Medical Error

His Name was Bill

Today I had the humbling opportunity to hear stories from individuals whose lives were turned upside down as a result of medical error. They spoke with grace, conviction, and courage. They also spoke with frustration and sadness. Their stories are important and what they shared today is heart-breaking. Their stories need to be heard, not only in the medical community but also throughout the general public.

As I reflect on the many stories I have read and heard surrounding medical error and the horrifying impact these errors have had on patients and their families, I am ashamed and heart broken. We, physicians, nurse practitioners, physician assistants, nurses, assistants, enter the health care field to heal, to bring hope, and to be there to provide comfort and expertise in, perhaps, one of the darkest hours of an individual’s life. However, as medical error seeps into our interactions and creates a culture… Continue reading

Day One Reflection

::SIGH:: As a graduate student who does online blogging daily it is rare that I don’t know how to start a discussion, today is the exception. There are so may factors that I want to touch on;

  1. I appreciate hearing from the different professions on the many viewing and stories we heard today. I am not currently at a major teaching hospital and wasn’t aware of the mounting pressure and expectations that exist among medical students/residents.
  2. One of the quotes I took to heart today was “Develop mindful engagement to have situational awareness to help create a sustainable safety culture through a shared medical model.”
  3. Another quote that I feel will become almost my mantra is that “change comes through disruptive innovation”

After hearing Lewis’ story, the shock of Carol’s daughter, Alyssa, and then the movie ‘To Err is Human’ I am left very frustrated and almost helpless. It’s overwhelming… Continue reading

Failure to Rescue: The Story of Lewis Blackman

An Interdisciplinary Viewing

As a surgery resident, I had a different reaction to the the film “The Faces of Medical Errors…From Tears to Transparency: The Story of Lewis Blackman” than some of my fellow scholars. This is absolutely the value of viewing and discussing it in such a forum, as every perspective highlights specific opportunities for improvement.

As our interdisciplinary discussion highlighted, Lewis’ death was the unfortunate result of a broken system.  Lewis was a 15 year old undergoing a new repair for pectus excavatum.  The first systems issue brought up by his mother, who remains a strong patient advocate, was the informed consent process surrounding a new “low risk” surgery.  The pectus repair was technically successful, but issues started intraoperatively.  He was making minimal urine during the case and after.  He received multiple doses of toradol, up to post-operative day #5, with minimal oral… Continue reading

Pre-Telluride Thoughts

As I look forward to the Telluride Experience next week, I reflect back to when I first really thought about patient safety in the context of my own career.  Thinking back to my White Coat Ceremony this past fall, I got chills as I pledged the Hippocratic Oath for the first time and made a commitment to “first, do no harm.” At that time, I was overcome by the excitement and seriousness of the journey that I was about to undertake. Since entering medical school, I have started to think more about how our humanness plays into our futures as healthcare providers. I have considered how our patients will need us to play a multitude of roles as their doctor—problem solver, caregiver, teacher, healer—but also, human—with a human’s compassion and empathy. I have also, however, experienced and reflected upon the fallible nature of our being in the context of… Continue reading

Day 2 Reflections

What to say….what a powerful day, full of emotions. Today and yesterday were difficult for me. They brought back memories that I didn’t want to revisit, painful memories. Losing a child is so painful. Losing a child because of preventable mistakes is unacceptable.

The faculty are so amazing, so strong, I don’t know how they do it. I have not been able to move past losing Sebastian. His death broke me and my wife. We were crushed, walking through life without really living, just existing. For me, it was like being underwater. I felt like I was always drowning, over and over again. Then I just stopped feeling, stopped caring about anything. I didn’t want to feel anymore, I didn’t want the tears anymore. It took me a long time to get back to living life again.

I remember family and friends trying to make us feel better. They would… Continue reading

Day 1 Reflection- Advancing Communication

Why are health professionals not listening to the concern of the patient?  A major theme from yesterday was advancing communication to prevent harm and address harm. We often take for granted that we have the ability to use effective communication. We started the day watching a video about leadership, which I thought was pretty powerful. I had not thought much about the following as I have thought about leadership styles. To lead, you have to be on the level of the follower or there will not be a movement. We continued on to watch the Lewis Blackman story. Diagnostic errors ignited my passion for patient safety when my mother in law passed away from a missed pulmonary embolism. As I continue in my medical journey, I want to always remember the phrase “What is the worse it can be?” to avoid premature closure and conformational bias. From the video,… Continue reading

Telluride Experience – Day 1

Lack of communication/false assumption leads to errors:
In learning about the Lewis Blackman case, an event that directed a conversation toward communication’s ability to either prevent or impose a drastic medical error in a clinical setting, one of the events that stood out the most was the idea that nobody asked, “What is the worst thing this could be?” I work for a home health care team that aims to improve the quality of care and the patient experience by communicating patient alerts. Effective communication in my organization is essential to the effectiveness of our team. Thus, the lack of coordination and communication that was exhibited in the Blackman case struck me because, as these nurses assumed that Lewis was fine, it was these false assumptions and the lack of communicating alerts that predisposed the patient to a detrimental error resulting in the patient’s death. When you assume that the… Continue reading

Day 1: Transparency

Today was very eye opening and inspiring. I learned so much about patient safety issues and ideas from the stories told, data presented, and patient experiences shared. There are a lot of lessons and information that I will take back with me after this experience, but for this blog post I will just focus on one that stood out to me.

The way MedStar handled the medical error case of Jack Gentry was incredible. I was so impressed to hear the steps taken by the surgeon and hospital to acknowledge the error from the beginning and ensure they did the right thing for the patient and their family. It was during the post discussion piece that someone mentioned the importance of asking how an organization dealt with their last serious medical error. I had never thought of asking this question before during an interview or as an employee of a… Continue reading

Reflections Day 1: Intern vs Senior Resident

It is already a very emotional first day at Telluride as I re-watched Lewis Blackman’s story as a senior resident. Two years ago, prior to any patient encounters, I first watched it as an intern, incredulous at the turn of events. At that time it baffled me how health care professionals could diminish patient and parental concerns so callously, and how so many errors could pile up to lead to a tragic outcome. As an intern I vowed to never allow such reckless practice to occur under my watch. As a senior I reflect on how many vital sign abnormalities I let go, errors I let happen, and lives I let slip through my fingers.
As an ER resident, the acuity of illness is higher than other specialties and inherently the potential for medical errors. Two years ago, my naive intern-self entered residency with the goal of committing no preventable… Continue reading

Telluride Day One

As I reflect back on today, what struck me the most was the video we watched covering the tragic case of Lewis Blackman. This will likely always stay with me because I met Helen, Lewis’s mother. As she shared his life and legacy with our group, I could feel the raw emotion and pain that she had endured. No one should have to experience what she did. The tragedy is that I could see this happening again. Too often healthcare providers dismiss our patients – I was shocked and upset to learn that a nurse had rolled her eyes at Helen when she explained her concerns. Are patients ever wrong? NO! This is so obvious to me, but a lot of healthcare providers clearly don’t agree. Even if patients may not be correct in the medical sense, this is due to a lack of clear, concise patient education on the… Continue reading

1 2 3 7
Telluride Experience 2020 Dates

BRECKENRIDGE, CO:
CMF Session One*: 6/8 – 6/11
Bennathan Session Two: 6/15 – 6/18
Session Three: 6/22 – 6/25

WASHINGTON, DC/MD:
Session Four: 7/22 – 7/25

*Session exclusive to the COPIC Medical Foundation Residents.