I must admit – I came into the trip feeling just a little bit defensive. As I read the beginnings of “Wall of Silence”, I felt like many of the (devastating, horrible) patient stories focused on what a specific doctor did/did not do. The stories involving trainees stated that the patients didn’t see “a real, fully trained doctor.” I felt blamed. While some errors were egregious, others seemed totally plausible in daily care, and I struggled to identify how I could make sure I do better every time.
As we discussed and examined the details of Lewis Blackman’s story, I noticed our focus begin to shift. Yes, his doctors made mistakes. His interns did not raise alarm bells or order tests that should absolutely have been performed. But rather than just dwelling on personal responsibility, we also discussed other ways in which the medical system as a whole failed Lewis,… Continue reading
I’m a resident physician in Ob/Gyn, and I’m very excited to meet you all in Colorado!
My patient safety interest started soon after my residency experience began in a jarring way. Within my first month as an intern, a missed diagnosis on our floor lead to a devastating maternal outcome. We spent days and months trying to peel back the layers of what happened and analyze every page, order, and decision that happened or didn’t happen during her hospital course. It was easy for each of us to blame each other – or even more so, ourselves – for what happened. But we tried to focus most on ways in which the system failed her, and how we could build better communication and protocols to prevent this from ever happening again. In the end, she had a devastating disease – perhaps we could not have saved her no matter what… Continue reading