I just wanted to comment briefly on a great learning moment I had yesterday. During the domino game, I was assigned the administrator role for the third and final round in which the doctor and nurse are allowed to communicate directly. By a slight miscommunication, our group misplaced one domino which later lead to misplacing yet another. While my group did a great job accurately placing the remaining dominos, I noticed that even after making the first mistake, using more effective communication with rechecks and feedback with the second misplaced domino would have actually helped us recognize the first mistake. I found it interesting how a standard way of communicating that’s understandable and learned how to execute properly by both parties (much like in aviation), makes the world of difference not only in a simple game of dominos but in patient safety.
I think it’s really hard as young physicians early in our training not to place blame on ourselves when we’re involved with a medical error or a near miss. It was helpful for me on both a professional and personal level to learn that our mistakes are more so part of system flaw rather than a personal one, and what is truly more constructive when approaching a medical error is asking what rather than who. I was partly involved with a bad outcome early in my residency and I experienced a tremendous amount of guilt. I feel that I carried the weight of that event on my shoulders for several months (which felt more like years) without anyone really noticing there was anything wrong. It’s given me a great amount of reassurance to hear stories of others an how they were more so part of a system failure, that expects… Continue reading
What struck a cord most with me from our first day was most definitely the comment made by Lewis’ mother that stated he “died because he was in the hospital.” There’s something truly gut wrenching about hearing a statement that strong but sadly, entirely true. I think at times people are slipping through the cracks right under our noses with absolutely no malicious intent. There was no one person causally responsible for Lewis’ death. His death was a failure of our system and an example of what can come of poor continuity of care. Moving forward in my own practice, I hope to be more aware that these events can happen if we aren’t constantly asking and preparing ourselves for the worst.