Many of us in healthcare know medical errors are the third leading cause of death in the United States.
We are also aware that healthcare is a high-risk industry. But unlike other high risk-industries however, such as aviation and nuclear energy, healthcare has been too slow to adopt tools, techniques and behaviors proven to lower risk to patients. As a result, errors made by well-intentioned caregivers continue to cause unintentional harm and even death to patients.
In my last ETY blog post, I shared a medical error I was involved in that led to patient harm. I also shared how we hid that error from the patient, as well as other caregivers who worked in our hospital. It is said healthcare “buries” our medical mistakes. Fear of malpractice claims, fear of losing our license, fear of admitting we are fallible and can make a mistake; doctors are expected to be perfect, and this behavior is an unintended consequence of those unrealistic expectations. These are just a few of the reasons caregivers and hospital leaders try to hide or even downright lie when medical errors cause patient harm.
This approach, known as “deny and defend”, is a common legal and malpractice insurance strategy, not only in healthcare but in other insurance-based industries. Not only is “deny and defend” morally and ethically wrong, but in healthcare it also keeps us from learning and improving our care systems when these very unfortunate events occur. If we don’t openly talk about, and learn from our mistakes, we will never fix healthcare so that future patients don’t suffer similar harm. In our wrong-sided surgery error, no one wanted to discuss how we could have prevented that harm from happening again. All we wanted to do was bury it, hoping no one found out. And then what happened? Wrong-sided surgeries continued to occur over and over again for years afterwards.
Historically, the role of hospital risk managers has been to protect the hospital at all cost, even if it meant lying to patients and families. Refusing to answer questions, denying patients access to their medical records, not returning phone calls, or referring patients to hospital lawyers has been routine practice for many health systems. Many patients and families wait years to have their calls returned, and still fail to receive truthful answers on what really happened when there is a conversation. As many plaintiff attorneys have shared through the years, “There’s a lot of lying going on out there”. The only option patients and families often have to get their questions answered, is to hire their own lawyer and file a lawsuit against the hospital and the physician. Once both sides “lawyer up”, the only thing that matters is to win the lawsuit, regardless of the financial cost or additional suffering incurred by all stakeholders. No one wins in a medical malpractice trial.
Fortunately, some courageous health systems, hospitals and medical malpractice carriers are discovering there is a better way…
As we at the Academy for Emerging Leaders in Patient Safety (AELPS) prepare for our 13th year of Patient Safety Summer Camps for future healthcare leaders, I always reflect on a personal story I share the first day of each session to kick-off our week of work together. The story captures many of the reasons we have a preventable medical harm crisis today, such as: fear, devastation, lack of transparency, refusing to learn and improve from mistakes, lack of embedded human factors. The story also serves to show our young learners that we all are human and we all make mistakes, and helps set up a learning environment where they feel safe in sharing their own personal stories. Those who have only worked in healthcare a short time will have seen, or been involved in, an event that harmed a patient. For those that have followed our blog through the years, you have read some of these personal stories…mistakes that even harmed our own family members. I thought I would share my story with all of you.
Many years ago, I was involved in a medical error as a resident – a wrong-sided hernia repair that unfortunately harmed one of our patients. As the anesthesiologist, my job was to bring the patient into the operating room, put the required monitors on so I could make sure he was safe during the procedure, and then administer the general anesthetic that would keep him unconscious during his right-sided hernia surgery. I did that successfully and was focused on my job but, like others in the operating room, I didn’t notice that the senior surgical resident had taken the scalpel and made the surgical incision on the patient’s left side by mistake. Two minutes later the attending surgeon who had been detained with a question from another surgeon, came into the operating room, looked at the patient on the operating table and asked, “I thought this was a right-side hernia repair?” When the surgical resident realized her mistake, she passed out…the impact making a medical error can have on us as caregivers.
