A resident’s perspective on the Medstar patient safety elective

When I began the Medstar patient safety elective last week I would have never thought that it would change the way I will practice medicine for the rest of my life.

What began with a basic understanding of the varying components that make up quality patient care and safety, ended with a passion and thirst for change in medicine.  I was astounded to learn the scope of medical errors in this country. In a high stakes profession built so heavily on patient trust, how is it that we have lost touch with the reality that as physicians we are human?  We make mistakes. We can offer the best medical treatments and technologies, yet we can’t save patients from ourselves. It’s time to turn the attention to the hand that is writing (or typing) the order. It’s time to slow down and focus on the person that makes up the patient. It’s simple right? It’s the golden rule. Deliver the kind of care to your patients, that you would want delivered to your closest family and friends, or, to you.  Take a patient-centered approach to medicine. Ensure that your patients are safe before you do anything to heal. It seems so easy, yet why do 100,000 people in this country still die from preventable medical errors every year? It is time to hold a critical magnifying glass to how we deliver patient care in the United States. As physicians it’s our duty to protect the patients we care for. We must take a thoughtful approach and make systems based changes in order to ensure that no one is harmed by our direct actions. We have to stir up this fire in the youngest generations of doctors in order to elicit lasting change. We have to take an honest look at the culture of medicine, eliminate hierarchy and start respecting each other. When we don’t, it’s the patients that truly suffer.

When I spoke to Helen Haskell (Lewis Blackman’s mother) during one of my phone interviews for the patient safety elective I could sense her lasting guilt and regret. She blames herself for not researching enough about the elective procedure her son underwent. She was forced to watch her 15 year-old son slowly bleed into his abdomen and die in the hospital with no one listening, with no one respecting her concerns, with nurses afraid to call or speak up to doctors, with inexperienced doctors unable to see past the diagnostic label written in Lewis’ chart. Since when has it become a patient’s responsibility to independently learn about their treatment options? Since when have we come to put more trust in a written word in the medical record than in a mother’s intuition and concern? Informed consent and shared decision-making are at the core of many harmful patient events.  It’s time we teach doctors to share information with patients rather than make decisions for them. One-paged, fill-in-the-blank informed consents should never replace meaningful conversation that involves patients in their own care. The best possible thing we can do for patients is empower them to understand their medical condition.  It will only promote adherence and respect for one another. We must be transparent and humble and recognize that mistakes happen and when they do, honesty and full disclosure is the best policy.  Improving communication skills are key. For patients, it’s not about how much you know but how you explain it to them, how you involve them and how you treat them on a personal level. I rarely hear a patient boast about how smart their doctor is. Patients talk about how much their doctor listened or how much time they spent learning about them or what a great job they did at explaining something. It’s not so much about what you do or even what you say but how you make them feel.

When I asked Helen what advice she would give to young doctors just starting out she said “Find your true professional and ethical foundation and be proud of it. You are part of a service industry that must be reliable. Remember that it takes courage to stand up to powerful sources and be transparent. Don’t help make medicine commercialized and full of propaganda. Resist the pressure to deliver high volume care, and practice thoughtful medicine.” Wow.

I have come to find that the leaders in patient safety make a small but unbelievably strong community. I can’t wait to join my enthusiastic fellow residents in Telluride this summer for the Transforming Mindsets: Patient Safety Summer School for Resident Physicians. I have no doubt it will be an unbelievable experience.


Human Error

No one in medical school told me about medical error and how to respond if a medical error was made.  I do remember the many presentations and “pep talks” about what an honor it is to become a physician and take care of a patient in need.  By the end of medical school I was ensured that I had received the necessary training and now had the knowledge to go out and treat people.

Now 1 1/2 years into my residency I do feel that I can manage my patients’ care very well at times.  What I didn’t expect was that despite my most compassionate care, errors have occurred that have affected, or come close to affecting, my patients.  I haven’t purposefully tried to cause harm to my patients.  My attendings haven’t tried to harm their patients on purpose.  The nursing staff has not purposfully tried to cause harm to their patients.  But despite our good intentions, error does happen.  Luckily, most of these errors are “near misses” where the error is caught before it reaches the patient and there is no actual harm done.

One of the most concerning issues is not necessarily the error in and off itself, but how our system responds to the error.  It is our natural human instinct to want to blame someone else for a mistake and absolve ourself of any involvement.  “If only we educate this one person who made the mistake than we have solved the issue and can forget about it.”  This is the wrong thought process entirely.  As I said above – no one goes to work intending to cause someone harm or put a patient’s safety at risk.  Usually when there is an error, there is a reason that the error was made and a high likelihood that a similar error will be made in the future.  A better response to error is to seek out ways that the error could be made in the future.  When we focus on the shame and blame game, we create an environment based on fear and the teamwork necessary to provide good and safe patient care is challenged.

I am lucky to be a part of a residency program that has a focus on patient safety and error reporting.  Our faculty provide a very welcoming environment to discuss these events and work as a team to create ways to prevent these events in the future.  We are working to help create a medical environment that involves open and honest communication with all of the staff of the hospital as well as our patients.  As much as I would like to think that I can be that unflawed and all-knowing physician that medical school pushed me to become, I can’t.  Good medicine involves open communication with the nurses, staff, and patients to ensure appropriate and safe care is given.  If we are not willing to have these conversations, we can only hope for more of the same mistakes in the future.

Resident Reflections Blog Purpose

Leadership in Patient Safety Excellence

At the core of proficiency in Practice-based Learning and Improvement is lifelong learning and quality improvement. These require skills in and the practice of self-evaluation and reflection to engage in habitual Plan-Do-Study-Act cycles for quality improvement at the individual practice level, as well as skills and practice using Evidence-based Medicine.

As residents complete their elective, “Leadership in Patient Safety Excellence” this blog will serve as a journal for self-reflection related to specific learning objectives.  In addition, this forum provides an opportunity for sharing of knowledge and interactive discussions through which we take our learning to a higher level.