I am privileged to work for an institution who has a robust safety culture, built on the basis of transparency and just culture. However, after hearing my colleagues share their stories of retribution, intimidation and blame, it is clear that more work is needed across the medical field. I was impressed by just how pervasive this problem is. I am also amazed at how easily event reviews can devolve into pointing fingers, blaming and shaming – this was evident in both the cases presented and the stories that were shared. We continue to see this occasionally in our own resident driven M&M cases, and it is something we need to address further – we need to adjust our culture to achieve a just culture.
I feel strongly that caring for the caregiver is an important cornerstone of fostering a just culture and a culture of safety. Knowing that someone will… Continue reading
The once lofty goal of achieving zero preventable adverse outcomes has now, thankfully, been proven to be possible at multiple clinical sites and across multiple clinical measures. However, much work has yet to be done to ensure ongoing success. Transparency in outcomes, communications and reporting have all helped facilitate this achievement, but further initiatives are needed to change the model of physician autonomy to a ‘collaborative/collegial interactive team.’ There should be an expectation of mutual feedback and transparency between peers, colleagues and inter-disciplinary teams. We are currently working on fostering this culture in my program and it is something I aim to dedicate time to next year.
The lessons learned from the aviation industry and eloquently presented by John Nance, serve as a reminder that success through transparency, principled integrity and culture change is possible, though these changes take time. In medicine, we must remember to be patient while we… Continue reading
Day #1 exceeded all expectations. I really did not know what to expect going into my first day of the Telluride Experience, but the presenters, topics and exercises managed to be better than I had anticipated and served to further galvanize my future career plans in the patient safety realm.
Our day began with the Lewis Blackman story. Though I had seen the film before in my medical training, today’s viewing was different. Having Helen Haskell present to provide context and answer questions finally made it real to me – it made it feel more personal. Sometimes, in our daily grind we fail to notice or minimize the importance and real-life consequences of our actions. Lewis was a real person, had real potential and had suffered real harm at the hands of the medical community. Medical mindfulness may have allowed Lewis to achieve his true potential in life.
Mindfulness was… Continue reading