The surgeon closed the incision on the left side and then proceeded to fix the hernia on the right side. The patient now had two surgical bandages on their abdomen: one to cover the hernia repair, the other to cover our mistake. I dreaded having to see the patient in an hour and explain my part in the medical error that harmed him. I had never been involved in a medical error before, and was very nervous about the anger he might feel towards me and our team. When I went to meet the patient in the recovery room, I noticed he had a big smile on his face. This struck me as very odd. Before I could say anything, he looked at me and said, “Today is my lucky day”. I was dumbstruck. He continued, “Yes, today is my lucky day because under anesthesia my surgeon told me he discovered I had two hernias, one on each side, and was able to repair both at one time so I don’t have to miss another day of work to get the second one repaired”. It then hit me. The plan was to lie to the patient and cover up our mistake. I didn’t know what to say or how to react. After a very long pause, I responded, “Yes, today is your lucky day,” and I signed the patient out.
Not only were my six words to the patient “Yes, today is your lucky day” morally and ethically wrong, our lack of honesty and transparency kept us from learning how to prevent others from suffering similar harm. As a result, wrong-sided surgeries continued to occur far too frequently.
In defining professionalism in healthcare we use words like altruism, honor, integrity, respect, caring, compassion, and accountability to name a few. In telling my patient “Yes, today is your lucky day”, I violated every one of those principles we take an oath on when becoming a caregiver.
On day three of our Academy for Emerging Leaders in Patient Safety…the Doha Experience, Dr. Seth Krevat, AVP for Patient Safety at MedStar Health, led discussions on the importance of in-depth Event Reviews, Care for the Caregiver, and Fair and Just Culture approaches to preventable harm events. Seth shared the event review process used at MedStar Health which was designed by experts in patient safety, human factors engineering and non-healthcare industry resilience leaders. This event review process has been adopted by AHRQ and AHA/HRET, and has been incorporated into the upcoming CandOR Toolkit being released shortly to US hospitals.
The young learners engaged in deep discussions around Fair and Just Culture – the balance between safety science and personal accountability. This topic followed interactive learning the previous day on human factors and system/process breakdowns. Similar to challenges we have in the US, the culture in the Middle East blames the individual first without a thorough understanding of all the causal factors leading up to an unanticipated event. After Seth showed the video, Annie’s Story: How A Systems Approach Can Change Safety Culture, and shared other case examples demonstrating how a good event review can disclose system breakdowns versus individual culpability, the young leaders gained a new appreciation of effective error reduction strategies. In the short clip that follows one of our young leaders, so empowered by the short three days with us, explains how she used what she learned to try to change her parents point of view on patient harm:
The passion and commitment of these future leaders to patient safety was inspiring for our US faculty, as well as for the leaders from the numerous Qatar healthcare institutions that participated in our sessions. I have no doubt this next generation of caregivers will be the change agents needed to achieve zero preventable harm across the world. We have seen many examples of their work already.
It was exciting to be in Qatar working collaboratively with others who are committed to “Educating the Young” as a powerful vehicle for change. Next stop for the Academy for Emerging Leaders in Patient Safety…The Sydney Australia Experience!
After a very engaging faculty development program for healthcare leaders from Qatar, we kicked off our Academy for Emerging Leaders in Patient Safety “Doha Experience” patient safety camp for future interprofessional healthcare leaders today. The collaboration is being sponsored by WISH – the World Innovation Healthcare Summit and the Qatar Foundation for Education, Science and Community Development.
Egbert Schillings, CEO of WISH, remarked: “WISH has a long-standing commitment to patient safety across a number of our programs. This training academy for students and faculty from all the health science colleges of Qatar takes our efforts to a whole new level. Her Highness Sheikha Moza bint Nasser founded WISH to help improve health through global collaboration. There is no better example of this vision in action than by bringing together the best expertise the world has to offer, for the benefit of young leaders and the patients they will take care of right here in Qatar.”
