Among the multitude of wonderful experiences and thoughtful discussions over the past few days, there are two examples of creating a just culture that were incredibly powerful for me.  The first was Dr. Mayer’s candid admission of his own involvement in a medical error. The other was John Nance’s story of a near miss during his career in aviation.  It was powerful to hear these leaders recognize their own fallacies and be courageous enough to share them. I hope that in the future, in my own moments of weakness and fault, I remember their stories and am inspired to be as courageous.  I hope that as a leader I will be cognizant of my own fallibility and demonstrate the value of all members of the team.

As complex and multifaceted as the healthcare non-system is, we can’t come up with all the solutions in a single… Continue reading →

Today was a great opening session of the Marseille Experience in Turf Valley.  I really enjoyed the opportunity to openly and honestly discuss patient safety with people of multiple perspectives.  It was a reminder to me that my understanding of the hospital landscape is one sculpted only by my experiences inside the hospital, which has been cultivated over years.  These are experiences that most people don’t have, thus hospitals remain a strange foreign place to them.

In discussing the tragic death of Lewis Blackman, I often found myself thinking, “I’ve seen that happen in the hospital.”  I’ve seen a group of highly educated and well intentioned individuals disbelieve a blood pressure reading, and reach for a new cuff multiple times.  I’ve seen a surgical patient bed on a medicine floor. And, I’ve seen families and patients who were scared, lost and suffering.  In… Continue reading →