Summary Post- Thank you

I am so thankful for this experience. It’s scary to imagine my lack of knowledge on such an important topic just one week ago, however, I am grateful for my newly acquired knowledge and now see it as my duty to spread the word and mission of ZERO to my classmates. Some of the main points I want to get across as I begin my journey to educate my classmates are as follows: CANDOR, Care for the Caregiver, and the High reliability culture in medicine.

Communication and Optimal Resolution is vital not just to improve patient safety and care for the future but for treating the patient and their family with the utmost respect following a tragic event. The latter point should not even be something we need to discuss, it should already be ingrained in medical practice since every caregiver can agree that the patient comes first. Unfortunately, things have evolved to where this needs to be brought up and focused on and by teaching CANDOR, it ensures that the patient and family are treated with respect because the open communication it enforces is what every family seeks in healthcare- they want, need, and deserve to be informed on their care. The optimal resolution part of CANDOR is so important in QI because it allows healthcare systems to learn from mistakes. This also seems self-explanatory and something that should already be in place (which is very frustrating that it is not) but after accepting it is not, we are able to highlight its importance and push for its inclusion. We need to report mistakes if we want any chance of learning from them to improve. In order to encourage caregivers to report mistakes for this very reason, we need to change the culture.

Changing the culture in healthcare is also a top priority because the hostile and hierarchical one we have in today’s practice provides a breeding ground for medical error to occur. It doesn’t encourage reporting mistakes when they’re made, being afraid or discouraged from asking for help actually allows more errors to occur, and it doesn’t lend any room to care for the caregiver- which, when left out, encourages errors to be made. Care for the caregiver is one step we can take to change the culture and thus, reduce the number of preventable medical errors.

Additionally, I think it’s important to address that medicine is a High reliability organization, therefore we need to treat it as such. Something that astounded me when we were discussing EHR’s was the fact we didn’t regulate it prior to incorporating it into numerous healthcare systems. The comparison was made to other HRO’s and it shocked me because we would never be okay with a brand-new software being placed into the airline industry without regulating it, so how did we allow a synonymous occurrence to take place in healthcare. The truth is that medicine is an HRO but we don’t act like it. We have no system in place to record mistakes that have been made and so we have no way of preventing them from occurring in the future. We have doomed ourselves to repeat mistake after mistake, one hospital after another. We should not be waiting for a disaster to happen in order to shock us into changing this, Tenerife should have been that tragedy, as it was a wake up call for the airline industry, but it seems as if we are waiting for our own tragedy. It’s terrible that we need to wait for a tragedy in the first place, but secondly, something that huge and acute is not going to happen because preventable deaths from medical errors is a gradual epidemic, killing one by one, always lurking in the shadow because no light is shed on one person dying here and another person dying there. The numbers are there when you compile them but the healthcare system refuses to accept that. We need to record and publish these individual mistakes so the public can become aware and provide the momentum and demand the change that we desperately need.

I believe I will be a much better physician because of this experience. I am so much more informed and have found something that really inspires me in the field of medicine now. I was never super passionate about the hard sciences, I followed medicine because I wanted to improve patient’s lives on a level that I could see and that they could see. This experience has opened my eyes to something I can be passionate about and work towards to instill change and improve the lives of countless patients, some that I may never even come in physical contact with. Thank you for educating me and helping me find my passion in medicine. Things may seem bleak and the battle uphill, but we need to remember that things don’t have to be what they have always been.

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