Rebal Turjoman, a third-year Qatar medical student and former Telluride Patient Safety Summer Camp participant, worked closely with organizers from the US and Qatar to bring the Academy for Emerging Leaders in Patient Safety curriculum to the Middle East. On the last day of our four-day sessions, every Telluride Patient Safety Summer Camp participant is required to make a public commitment to become a change agent for safety, and to identify and lead a specific program that will impact patient safety back at their home institutions. Rebal felt so empowered after his week-long immersion in patient safety, he decided to make his commitment a challenging one. “I was quite eager to help bring the Academy to Qatar, as the curriculum is unprecedented for students here,” he said. He shared his vision, knocked down obstacles, built coalitions and made it happen. Because of Rebal, over 70 young healthcare leaders from Qatar are experiencing the same curriculum that empowered Rebal to become a true leader and change agent.
After just one day of shared learnings with faculty and students from the region, it became very clear to all of us that our Academy for Emerging Leaders in Patient Safety curriculum resonates deeply and brings great value to others facing similar challenges across the world. We are excited to be in Qatar and working with fellow healthcare leaders who are also committed to “Educating the Young” as a powerful vehicle for change.
For more information, the Qatar Tribune covered the event: WISH to hold global academy for emerging leaders in patient safety
Today’s post is by guest author, Carole Hemmelgarn, who generously shares a reminder to all on why patient safety work is so important, and why National Patient Safety Week will continue to matter even after we get it right. Carole continues to give her time as a patient advocate, coaching healthcare organizations across the country on the power of words, as well as a better understanding on what it means to truly communicate with patients.
March 8th starts National Patient Safety week and it is with great irony that I write this blog because it is the anniversary of the day my daughter, Alyssa, died from medical errors. I am grateful for the focus being made in the field of patient safety. We need to become High Reliability organizations, enhance our communication skills, offer communication and resolution programs, implement bundles and the host of other programs that impact safe patient care.
However, I want to bring the focus back to the human side of patient safety and that is the patient and family after harm has occurred. There is this aftermath, which is rarely spoken of, and it is what happens to those survivors living without their child, spouse, parent or sibling years down the road.
I’ve come to realize grief is my twin. It will never go away and we have learned to coexist. Please understand grief is not always bad. I find solace in my grief because we speak the same language. We laugh and cry together and there is no judgment. At other times, my twin is like an anchor weighing me down causing me emotional pain and draining my often limited resources. So you may ponder why the dichotomy? Well, because life moves on, but it is different for us now. I’m a different person. My beliefs, values and what I held to be true have turned upside down.
What most people don’t realize is loss of a loved one, and in particular, a child, changes so many things.
- Marriage changes. I’m no longer the person my husband married and trying to figure out who we are in this new space is exhausting. Parents grieve differently and the one thing they don’t want to do is hurt their spouse because they know they are already in pain. This just opens up the door for communication problems.
- Your children are affected, but rarely do we talk about the impact it has on them. My husband and I often ask the question “Is this who our son is, or is this who he became after his sister’s death”? It is difficult to watch your son cringe when asked if he has any brothers or sisters and he says “no” because he can’t go there and talk about his sister.
- Your relationship with family members change. Sometimes they become stronger with certain members of your family, and others, a riff occurs because they expect you to move on or be the person you were before, and that individual no longer exists. Partaking in family events that once use to be enjoyable can be extremely emotional. You are there, but only as the great pretender, when underneath you are screaming to be set free. Why? Because you are watching their children progress through life, and do the very things, your child will never get to do.
- Friendships change…..
The most difficult are the milestones your child will not experience: moving through elementary, middle, and high school, not graduating from college, getting a job, married or having children. These events go on for years and this is the aftermath not seen.
I share this with you because I want you to see the importance of the work you do in the area of patient safety. So as you participate in the 2015 National Patient Safety Week, your goal is to make sure we minimize and mitigate the aftermath of harm I discuss above, and my goal is to help others avoid having grief as their twin.
