Today our group watched “The Faces of Medical Errors…From Tears to Transparency: The Story of Lewis Blackman” as the beginning of the 10th Telluride Patient Safety Student Summer Camp. The film brought up so many emotions for me, including sadness, rage, shock, and embarrassment. Even as a new member of the healthcare community, I felt embarrassed to be associated with such an out-of-control beast that could make not one, not two, but such a series of errors as to end the life of a 15 year old boy, a tragedy that could have been prevented at so many stops along the way.
The most eye-opening line of the film came from something said by Lewis’s mother, Helen, while reflecting on the events of that week. She said, “The hospital was the only place that he couldn’t get the medical attention that he needed.” She went on to talk about having the urge to call 911 from the hospital room. How terrible that we could create, maintain, and, at times, blindly live within a system that could make a mother like Helen feel so incredibly helpless as she watched her son deteriorate. Equally appalling was the aftermath of the event, during which time there seemed to be little effort made to reach out to Lewis’s family for information, no less consolation.
As I mentioned during our group discussion, this story would have been less believable or more outrageously shocking to me had I viewed it before spending the last year in the hospital on my clinical rotations, but now I can easily see how this same mistake, or any number of similar errors with a similar result, could happen today, in my hospital, and possibly with me as one of the players. What a staggering realization that I could be involved in such a tragedy. I don’t want to contribute to this problem! Does any young person who enters healthcare training hope or even imagine that he or she could be an accomplice in such a grave error? Of course not, yet it continues to happen to too many unprepared trainees, professionals, patients, and families every day.
This is a huge problem, a mountain that feels nearly impossible to tackle, and yet, here we are, in Telluride, hopefully laying the foundation for a new generation in healthcare, and I feel so privileged to be one of the students fortunate enough to begin learning these lessons early in my career, to hopefully help build a system that prevents me from ever playing any role other than that of care giver.