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 of defensive medicine, deceptiveness, and fear, we can lose sight of the humanity of medicine and the detrimental impact of the harm we have the potential to inflict. Research from Johns Hopkins asserts that medical error is the third leading cause of death, with safety experts calculating more than 250,000 deaths per year as a result of medical error.

I personally have caused harm to a patient through medical error. I have had my Certified Nursing Assistant (CNA) license for nearly ten years, first beginning my time as a CNA in a nursing home and rehabilitation facility and then transitioning to in-home care. One evening I was caring for a gentleman that I knew well. I had cared for him for months and worked the night shift multiple days per week. He was in his nineties and had some mild dementia with sundowning, which meant that his dementia was significant in the evenings and at night. Now, the shift I worked was fairly simple. I provided companionship and helped with dressing and using the bathroom; however, due to his sundowning, I needed to be vigilant at night to be sure he did not transfer out of bed without my assistance. I was allowed to sleep through the night and wake when he rang a bell for help. He often would ring the bell once or twice, though sometimes would forget to ring it at all, and I would hurry into his bedroom and help with whatever was needed; however, this particular weekend was prom weekend. I had went to prom the night before and then came to work the next evening. I was tired and, though at the time, did not realize how tired I was or have the foresight to reflect on how that may impact my care for this gentleman. That evening I helped him with dressing and toileting and tucked him into bed as usual; however, that night I didn’t wake up. I didn’t wake up if the bell had been rung, I didn’t wake up when he used the toilet on his own, and I didn’t wake up if he called for help.

But, I did wake up to the crash.

I woke up to this gentleman, who I was supposed to be caring for, lying on the ground with his blood soaking the carpet after hitting his head. He had oozing skin tears across his legs and was mumbling how “it hurts”. I made a mistake and it caused this dear man harm. At 18 years old I called his daughter in tears and sat in silence with her as we followed the ambulance to the emergency room. The shame and guilt I felt that day is unforgettable. Her father returned home and lived for a year or two after that incident. His daughter showed me grace and forgiveness that day and in the days and weeks after that event. She allowed me to continue working at his home and it forever impacted my self-awareness and attentiveness to patient safety while providing care to him and similar patients.

That mistake and the grace I was shown made me vigilant to continually improve myself and the environment in which I worked. I advocated for the safety of my patients in every work environment as a result of that event and will continue to do so as I enter my rotations and residency. His name was Bill. I am sincerely sorry for the mistake that I made and for the harm that I caused to him and his family. I will forever be humbled and thankful for the understanding of his family and the lessons that I learned through that experience and it will continue to motivate me to work to mitigate error, always striving to improve patient safety.

What stories do you have? Which “Bill” has motivated you to strive to be the best you can be? How will you make changes to positively impact patient safety? I would love to hear your thoughts.

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