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Measure added after man wandered from hospital, died

By Paul Sisson

The legacy of Thomas Vera, the 57-year-old man who wandered from his hospital bed on May 27 and fell to his death in a nearby canyon, can be seen today on the wrists of some current patients at UC San Diego Health System hospitals.

About 17 patients per day at the university’s two hospitals in Hillcrest and La Jolla now wear special orange wristbands designed to provide hospital staff, from doctors to orderlies, a visual clue that they should not be roaming the halls without a care giver or family member at their side.

The program started June 17 and comes as the state continues to investigate whether Vera’s death was what many in the health care industry call a “never event,” one of 28 preventable medical errors that should not happen.

The orange bands represent a new line of defense that UC San Diego Health System employs to keep patients from wandering. It also uses regular nurse visits, bed alarms, video cameras and sitters.

Those tools apparently failed to prevent Vera from leaving the hospital. His body was discovered in dense canyon brush on May 31, five days after his departure. He had been admitted to the hospital, family members said, after suffering a head injury after falling down a flight of stairs at his Chula Vista residence.

Gerard Phillips, a nursing director for UC San Diego Health System, said hospital workers have been told what to do if they see a patient with one of the bands who is not in their assigned ward.

“They are to approach the patient and see if they can assist the patient with going back to their unit,” Phillips said.

No additional patients have wandered from UC San Diego hospitals since Vera’s departure, hospital officials said. Spokeswoman Jacqueline Carr said in an email that hospital workers have occasionally escorted wristband-wearing patients back to their beds.

While administrators seem to believe the wristband program is working, some at the hospital remain skeptical, saying they believe the true issue is a lack of staffing.

Teri Traylor, a certified nursing assistant at the Hillcrest facility, said she believes the wristband program is really about avoiding hiring more sitters to monitor patients.

Traylor is a member of the American Federation of State, County and Municipal Employees Local 3299, which represents 2,061 of the system’s technical workers from licensed vocational nurses to respiratory technicians.

The union, which represents 13,000 workers at university hospitals across the state, staged a one-day strike at facilities including UC San Diego Hillcrest on May 21. For months the union, which is locked in contract negotiations with the university, has hammered the organization for cutting back on front-line caregivers.

Union spokesman Todd Stenhouse said in a recent email that the number of certified nurse assistants working at the Hillcrest hospital has been cut 5 percent over the last year.

“At UCSD you have patient load increasing, and you have the number of front-line care staff not keeping up,” Stenhouse said.

But the university said that nurse assistants do far more than supervise patients. Carr said staffing per patient at Hillcrest has remained stable even as different techniques, like video monitoring, have been used to observe some patients deemed a fall risk.

[Source]: U-T San Diego