Second Time Around

I feel so privileged to be able to attend this conference for a second time. Things resonate so differently one year after submerging myself into the field of patient safety. What I’ve learned so far…is that there’s always more to learn. Watching Lewis Blackman’s mother tell their family’s story the second time around was so powerful. I vividly remember watching this film the first time and feeling so frustrated. I had many of the same thoughts and emotions that were expressed today (“Why wasn’t the resident interviewed? Surely they have a good explanation for what happened…they probably tried to tell someone and didn’t feel heard, or they’d never been put in this situation before and didn’t realize how dire the consequences could be. This story can’t be told without their voice!”) Today, all of my thoughts were solution-oriented and not specific to my fellow residents. Although this is an intensely personal story and, as Dave mentioned, a catastrophic event (‘a plane crash’), in many ways it’s universal. I have not personally experienced the death of a patient as a result of a medical error, but I have been involved in very serious harm events due to delayed diagnosis or diagnostic inertia. With so many competing priorities it’s insanely challenging to stop, think and do the deep work that our patients require to receive the best care possible. Today when I watched this video I thought, “are there clinical support tools that could have been implemented in this case that would have saved Lewis or led to earlier intervention?” (e.g. vital signs alerts that prompt an immediate bedside exam and consideration for transfer to a different floor), “how can we flatten the hierarchy in hospitals so everyone feels empowered to speak up?”, “how can we bring JOY back to practice so clinicians don’t feel so stressed??” (the IHI just wrote a great white paper on this that everyone should check out called the Framework for Improving Joy in Work).

Two quotes from our fellow scholars stuck with me today:

“Culture begets itself if not corrected.”

“We don’t know we’re not being transparent because we don’t know what patients don’t know.”

This is such a wonderful forum to share ideas, frustrations and ultimately solutions. I’m excited to read all of your blog posts and continue with this rich discussion!

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