Including Patients in Safety Culture
This post will be relatively short. I spent time writing a rather lengthy post about the healthcare story of someone close to me with her blessing. However, when I read what I had written back to her, after telling me to make a couple changes, she decided that she did not want me to post the story anymore. I respected her wish, but asked her why she changed her mind. After all, I had not included names. She said that she felt bad that some of the healthcare providers in her story looked bad and could maybe somehow figure out the story was about them. I think there was something to be learned about the premature closure, lack of informed consent and shared-decision making, and lack of respect for the patient’s perspective on her illness that led to harsh complications, but I realize that we have already had this opportunity… Continue reading
A Mother’s Guilt
While the presentations today were enlightening and provided me with a good framework and better tools to think about and discuss patient safety, Dave was absolutely correct in saying that it is the stories that stick out to you most. I was deeply disturbed as most would and should be by Lewis Blackman’s story. The missed alarming symptoms, the lack of respect for the family, the miscommunication, the strained staff came together in a horrific (all too common) perfect storm.
What struck me the most, however, was Helen (Lewis’s mother) speaking of the guilt she felt. It honestly made me angry to think that after this nightmare she went through, the completely preventable death of her son at the hands of healers, this mother felt responsible for her son’s too soon departure from this world. She thought it was her fault. I find this atrocious that not only did the… Continue reading