It always saddens me when a medical mistake is reported in the media, and the immediate reaction of so many people is: “Someone that careless and incompetent should be fired. There is absolutely no excuse for hurting a patient by omitting such a basic step as calculating the right dose / making sure you have the right patient / checking for allergies / etc… ”
My immediate response to this is always: “Have you ever locked yourself out of your house?” Human beings make mistakes. Human beings sometimes omit basic, crucial steps from tasks they supposedly have mastered. We make small, stupid, high-consequence mistakes so predictably, so inevitably that an entire industry (locksmithing) is dedicated to undoing the small, stupid, high-consequence mistake of not ensuring we have our keys when and where we need them.
The keys analogy is actually a great way to think about… Continue reading
“I’m a little obnoxious sometimes,” claimed Dan Ford this afternoon discussing his fervent advocacy of root cause analyses in response to sentinel events. Earlier that morning, Mandy too had confessed to being “that annoying nurse” who unabashedly telephones on-call residents when a concern arises. These champions of patient safety proudly own these deprecatory adjectives like “obnoxious” and “annoying” because they know that their actions are challenging the status quo for the betterment of patient care.
It is my hope that all of us, students and professionals alike, emerge from this week in Telluride a bit more enthusiastic about being obnoxious. To be “obnoxious” in this context is to put our patients’ needs first in spite of a bruised ego. We “annoy” despite the fear of openly defying the medical culture’s norms, and we “irritate” others because we have the courage to understand that it will take assertive individuals to lead… Continue reading