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
Before coming to this camp, I was trying to explain the purpose of this camp to some of my family and friends, and I struggled to find ways to explain why we shouldn’t just blame health care workers when medical errors occur. Placing blame is such a pervasive method in our society for “solving” problems that I struggled to find ways to frame the issue of medical errors in a new way to help them understand. Over the past two days, we’ve said over and over again that medical errors are not caused by mean people, and I think that is one of the key phrases I will use in the future in trying to explain this experience. Medical errors are not caused by mean people. In fact, the vast majority of the time, the people involved in medical errors were actively trying to avoid… Continue reading
We started our week of patient safety discussions with the story of Lewis Blackman. As we watched the tragedy unfold, I felt sick watching well-meaning medical professionals ignore numerous red flags as well as the concerns of Lewis’s mother during the four days following his surgery. One quote from Lewis’s mother, Helen Haskell, stayed with me long after we finished the film and it is something I will never forget. She said if Lewis had been anywhere else but a hospital, she would have called 911 and Lewis would still be alive today. To me, this speaks to the horrifying extent to which the healthcare system has failed patients and the poisonous Wall of Silence that continues to be perpetuated. How can the place where you are supposed to be the safest be the one place where you are most isolated from the care that you need? For a person… Continue reading
My mind was reeling with ideas and questions after the first day of the conference. Where to start? There’s so much we can do. It was both exciting and paralyzing. Today, I was especially interested to hear Mr. Nance’s discussion of his book. I had this sinking feeling I might hear, again, that we’re not doing enough. We’re not safe enough, smart enough or reliable enough. We need to change everything, and fast. Starting with x,y,z (work less, decrease distractions, don’t come in tired). If aviation could do it, what’s wrong with our field?
I had settled in for the boom, but instead was given encouragement, strength, and validation. Medicine IS difficult; there are complexities unique to our field. I’m (usually) very happy to be a doctor. The acknowledgment of its challenges felt like grace. It was a comfort to find that familiar passion… Continue reading
My time spent at the Telluride Patient Safety Summer Camp was enlightening and life-changing. It was life-changing for me and my future patients. In my application essay I spoke about how “I want to be part of the solution and enhance patient safety by figuring out how to prevent nosocomial infections, lower remittance rates, and develop better communication strategies between health professionals”. I learned this and much more.
The statistics presented to us were powerful. I cannot believe I was never informed about the infamous IOM report in my first year of medical school. The Hippocratic Oath says we must do no harm; it would be wise if we learned how to actively not do this in medical school. However, this patient safety conference has educated me and I plan to spread awareness to my class. Medical errors account for the third leading cause of death in the U.S.; 100,000… Continue reading
Patient engagement is crucial for helping patients to make informed decisions about their own healthcare. Transparency in communication through full disclosure of risks and adverse events will help improve patient outcomes and deliver patient centered care.
The second day at the Maryland/DC session was engaging and focused on some patient safety issues for providers to consider. The first half was on the importance of informed consent and shared decision making. The Michael Skolnik story and Lewis Blackman story shed light on the failures of medical staff to focus on the patients’ needs, values, preferences and goals. The main takeaway from the film discussion was that shared decision making is not an event, but a process. One single medication error may or may not result in patient harm, but almost all medication errors are considered as preventable with proper information sharing. It is also important for the medical staff to to… Continue reading
The films telling the stories of Lewis Blackman and Michael Skolnik served their purpose of putting faces on medical errors very well. More than once I found myself struggling, and failing, to keep my tears from running as the stories were told. It is one thing to know that hundreds of thousands of people die due to preventable medical errors each year; it is a whole other thing to observe one or two of those deaths closely as a human tragedy. One may want to reverse the order of the sentences in Stalin’s famous quotation into “a million deaths is a statistic; a single death is a tragedy”, just so as to remind oneself of how devastating each single one of those “numbers” are.
As tragic as they were, the deaths of Lewis and Michael were [arguably] not totally in vain, thanks to their dedicated families and shrewd professionals… Continue reading
There can be nothing more grave, more profoundly unfortunate than when a medical error results in a patient’s death. I will share, what I have kept to myself for over 30 years. A story, that I feel compelled to disclose; the loss of my closest childhood friend.
My fondest childhood memories of playing hide and seek, coloring Easter eggs, and building forts with pillows and sheets under the dining room table are still vivid and cherished. Christopher was the best friend anyone could have.
I remember, I was 10 years old, answering the phone and hearing his grandmother who I loved dearly, say in a calm but shaken voice, “Christopher is dead. He died yesterday.” I was numb. I couldn’t find any words, I just hung up the phone. In fact, I didn’t utter a single word for several days. Although I don’t recall that part, my parents remind… Continue reading
As I’m sure many other Telluride Patient Safety Conference participants did, I experienced many different, strong emotions upon viewing the “The Faces of Medical Errors…From Tears to Transparency: The Story of Lewis Blackman” documentary. From soul-wrenching sadness for a bright, young man’s life cut short, to profound empathy for his suffering family, culminating in overwhelming anger regarding the broken system that allowed a series of poor-made decisions and mismanaged situations lead to a tragic death.
What infuriates me most is the overreaching power the culture of independence, overinflated confidence, and not needing to ask for help that affected the actions of many of the figures involved in Lewis’s resulting sub-par care. While I feel for the medical personnel who will have to live with the guilt that their actions directly or indirectly resulted in a patient’s untimely demise, I do wish we lived in a world where people did not… Continue reading
The approach to patient and family aftermath reconciliation.