It has been five years since my father died. It took 3.5 years for us to learn what happened. In March my mother and I spoke publicly about this for the first time.
My family has started working with the Collaborative for Accountability and Improvement. They work to help hospitals to establish Communication and Resolution Programs (CRPs) for responding to patient harm in ways that promote healing, learning, and accountability.
This video was filmed at a training session at Lakin, Kansas. My mother and I gave the first presentation at this event.
I was at the Kansas Healthcare Collaborative (KHC) 2015 Summit on Quality two weeks ago. During the presentation on the Kansas Hospital Engagement Network I learned something disturbing: many hospitals throughout the country agreed to a goal of reducing preventable patient harm by 40% by the end of 2014, as compared with 2010 levels. This goal was set by a program called Partnership for Patients from the Center for Medicare and Medicaid Services (CMS).
Let me state that again: the GOAL — the target that hospitals are striving for as they serve the community — is to reduce preventable patient harm by 40%. I was not aware that harm comes as a mix of acceptable harm and unacceptable harm and the concern is getting rid of the unacceptable portion.
But if hospitals are striving for such a goal, I simply ask that they fully explain this to patients and families. And to help, I would like to provide some ideas for facilitating this communication. Continue reading
I strongly believe the term “second victim” needs to be abandoned. I suspect this term serves a purpose in making the topic of medical errors more palatable to healthcare workers. But I don’t think the choice of words is appropriate. I hope I can explain why. Continue reading
The team at the Educate the Young patient safety blog has posted a video about the Telluride patient safety leadership training experience. It is a 12-minute documentary that explains the experience and rationale behind this camp for medical students and residents, which my mother and I had the wonderful experience of participating in last summer.
John Banja, from the Center for Ethics at Emory University, has written a book about the psychological reactions of physicians to causing harm to patients, and why disclosure of harmful errors to patients is so difficult. His book is called Medical Errors and Medical Narcissism, and I highly recommend reading this book to gain a perspective on why physicians have such a difficult time honestly talking with patients about errors. In this post I summarize Chapter 2, in which Dr. Banja describes two models for rationalizing the concealment of medical errors. These rationalizations provide a way for the physician to feel satisfied with giving a less-than-truthful explanation (or no explanation) to the patient. Continue reading
As a student in Biomedical and Health Informatics at the University of Washington, medical errors were a frequent topic in my first-year classes. I learned how informatics can help to prevent errors, but also how poorly designed informatics systems can contribute to errors. But once I had completed my required classes and moved onto my research, I left the topic of medical errors behind. I don’t work in clinical informatics (I make tools to help researchers retrieve biomedical knowledge), so medical errors were simply someone else’s problem, not mine.
But then my father was the victim of a medical error. I was now seeing the other side of medical errors. The side that wasn’t real before. The side that wasn’t supposed to be a part of my life.
I have often wondered what medical students think about medical errors. I suspect that many have a view similar to the way I once perceived errors—scary and terrible, but abstract and detached from my own reality. But medical errors occur with alarming frequency. And that means that someday many of those medical students will experience a harmful error in either their own healthcare or that of a family member. And then they will see the other side, the side that wasn’t real before. The side that wasn’t supposed to be a part of their lives. And when that happens, I hope it is a transformative experience. Because those of us outside the healthcare system can push for change by speaking up about medical errors and refusing to be silent when they happen. But ultimately, safer healthcare comes from changes made by those inside the healthcare system, those responsible for delivering healthcare.
I found a book in the Health Sciences Library at the University of Washington called Should the Patient Know the Truth?. This is a collection of essays written by healthcare professionals and published in 1955. This book is not on the topic of medical errors. Instead, it debates whether patients should be told serious and unpleasant news (for example, that they have a terminal disease). This book was written at a time when most types of cancer were fatal, and many essays use cancer to frame their argument of telling (or not telling) patients the truth.
This book is a little time capsule of the culture of medicine from sixty years ago. I decided to read this book to see what I could learn about perspectives on concealing knowledge from patients.