Pre Reflection

As an anesthesiology resident nearing graduation, I’ve seen my fair share of medical mishaps throughout my four years in training. Healthcare as a field is uniquely open to human error, and teaching hospitals are perhaps more prone to medical errors than other places where health services are rendered. In fact, the “July Effect” is a phrase often used to describe a perceived increase in medical errors during the month of July when new residents are just starting to take care of their first patients. Some of these occur in the heat of the moment during trauma situations where no information is known about the patient and the focus is keeping them alive, while others just happen during routine care on the wards. Some of these errors are well known and well accepted risks associated with the various procedures we do, while others can occur even if things are done 100% by the book. However unfortunately, there are some which are due to oversight or complacency with routine, and such errors have the potential to place patients at risk. Despite the variability in terms of root cause, what remains true regardless of the cause is that transparency should be encouraged.

The pre reading assignments show that being open, honest, and having an environment free of judgment and ridicule regarding medical error reporting leads to a better relationship with patients and to the problem being discussed. This in turn will hopefully open up discussion regarding a process or implementation of a procedure which could help to prevent the error from occurring in the future. Too many times in my training have I seen medical employees make mistakes and be afraid to report due to fear of consequences as well as potential ridicule from colleagues. This often leads to the event going unreported or even covered up, similarly to what was outlined in the reading. Such a hostile environment also leads to potential recurrences, as the root cause remains perpetually unaddressed. As I was doing the reading, particularly “Wall of Silence” I found myself amazed at how I have seen many of the examples listed. Also during this time, I thought about how the culture of training lends to this process. It is a common thought process in training to “make an example” of someone and they’ll never forget the lesson. This a lot of times is true, they’ll most likely never forget it, but the problem is no-one else can learn from it. In order to get the process changed you have to first change the culture and prompt judgment free reporting.

Just the pre-reading has prompted a lot of thought and given me insight to errors in the system. I’m excited to see what other lessons the academy has to offer. Attending the Academy for Emerging Leaders in Patient Safety is important to me because I would like to be a force for positive change in my own workplace culture.

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