After a brief hiatus for the #IHI26Forum, and in preparation for launch of Using Stories to Influence Change in Healthcare as an Amazon eBook, we are back online! With all the repeat hits to our ETY storytelling posts, it seemed of value to put them in a collection along with some of the ‘how and why’ storytelling has become of even greater value in healthcare. Here is the link if interested in having all of the storytelling posts in one place along with new commentary. From the description:
…as long as there are patients who fall victim to preventable harm in healthcare, there are healthcare professionals who also have a story rich in learning material from the other side of the bedrail. Both sides of the patient harm story will need to be embraced by healthcare leadership in order to achieve the delivery of reliable, high-quality, safe care everyone desires. Because the numbers harmed by healthcare have at the very best plateaued, an urgent need to pick up the pace for change remains. Sharing the stories of patients and healthcare professionals on a larger and more strategic scale throughout the industry will allow others to learn vicariously from mistakes as well as successes, building upon the positive momentum found when utilizing storytelling as a medium for change. Once again, our stories can provide the guiding light leading us into a new world for healthcare—where the patient voice is welcomed, and healthcare professionals are allowed to speak their truth.
And finally, our healthcare stories also serve many masters. When patients share their story of illness, they heal. When families tell stories of loss, they grieve. When healthcare professionals relate stories of guilt or near misses, they unburden their souls and can fix what is broken in health systems, enabling them to once again care for others as intended. Freedom to tell our story has always been a way to health and happiness. Using Stories to Influence Change in Healthcare is a jumping off place for those interested in learning more about how stories are being used in healthcare, and why they hold the power over us that they do. Tips from expert storytellers on how to craft good stories, as well as a glimpse into the science of story round out this introductory collection on using stories in healthcare…
The 7th Annual National Patient Safety Foundation and Lucian Leape Institute Forum and Gala was held last week in Boston, gathering patient safety leaders together to share knowledge, recharge and re-energize their efforts in making care safer for healthcare professionals and patients. The opening keynote, Using Informal Influence to Drive Positive Change in Healthcare, was given by Andrew Knight, PhD. Assistant Professor, Organizational Behavior, Olin Business School, Washington University. Knight has studied innovation implementation, leadership and teams in high risk environments, such as the surgical suite, ICUs, Emergency Departments and the military.
Knight’s talk provided a number of take home tools for healthcare leaders to approach internal change with new power. He supplied a different lens through which to view company politics, one that allows for consideration of “the other” versus leaving a footprint on even your mother’s forehead to reach the top. He shared insight into the influence skills and the collaboration across teams necessary to move quality and safety initiatives forward. And, he stressed that data alone has not been the sole catalyst for the large-scale adoption of change needed to make the healthcare workplace as safe as we need it to be, using the tragic story of Ignac Semmelweis as evidence. Many are familiar with Semmelweis’ story–the doctor who discovered hand washing as a “cure” for the high number of deaths related to childbirth in Vienna clinics. His findings at the time went against the medical community’s thinking of the day, with physicians even taking offense at the request to wash their hands before caring for a patient. Unable to convince, or influence, others of his findings during his lifetime, Semmelweis was ultimately committed to a psychiatric hospital at the age of 47, and beaten by guards two weeks after his arrival. As the story goes, Semmelweis died shortly after from the same infection he was trying to protect patients from through hand washing. This simple, cost-effective step in the delivery of care at the desired 100% adoption rate still eludes health systems today.
Additional takeaways from Knight’s talk include the following. He is an excellent speaker and the topic couldn’t be more timely for healthcare.
- When it comes to navigating the waters of company politics, do you consider yourself an innocent lamb, a straight shooter, a survivalist, company politician or Machiavellian? Knight asked the group to respond via a text message survey. Results showed a normal distribution, the majority claiming to be survivalists with one Machiavellian in the group, prompting Knight to tongue-in-cheek, warn all to watch their backs.
- A more realistic view of company politics was offered, such as: Instead of considering what tactics might be used to influence someone, walk a mile in their shoes to understand exactly how what you offer might affect another. Or, instead of kissing up to those in power, feel free to compliment those you admire!
