A story resonated deeply with me today was that of Melissa Malizzo, a young mother of two who died while under anesthesia for a liver shunt at the University of Illinois. The event was unquestionably a terrible tragedy, and errors in monitoring and staffing while under anesthesia undoubtedly contributed to her death. However, unlike many hospitals, University of Illinois did not confound the family with obtuse language and communicate only through a bevy of lawyers. Instead, Dr. Tim McDonald, one of our faculty members who was the hospital’s chief safety and risk officer for health affairs at the time, was honest and forthright with the family. The U of I had adopted the CANDOR model of communicating, which is used when unexpected events cause patients harm. The model focuses on communicating in a way that is timely, accurate, transparent and just. The hospital took ownership of the error and made… Continue reading →

Can the goal of zero errors ever be achieved in the medical field? High risk but complex industries such as aviation and nuclear power set a precedent of admirable safety records, that approach that zero mark.

But is this an attainable goal in medicine? To me, certain aspects of this goal feel manageable, while other feel as though they could be insurmountable. With technology as an adjunct, medication errors are reduced via the use of bar code and electronic versus hand written orders. EMRs can also be designed to prompt reminders if a dose is well beyond the typical limits or the drug interacts with another of the patient’s medications. Similarly, the path to reducing complications from typical procedures also seems clear. Standardized bundles of supplies, clear protocols for the procedure, increased adherence to maintenance of a sterile field all contribute to decreased risk for the patient.

Eliminating medical error… Continue reading →

“You can’t solve everything at once. You need to break down big problems into little problems and then solve them one at a time. Do one thing at a time and do it well.”

These were the final thoughts from the first day at the Marseille experience. Medical students, nurses, and residents from around the country had come to beautiful and sunny Napa California to learn about crafting a safer and more effective medical system.

Our first day was busy and full of learning. Through narrative, we connected with the deeply tragic and painful consequences of unsafe care. We reflected on the necessity of incorporating the observations and concerns of patients and caregivers when providing care. Additionally, we explored the deep-seated cultural differences that can serve as barriers to effective doctor-nurse communication and prevent providers from asking for the help they need.

One of the most inspiring moments on the… Continue reading →