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 full cardiac arrest immediately afterwards is haunting enough. To think oneself responsible for causing such a catastrophe is unimaginable. Add to that the repercussions and scorn from one’s peers that the traditional medical culture routinely wrought, and I don’t know how I would ever be able to continue in this profession if that were me in his shoes.
I am glad that these things are changing for the better, and am hopeful that they will continue to with the guidance of forward-thinking patient safety leaders and the courageous patients and loved ones who share their stories. Compassion is at the heart of all we do as healthcare professionals, and responding to medical errors should be no different. The CANDOR process appears to be a rational, compassionate, and therapeutic approach to responding to medical errors, and I am glad of its existence and adoption. There is a way to do this right, and it’s incumbent upon all of us to make it so.