced as part of healthcare training, especially before starting professional activities. A more explicit and clear comprehension is needed in order to define a core set of activities for training healthcare workers.

Compression device: Intermittent pneumatic compression is therapeutic technique designed to improve legs’ venous circulation especially in patients with edema or increased thrombosis risk. Among these devices there are air pumps, inflatable sleeves, gloves and boots.

Incision: a surgical cut made in skin or flesh.

Urinary catheter: a urinary catheter is a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag.

Blood clots: a blood clot is a clump of blood that has changed from a liquid to a gel-like or semisolid state.

Pressure ulcers or bedsores: are injuries to skin and underlying tissue resulting from prolonged pressure on the skin.

Identification bracelet: is a plastic or silicone bracelet worn usually on the patient’s wrist. This bracelet contains at least two elements that identify (name, passport, social security number) in order to make the patient different and unique.

• Make sure you have an updated medication list, especially if changes were made in your medication during hospitalization.
• Ask for a printed copy to take home with you.

Do not leave without this! Go over the printout with your doctor and fill it in on the medication log.

• Ask when you need to come back to see the doctor again, for follow up, and where you need to go.
• Ask about alarming symptoms that – should you have them – would make you need to come back to the hospital immediately.
• Make sure you know when you can resume your daily activities (driving, exercising, weight lifting).
• Ask about your diet, what to eat and when you can return to your normal eating habits.
• If you go home with drainage tubes, pumps, or intravenous lines, don’t forget to ask your doctor how to take care of them.

If outpatient blood tests, physical therapy, other therapy, home health supplies or anything else is needed, you need to write this down and understand it thoroughly.

To learn more about the Louise H. Batz Patient Safety Foundation, please visit www.louisebatz.eu or contact us at contact@louisebatz.eu