Every story of patient harm from medical error has broken my heart, but the story of Michael Skolnik hit home.  As a neurosurgical operating room nurse, I have both circulated and scrubbed numerous neurosurgical procedures.  I have met the young, the old, the mom, the dad, the child, and more but ultimately we place a sterile drape over the patient and our attention instantly shifts.  We can become so focused on an intervention that we can lose sight of the big picture.

It had never occurred to me that a witness is not required on an informed consent form, or it is institution or state specific.  When I learned that information this morning, my mind was blown.  I can think of numerous situations where having a witness has been a critical step.  Not only can a witness stop the line if there is… Continue reading →

This first day of education has been a whirlwind of information, but nothing can compare to the personal stories of harm that has led to adverse outcomes.  Most of us as medical professionals have gone through an educational journey that teaches the importance of patient safety and quality, but it becomes so much more real when we listen to honest experiences shared by those who have lived it.  We could all speculate and say we would do things differently in that situation, but the truth is that medical errors are usually committed by good people with good intentions.

After reflecting on the movie that featured Lewis Blackman’s story, I began to wonder if a contributing factor to the critical error could have been a normalization of deviance in his vital signs.  If Lewis’ heart rate had shot up unexpectedly, or there was a sudden change in blood… Continue reading →