Why I’m attending

Attending the Academy for Emerging Leaders in Patient Safety is important to me for academic and personal reasons. Let’s start with the academic. It is hard to find a precise number of how many patients are hurt or killed every year due to medical errors but estimates of deaths range from 22,000 to 250,000 in the United States. Put another way, as a future oncologist I interpret this as medical errors killing anywhere from leukemia to nearly all cancers combined.

The problem with numbers, though, is that focusing on these neat arithmetic devices obscures the human tolls. At a minimum, 22,000 husbands, wives, brothers, sisters, cool aunts, goofy uncles, and favorite grandparents were lost unnecessarily. At least 22,000 families shed tears, attended funerals, and experienced gaps in their lives that did not need to be. Thousands of shocked family members, I’m sure, thought their loved ones were recovering only to show up the next day to find them in the ICU, or worse. Each one of those numbers represents heartbreak and a loss for families, communities, and our species. It is not just the families who suffer- I’ve seen colleagues from nurses to fellow residents racked with guilt, brought to the point of tears, and affected for days to months, at being involved in a poor outcome. Why did this happen? How can we fix it? Families wonder. I wonder.

As far as I know, I haven’t contributed to a lethal medical error. However, I have snowed grandmas with morphine (not a great idea when they have renal failure…), placed lines such as “nasojejunal tubes” into the wrong lumen (right mainstem bronchus equals not the jejunum!), ordered the wrong dose, route of administration, or frequency of multiple medications, and ordered the wrong tests for patients. While I apologize in person when a harm reaches a patient, make a point of debriefing with my team, and have even filed incident reports on my own actions, I am highly cognizant of my ability to make errors despite my best efforts. Did I mention that in approximately one month I am going to start prescribing chemical warfare agents known as chemotherapy? Thank God for pharmacists, and for Epic alerts!

Cognizant of my own limitations, saddened by the statistics, and humbled by my future ability to cause both good and harm as an oncologist I want to learn how to make medicine better and safer. Furthermore, I want to learn how to lead others to do the same. What are the best ways to analyze patient safety? How do you motivate and lead a QI team most effectively? What different methods are there to improve patient safety and ensure that hard-earned gains are not lost? These questions are why I am attending the Academy for Emerging Leaders in Patient Safety.

 

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