Listening to Patti and David Skolnik speak about their late son Michael really brought to light how failures in communication can have devastating consequences. Though there were many missteps in the handling of Michael’s case, one area of concern that really stood out was the failure in communication between Michael’s family doctor and his neurosurgeon. Despite the family doctor’s unease that the surgery was being performed unnecessarily, the surgeon quickly diminished those concerns on the basis that the family doctor was “just a GP.” We often discuss how interprofessional collaboration and shared decision making with patients are lacking, but too often we forget that even within our own professions, there are many problems that can create tension and conflict and ultimately result in poor patient care. How can we work with patients and other professions, if we can’t work together within our own groups. I’ve witnessed this all too often… Continue reading
Yesterday, our group took a trip down to Arlington National Cemetery. As we wandered around the memorial site, which served as a solemn backdrop for reflection during our meeting on patient safety, we were reminded of the many people who gave their lives for something greater than themselves. We were reminded that their lives must not be lost in vain. Many of us are fortunate to have the freedoms that we do as a direct result of their service, and these freedoms must not be taken for granted. Despite our noble intentions, not every war fought in our history was worth the price paid. As a result, we are tasked with the responsibility of being continually reflective and learning from our mistakes. And as we’ve seen throughout world history, in fields from war to medicine, doing so is easier said than done.
The perfect storm of missteps can lead to terrible outcomes in our hospitals. The more obvious and egregious errors such as wrong-site surgeries and misprescriptions are easy to identify and address (at least in theory). But how do we go about identifying and subsequently correcting the more subtle actions that contribute to poor outcomes, especially those that many of us would hardly view as “mistakes?” Some examples may looking at one’s watch when a patient is talking, forgetting the name of a patient or colleague, and providing false hope when breaking bad news. All of these work against the values of patient-centered care, interprofessional collaboration, and open communication, but are perhaps both the easiest and most difficult to address. However, I am hopeful that over the course of the next few days, we’ll be better equipped to first identify… Continue reading