Today’s sessions tied together a lot of information that we’ve seen in the past few days. The focus today was on just culture, which ensures that a system can be both fair and accountable. Both aspects are important: people need to be held accountable if they are truly being negligent or malevolent, but they should not be judged unfairly if the system is set up to fail. I was really fascinated by the Unsafe Acts Algorithm, which is an extensive tool that can be used to show the range of outcomes for a healthcare worker in question. There are cases that are truly culpable (a person should be held accountable), truly blameless (the system was not fair), and a gray area that can vary on a case-by-case basis. This algorithm reminded me of an idea I had earlier this week.

Just as we compared healthcare systems to… Continue reading →

This first day has been incredible! Meeting nurses, residents, and other medical students has been an amazing way to discuss patient safety issues. With so many different perspectives, we are able to piece together a much clearer picture of patient safety issues that can occur on a day-to-day basis. During our discussion of Lewis Blackman’s heartbreaking story, I learned the term “premature closure”. The term refers to a diagnostic error made when a medical professional makes a diagnosis without completely analyzing everything on the differential. I realized that premature closure could cause two very serious issues.

If an attending or other senior member of the team announces a diagnosis, everyone else on the team feels like they can stop going through the differential in their heads. It is so important that we constantly have a voice in the back of our heads asking, “What’s the worst that can happen?” rather… Continue reading →