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.
Time and time again, medical errors and bad outcomes get traced back to failure of communication. Today, the story of Michael Skolnik illustrated how lack of honest and transparent communication between a surgeon and the young man who, along with his family, entrusted his life to him resulted in a devastating brain injury that left him forever disabled and his family forever scarred. It truly is tragic to think that an honest open conversation could have avoided all of this.
In a different way, our teeter-totter activity illustrated how great things can be accomplished when teams embrace the concept of “barrierless communication” emphasized in the book “Why Hospitals Should Fly”. By having every team member, each with a unique perspective, share their thoughts freely and openly with one another, we were finally able to succeed as a whole in a task that appeared so daunting not much earlier. After… Continue reading
Our session today featured two very powerful videos, one about Lewis Blackman and his death due to a missed diagnosis, and the other about Mrs. Morris and her catastrophic injury from a routine bedside procedure. These stories made me think of how victims of medical error, including the well-intentioned healthcare professionals involved, can often be made to suffer repeatedly after the incident by how the system responds to the error. In the case of Lewis Blackman, for his mother to have nobody reach out to her after returning home from the hospital and to not be included in the investigation of what happened to him must have added another layer of pain even beyond the devastation of losing her son. In the case of Mrs. Morris, for a young doctor to be joking and laughing with a patient one moment and then have her go into… Continue reading