I sincerely appreciate all the conversations we had during John Nance’s presentation. I am so proud of every comment that was made and am proud to be a part of this group. However large or small, I feel that each and every one of us will make a difference towards a common goal.
Perception, assumption, and communication. These are all so powerful in terms of areas in which medical errors may occur. Just focusing on communication alone, we were all unable to recall when a sentinel event occurred in the absence of a communication issue. I strongly believe that at least 12.5% of the communication that goes through between person to person is misunderstood. Just from the domino game we had from day 1, such a simple task was actually not so simple. There were so many ways in which an error was made through misinterpretation. During the last exercise… Continue reading
As we discussed the various topics related to patient safety today, I kept thinking about all my personal experiences and experiences from other colleagues from positive to negative outcomes. What really struck me the most today was Lewis’ story and unfortunately mishaps such as this happen much too frequently. I am constantly taught in my curriculum to always integrate the patient and family members in the plan of care, because patient and family members know themselves best. It was unfortunate in Lewis’ situation that they were not well informed of everything that had happened to Lewis’ care every step of the way, even until Helen was called to the conference room in the end. Had Lewis and Helen been active, well informed members in Lewis’ care, the outcome may have been different.
As a healthcare provider and family member of someone who was recently hospitalized at a large institution,… Continue reading