Reflection Day 1 Esra Bennathan Scholar Session

After Day 1, I am feeling so grateful to be part of this group- to meet and make new friends with medical students, residents, nurses, and nursing students from all over the country with a common interest in patient safety. I am also grateful for our faculty, and for the patients we heard from on day 1. Watching the emotional video about the Lewis Blackman story, I was struck by how everyone clinical questions to ask and ideas about what went wrong, but people typically started with their emotions: “That was hard to watch”; “that was heartbreaking”; “I feel so badly for the Blackman family”. I think that was interesting because again it shows that our emotions were where we started and where we felt the same. Our ideas about how to fix the problem might be different- which part of the process/case to tackle- the resident who didn’t call for help, the blood pressure cuff, the lack of diagnostic testing such as Xray, anchoring bias on ileus– all these things have system-level solutions, but what we learned what Helen really wanted was empathy and an apology. I think realizing that we all start there is important because it’s when fear, shame, hierarchy, and burnout get involved that I think people don’t take responsibility, aren’t transparent, and don’t apologize. I felt this was an important lesson to think about for me as I head towards clinical training. I know how to be authentic, and I know that this situation as a mother or sibling would be frightening and heartbreaking, so I can start there. I can start by being honest and apologizing. Then triggering the appropriate channels for how to mitigate these errors and change the system for the future. I feel like an important point made this day was that blame should not be placed on any one person, and the family typically doesn’t want to blame one person– everyone recognizes the system was built in a way that things will fail and it is error-prone, however that doesn’t mean we cannot take responsibility while also working on solutions to reduce risk.

 

I am loving this leadership summit and excited for Day 2.

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