Humans are fallible and Error is predictable

We are all susceptible to errors and errors can never be eliminated. Focus should therefore not be on elimination of errors (mission impossible) but rather on building a robust system to mitigate against unavoidable human errors. Under normal conditions humans average 5-7 errors/hr. This number increaser to 11-15 errors/hr under stressful conditions

Astounding statistics about medical errors should be a wakeup call. When you have patient safety concerns in your work place, raise them, don’t be quiet. When you see something, say something

At the same time, we have to change from a punitive culture to one of learning and sharing. We cannot discipline errors out of people, we need a ‘just culture’.

 

Train Ride Home

Writing this on my return train ride back home from the Telluride Patient Safety Experience in Turf Valley. Reflecting on the entirety of the conference I think the story that impacted me the most was the Lewis Blackman story. As an emergency physician, missed diagnosis is what we as a profession fear above all in our daily work. The failure of a timely diagnosis like that in Lewis’ case could just as easily happen on one of my shifts so I am making a personal commitment to use the lessons learned to improve my practice and to teach them to my colleagues around me.

After learning about all the patient safety errors that occur on a regular basis, it can seem daunting to try fix the problem. However I am reassured by all the Telluride graduates and others who will be alongside me to confront the issue and be the… Continue reading

Wake Up Calls

I’ll never forget the patient safety lecture I had early in my first year of medical school.  The statistics on patient deaths due to preventable medical errors both shocked and horrified me, and it was this information that drove me to apply for the Telluride Academy for Emerging Leaders in Patient Safety.  During one of our lectures, parts of our applications were shared with the group and that moment when I found out the truth about the rate of medical errors was the part of my application which the lecturer shared.  As he put it, that moment was my wake up call.  And this is true.  However, like our alarm clocks it’s easy to hit snooze on our wake up calls.  It’s easy to push uncomfortable truths to the back of our minds and focus on the good in medicine, not the bad.… Continue reading

Telluride Experience aka Career Orientation

These past few days have been a time of listening and reaffirmation for me. As a newly-minted third-year medical student, I’ve only just begun interacting with patients on a regular basis and contributing to their care. My practice has very few habits, which means any principles I set for myself can be more easily adhered to than if I had attended this conference a few years from now. Listening to the residents speak about their experiences in such a diverse amount of care settings has given me a better idea of what the next step in my career will be, or rather, what it can be.

In medical school, the common refrain is “I’d love to do _____, but I’m just too busy studying.” Evidently, that refrain turns into “I’d love to do ______, but I’m just too tired and too busy working” after graduating medical school. I don’t mean… Continue reading

Take Pride

After our visit to the Arlington National Cemetery and National Mall today, it’s hard not to feel a sense of pride for our country, its history, its people, and all the dedicated servicemen and servicewomen who have lost their lives so that we can all make the most of ours. Similarly, we should all feel a sense of pride in our respective professions, united by the mission of caring for the ill and injured, and having gathered together these past few days with the goal of being better and doing better for the sake of our patients.

I Would Like to Honor My Mother

Rosemary’s presentation this afternoon was so incredibly moving. After breaking up to tour the area individually I stood along the bluff overlooking the cemetery feeling ashamed to be part of an industry that causes so much harm. I was also feeling shame for not honoring my mother during our moments of reflection.

Fifteen years ago my mother nearly died after a complication from a cardiac procedure caused a massive internal hemorrhage. My parents never blamed anyone. In fact, my mother continued to see one of the doctors involved in her case long after the near-fatal technical error, despite symptoms of severe blood loss being missed at her post-op appointment just hours before she crashed. What my mother chose to do was become a patient advocate at the very hospital where she was a victim of medical error. She’s an inspiration to me and a big reason I’m drawn… Continue reading

To Err Is Human, To Forgive Is…Another Story

Something that has been weighing on my mind since our discussion on human error has been the uneasy feeling that I can imagine myself all too easily making the same devasatating mistakes as the healthcare providers in our case studies. Although I immediately jump to forgive and defend Kimberly Hiatt and other healthcare providers who have made such fatal errors, I am not sure that I could ever forgive myself or return to medicine if I was in their shoes. If I have learned anything this weekend, it has been that it could be any of us miscalculating a medication dose, misreading a glucometer or missing a diagnosis that ultimately ends up hurting our patients. Mistakes happen every day and whether or not those mistakes end up killing a patient and whether or not it is me or my colleague making the mistake seems entirely up to fate. What… Continue reading

We Need Help Too! – Caring for the Caregiver

Throughout today’s discussions a quiet theme churned in my head…caregivers need care too. Although it is often said, I do not believe we truly pay attention to those few words or give thought to how we can accomplish it. Too often medical professionals are skipping lunches, expanding their forever growing bladder capabilities, and ignoring the ache in their back and feet…and this is only the tip of the iceberg. When a patient experience undue harm, the caregiver feels it too. It is as if the bullet of medical error that went through the patient made it’s way to the tender heart and mind of the caregiver, creating a second victim within the scenario. Unfortunately, current practice is to give the caregiver a pat on the back and say “better luck next time,” as if this is a game. As healthcare workers we are responsible for standing up and making it… Continue reading

Just a ……

Wow, I cannot believe how many times I have made this comment to people.  I have made this comment to patients, friends, and family. After what I have learned during the Telluride experience I will never make that comment again. I will expand that comment to include I will not allow any member of the health care team to refer to themselves as “just a”. Every member of the health care team has an equally important role in providing safe, high quality health care.  The patient, family, housekeeping, dietary, volunteers, maintenance….the list is immense and each person has a vital role in the health care team.  Words truly do have meaning!

No One Cared

I am truly grateful for all the knowledge I gained in today’s discussions on patient safety.  As I sat and watched the video Lewis Blackman, I became emotional.  Fear, anger, sadness, I think I felt them all.  I can only imagine how Ms. Blackman felt in the hospital room helplessly watching her son suffering.  I remember Ms. Blackman saying in the video the medical staff was only interested in completing tasks.  No one cared about her or her son.  I believe we have lost site of the main reason many of us went into health care, caring for our patients.  I have seen similar situations happen too often in my career.  As health care workers, we have so many tasks to complete and hoops to jump through that we are often married to the computer screen.  We look at numbers and… Continue reading