- Driving positive change is hard work! A 2005 study showed more than 50% of attempts to implement innovations end in failure, and that over $500 Billion is wasted annually on new technology implementations, according to Morgan Stanley
- To implement change, groups outside one’s direct circle of influence need to buy-in, collaborate, support, and supply resources to be successful. Influence skills can help gain the buy-in!
- Informal influence at all levels of the organization is what makes for the successful adoption of new initiatives.
- A numeric equation to map the political landscape related to change was provided, quantifying the amount of current support for any given project, by any given stakeholder, indicating likelihood of success.
- “For most change initiatives we need commitment. Compliance is rarely enough.”
One of the highlights of our Telluride East Patient Safety Summer Camp each year is our trip to Arlington National Cemetery. The cemetery serves as a burial-place for “laying our Nation’s veterans and their family members to rest with dignity and honor.” Numerous daily honors, such as a horse-drawn caisson carrying an American flag draped casket, the firing of three rifle volleys, and the long bugler playing Taps, remind visitors of the service, sacrifice and valor displayed by those in the military protecting our freedoms.
As we walked through the cemetery, it was hard not to grasp the magnitude of the gravesites beside us. Everywhere I looked, white gravestones dotted the landscape. The tombstones seemed to go on forever…in the lower areas of the cemetery close to the main entrance, walking up the hill to Arlington House, or following the signs to the Tomb of the Unknown Soldier. Everywhere I looked there were rows and rows of white tombstones – tens of thousands of them. Six hundred and forty-eight acres of tombstones marking burial sites with little room for much else–the cemetery is pretty much full, and needs more acreage. In fact, they recently chopped down a controversial 2 acres of trees to find a place for our more recent casualties of war. The informational brochure says the cemetery is currently the final resting place for more than 400,000 people.
400,000 people…the irony of that number struck me. That is the same number of patients who die every year due to preventable medical errors according to an article published in September 2013, A New Evidenced-based Estimate of Patient Harms Associated with Hospital Care in The Journal of Patient Safety. Lucian Leape brought some conceptual reality to the medical error crisis years ago by using the analogy of one jumbo jet crashing every day. All those white tombstones that stretched to the end of the landscape and seemed to go on forever reflected the same number of patients who die each year from things like unnecessary infections, failure to recognize or rescue, medication dosing mistakes. We fill an Arlington Cemetery every year.
We have surpassed one jumbo jet per day. Standing at the top of the hill, looking in all directions…north, south, east, west…seeing the 400,000 gravesites spread out before me, and thinking this could be a preventable medical harm cemetery for just a single year is incomprehensible and unacceptable. What does it require for others to take this national epidemic seriously? When will we see the urgency needed to create meaningful change? It is a visual all Hospital CEO’s and political leaders should be required to experience.
Patty and David Skolnik were again faculty at the Telluride “East” Patient Safety Summer Camp this week. They came to lead the discussion after sharing the educational documentary film, The Story of Michael Skolnik, and their family’s story, with almost 75 medical and nursing students and resident physicians. As always, and as quite an understatement, the film is part of the patient safety intensive curriculum that illuminates the need for change in healthcare and healthcare education–not only to make it safer for all, but to also cultivate the skill sets that engender meaningful conversations built on honesty and trust between patients and providers. Following are reflections shared by Patty and David today, ten years after losing Michael to medical harm. Thank you, Patty and David, for your continued presence within healthcare, serving as a reminder that we still have much work to do.
David and I feel many emotions 10 years after our son’s death:
- Anger that we have lost our child unnecessarily
- Strange relief that Michael is no longer suffering
- Unexplainable sadness that Michael is gone and his dreams are unfulfilled
- Guilt for making decisions we regret because we trusted the doctor and didn’t look further
- Awe at the courage one young man could manage. Michael was a fighter; he had unbelievable strength to fight back
- Admiration, immense admiration for the love and unstoppable caring he showed through his horrible ordeal
- Appreciation for what we all learned from Michael, he had no room for weakness, failure or lies
- Regret that we lost our best friend and a large part of our souls
- Happiness that we had a child that never hesitated to participate in life or have any goal intimidate him
- A love of Michael’s was sailing. Through sailing he learned: ingenuity, resourcefulness, trust, caution, adventure, discipline, and perseverance
Michael has also taught us many other lessons that I want to leave with you, namely that we all have choices, choices about how we live and how we die. If Michael were here he would tell all of us:
- To smile always
- To laugh daily
- To sing every chance you get, whether others think you can or not
- To dance, even if you have to do it in a wheelchair or bed
- Not to feel guilty if you don’t know what you want to do with your life
- To meet new people and make new friends everyday
- To enjoy your body. Use it every way you can. It’s the greatest instrument you’ll ever own.
