Our day started with a video about an event in an OR wherein a complex dynamic at play led to an unintended event culminating in hypoxic brain injury and subsequently death.  Since the victim’s spouse was in aviation – another high risk industry who was in a position to provide inputs about the errors made: leadership, situational awareness, support, communication.  Emotional story of a healthy young woman whose had donated her organs for the good of others.   A simple puzzle game drew me towards reflecting on not only the dynamics of team work but also the hierarchy.  While our team had good cooperation there were still voices of frustration from observers who could look at the errors being made but could not voice their opinions.  A highly information packed and an entertaining lecture by John Nance highlighted the similarities between aviation and medicine,… Continue reading →

Our day started with an introduction to the tragic story of a gifted boy Lewis.  Narrated by his mother it was an emotionally intense documentary of death due to a preventable medical error.  Interwoven in the narrative was the idea of reflection and mindful practice as means of improving our practice.  This gave rise to an interesting dialogue wherein we all inquired our individual emotions, trying to understand how this could have been a loved one.  The faculty engaged the audience in a healthy constructive discussion about how to change our practices once a medical error is identified.  While data backs the evidence that patients and their families are more understanding if a physician admits to an error, it needs to be done because it is the right thing to do.  The highlight of the day perhaps was the teeter totter game. … Continue reading →