How many talks on patient quality and safety have I seen where numbers are quoted (18% of GDP, 3rd leading cause of death, 26th in mortality) but stories are left out? Numbers have their place, to help policymakers and advocates for health system redesign (like me) to make a rational argument for change. I’ve been compelled by these numbers for years now, and in fact, I’ve decided to make a whole career out of making those numbers move toward equity. But it’s been a long time since I reflected on the stories that originally brought my attention to the world of patient safety and quality. Reflecting on that this week, I think I’ve missed those stories.
A story has a particular power to compel, because it reaches out and reminds you that you’re human. I think we humans derive much of our meaning from life by seeing ourselves as part… Continue reading
Our session today featured two very powerful videos, one about Lewis Blackman and his death due to a missed diagnosis, and the other about Mrs. Morris and her catastrophic injury from a routine bedside procedure. These stories made me think of how victims of medical error, including the well-intentioned healthcare professionals involved, can often be made to suffer repeatedly after the incident by how the system responds to the error. In the case of Lewis Blackman, for his mother to have nobody reach out to her after returning home from the hospital and to not be included in the investigation of what happened to him must have added another layer of pain even beyond the devastation of losing her son. In the case of Mrs. Morris, for a young doctor to be joking and laughing with a patient one moment and then have her go into… Continue reading
What if we lived in a blame free world where everyone could openly admit to their mistakes? How would the world of health care be different if we took the time to learn from one anothers mistakes before we are doomed to inevidably repeat them?
Walking down a narrow dirt path along the water, I couldn’t help but feel dwarfed by the snow capped giants above me. Among these natural pillars of the earth, our time on this planet can feel smaller then a speck of dust. Thinking about the stories Lewis Blackman and Michael Skolnik, I began to think that in an average lifespan of 42,048,000 minutes (approximately 80 years), if we spent just a fraction of those minutes pausing to have open and honest crucial conversations with our patients, we can singlehandedly save dozens of lives over our careers before ever prescribing a medication or… Continue reading
As we discussed the various topics related to patient safety today, I kept thinking about all my personal experiences and experiences from other colleagues from positive to negative outcomes. What really struck me the most today was Lewis’ story and unfortunately mishaps such as this happen much too frequently. I am constantly taught in my curriculum to always integrate the patient and family members in the plan of care, because patient and family members know themselves best. It was unfortunate in Lewis’ situation that they were not well informed of everything that had happened to Lewis’ care every step of the way, even until Helen was called to the conference room in the end. Had Lewis and Helen been active, well informed members in Lewis’ care, the outcome may have been different.
As a healthcare provider and family member of someone who was recently hospitalized at a large institution,… Continue reading
To err is human, and to fail to recognize our humanity is disastrous. It think this recognition is at the core of what we’re talking about this week. One of the reasons that I’ve seen people being resistant to QI is because they are afraid that QI and patient safety interventions are making clinicians more “robotic” by introducing standardization and guidelines. Really though, I cannot think of a field that is trying harder than Patient Safety to get clinicians to recognize and accept themselves as human beings capable of error, empathy, creativity, mistakes, and brilliance.
We are all capable
Of humility. We began our second day in Telluride discussing disclosure of medical errors to patients and families. Recognizing our humanity in this situation is being able to admit failure, learn from it, and be humble enough to accept its consequences. That humility will allow us to tell patients and their… Continue reading
My take-home points and remaining questions from today:
1. Transparency is critical when dealing with medical errors. We are doomed to repeat mistakes if we don’t learn from the past. Barriers exist, but when the focus is re-centered on patients, money and professional integrity fall into the right place.
What the patients and families want to hear after medical errors
2. Strategic negotiation:
Just having completed my first year of medical school my clinical experiences are limited, but my exposure to the world of healthcare is not. Having spent the 4 years of my undergraduate career working with the geriatric population I had great exposure. The sales team at the assisted living facility I worked at frequented the high spots on their tours with nervous families – the courtyard, the dining and activities rooms, the bar and fancy lobby – and just as often spouted out words of assurance to families about the services their family member would “receive”. Perhaps this informal and false reassurance was not legally wrong, but over time I came to know that regardless of legality the promises the salesmen/women recited held little truth. The deals were not transparent, and at a time when families desperately needed that kind of honesty.
These sales pitches flashed through my mind the… Continue reading
A flurry of faces, information, challenges and thoughts have accompanied the start of Telluride East 2014. Several issues were discussed, all equally valid and important, but one occurred early and stands above the rest. It set the tone for the rest of the day as its message remains the proverbial yoke weighing on our shoulders – the impact of ignoring the human element in the face of error. We can’t just press the reset button once an error is made, but we can reset our perspectives on the best way to mitigate, manage and cope with the error, or even the potential for error.
So why reset the perspective? Well, it’s due to an unanticipated emotional response that led me to wonder (in text-speak) WTF? Lewis Blackman’s story, although tragic and emotionally charged, led to a slew of… Continue reading
I am now back in Seattle, home from the Telluride Patient Safety Roundtable & Summer Camp. I am very thankful I had the opportunity to participate. It was emotionally exhausting (I cried the first three of the four days), but I have a sense of hope. I met leaders in patient safety—some of whom I had seen in online videos, others I had not heard of. But the message from all of them was clear: There is no compromise in patient safety. No compromise in disclosure. No compromise in informed consent. Safety and transparency must underlie all of healthcare.And that is a very different perspective than my family has encountered in Kansas, at both the local hospital we are dealing with and at the state level. So today I feel hope knowing that my family is not alone, but I also feel overwhelmed knowing that those… Continue reading
Shared Decision Making – perhaps better known as Informed Decision Making
— It would be interesting to have stock videos to educate patients about procedures, but this has to be used in conjunction with explained. (apparently this occurs with a single company out there)
— It would be cool to have specific consent forms for specific conditions that look like this (see attached pic):
— We have to be careful with numbers (risk) and make sure it’s meaningful and the data is being applied correctly and that the numbers cited are actually applicable to the case at hand.
— We can’t rely overly on numbers as there are certain things we can’t really quantify: for example, I can tell you that the rate of infection for LP is 5%, but I can’t quantify the risk of not doing the procedure – it’s hard for me to say you have… Continue reading