- Get to know your family and especially your parents. You will likely discover that they are the best friends you will ever have.
- Do one thing every day that thrills or excites you
- Respect those that earn it
- Be the Best medical professional you can
We are determined to make a difference for Michael’s life. This is what Michael would have wanted–to have his voice still heard and all the others that have no voice. Thank you for what you do and for helping us keep our promise to Michael–that we all leave the medical field better than he found it.
Many of you may have already read Josie’s Story. Sorrel King sent me a copy a few months back, and it has sat patiently on my bookshelf, waiting for me to discover the beauty that lay inside. I think I waited to read it because my heart has been filled with Lewis’ story, and Michael’s story and Alyssa’s story…young people I never knew, but who have influenced my professional journey in ways I could have never imagined when planning a course of study or career path. I think I waited to read her story because I wasn’t sure I had room to take into my heart yet another story of loss at the hands of the industry in which I work. But I picked up Josie’s Story last week, and could not put it down.
While the book reads like a fiction novel with well-written, lovable characters moving through the journey of an unthinkable loss, the unfortunate truth is that it is an autobiography. While Josie was here only a short time, I believe she was here to inspire her Mom to tell their family’s story in a way only she could–with honesty, love and a strength that is truly inspiring. Their story is a road map and a touchstone for dealing with grief–a reminder that the only way through something so painful, so unimaginable, is to feel it. It’s also a reminder that grief is an individual journey, but that in time, you can reach the other side and find a life you may have never imagined could be so wonderfully different from what you had planned.
Josie’s Story is also a brief history of patient safety, as the origination of so many Patient Safety programs in place today began as a result of the Josie King Foundation, and Sorrel’s blood, sweat and tears. Care for the Caregiver, the Keystone Capstone, CUSP and a partnership with Peter Pronovost–all of these lifesaving programs have a tie to Josie, Sorrel and their foundation. The book itself is also being used as a foundation for teaching patient safety principles across healthcare, and in book clubs around the country. It’s a must read, and a heart-hitting reminder of the basic reason we go into healthcare–to protect patients first from harm, and then to heal them. It’s a reminder that we must also change our systems to protect the well-meaning, hard-working care providers who often suffer in silence when patients are harmed. From the book:
I realized as I flew home that Josie’s story had struck a chord with the very people who could fix the problem. I could not stop thinking about their reaction, how they listened to me, how they cried and confided in me. They seemed hungry for something, though I wasn’t sure what. Maybe it was the fact that I was coming at patient safety from a different angle. I wasn’t talking about the data and statistics. I didn’t have a lengthy PowerPoint presentation. I wasn’t one of them: I was an outsider with a real story.
I’ve known Sorrel a relatively short time on my own patient safety journey, and have always been inspired by the way she carries herself, her professionalism and especially, her sense of humor. I did not know the details of her family’s story until recently, and having read their story, I have a new level of respect for her as person. The ability to live life authentically, bravely in the best of circumstance is admirable but to do so throughout a time of such trial is a reminder of how resilient each of us can be if we open our hearts to the love and strength within. Thank you, Sorrel, for being here to show so many a path through grief, and for being someone the healthcare industry has listened to. As we continue the work intended to make care safer for every patient, I truly believe it is stories like Josie’s that inspire the greatest movement forward. We are after all, humans caring for humans, and it’s our stories that make life worth living.