I love this quote from Jack Gentry, the man who’s life was completely changed after he was paralyzed during a cervical spine surgery. It shows that ultimately Jack felt empowered by an organization totally dedicated to correcting its mistakes and supporting victims of medical errors. That quote encapsulates everything that is good and right about CANDOR and the Seven Pillars approach. Instead of spending years in courts in an adversarial relationship with a hospital system that inadvertently caused him harm, he became one of their greatest collaborators and continues to work to make MedStar safer.

Everyone had such great, achievable plans to increase patient safety and quality improvement awareness at their own institutions – please keep us all updated with your progress! I hope you all find your first follower or become a first follower of a colleague whose vision aligns with yours. It takes a… Continue reading →

Rosemary’s presentation this afternoon was so incredibly moving. After breaking up to tour the area individually I stood along the bluff overlooking the cemetery feeling ashamed to be part of an industry that causes so much harm. I was also feeling shame for not honoring my mother during our moments of reflection.

Fifteen years ago my mother nearly died after a complication from a cardiac procedure caused a massive internal hemorrhage. My parents never blamed anyone. In fact, my mother continued to see one of the doctors involved in her case long after the near-fatal technical error, despite symptoms of severe blood loss being missed at her post-op appointment just hours before she crashed. What my mother chose to do was become a patient advocate at the very hospital where she was a victim of medical error. She’s an inspiration to me and a big reason I’m drawn… Continue reading →

I feel so privileged to be able to attend this conference for a second time. Things resonate so differently one year after submerging myself into the field of patient safety. What I’ve learned so far…is that there’s always more to learn. Watching Lewis Blackman’s mother tell their family’s story the second time around was so powerful. I vividly remember watching this film the first time and feeling so frustrated. I had many of the same thoughts and emotions that were expressed today (“Why wasn’t the resident interviewed? Surely they have a good explanation for what happened…they probably tried to tell someone and didn’t feel heard, or they’d never been put in this situation before and didn’t realize how dire the consequences could be. This story can’t be told without their voice!”) Today, all of my thoughts were solution-oriented and not specific to my fellow residents. Although… Continue reading →

As I stood on the banks of the freezing cold San Miguel River listening to the leathered guide rattle off 73 different ways disaster could strike on our imminent rafting trip I thought, “WHAT in the WORLD have I gotten myself into? Intelligent people do not willingly throw themselves into an angry, foaming body of water with five strangers on a piece of plastic!” I was pacing, sweating, hyperventilating, silently imploding – when a colleague turned, looked me straight in the eyes and simply said, “Now imagine how our patients feel when we consent them for surgery.” I was blown away at the profundity of this comparison. Here I was about to embark on a journey considered to be relatively safe and yet all I could hear were the rare, but possible, adverse events. Everyone in my immediate vicinity, sensing my panic, whispered “they have to go over this stuff,… Continue reading →