I wanted to take a moment to think about our conversation on the central line removal case. We’ve spent time talking about how systems are perfectly designed to give the results they produce. So when we consider the central line case, a systems based approach would say that not having standardized protocols would be one of the primary factors in the outcome that resulted. Going off of that, I appreciated that our discussion was based on identifying the faults we found in the system rather than asking what the intern did or did not do leading up to the events. Saying “this error occurred in part because the documentation on heparin had not been added to the chart yet” is vastly different than saying “this error occurred because X person had not added it to the chart yet,” and I appreciated that the first phrasing was used by most people… Continue reading →

Reflecting on our first day, I feel incredibly grateful to be here with you all and be given the chance to contribute to the future of a better state of medicine. I loved how nebulous our conversation was, covering the impact of hierarchy on professional relationships, the importance of communication (and how easily communication streams can break down), and even the interaction of different cultural backgrounds. At the same time, my heart was broken by the stories we heard today – medical error is something that I always knew was real, but having a tangible story helped me understand the perspectives and experiences of family members that I am lucky to never have personally gone through. As a medical student, I think at times it is easy to lose sight of the big picture with studying, tests, and trying to stay afloat – but today really helped me remember that… Continue reading →