2015 is well under way and our friends at the Josie King Foundation are determined to increase awareness and action around their mission of keeping patients, and providers, safe from medical harm. So determined, in fact, that Sorrel King is sacrificing her joints to run the Boston Marathon in April to raise awareness and funding for the cause. If you are going to be in the Boston area on Monday, April 20th — or running yourself — be sure to reach out and join the mission.
For more information or to make a donation, you can go directly to the Josie King Foundation website, or click below to read more!
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.
As with all of our patient safety teachings, we used real cases – both internal and external — to reinforce the educational messages taught throughout our Patient Safety curriculum, and hopefully, to keep the knowledge fresh. Two cases that always generated intense discussion included: (1) a Seattle Children’s Hospital nurse who committed suicide after making the only recorded medical mistake in her 24-year career, and (2) the Julie Thao Wisconsin case, which Bob Wachter described on his blog back in 2007 – When is a Medical Error a Crime? on November 5, 2007.
Medical errors can have a profound impact not only on the caregivers involved, but entire health systems. Charles Kenney eloquently tells the story of how one patient’s death due to a medical error impacted the Virginia Mason Medical Center in Seattle. In his book, Transforming Health Care – Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience, Kenney retells this experience through the eyes of those involved, beginning on page 58. It is the sharing of cases, and stories like these–told from the hearts of those involved–that provide healing to others across the country. Students need to know that by choosing to take on a responsibility so noble and great as to care for another human being, that this does not make them super-human and infallible. It makes them people who care deeply about others, very human and fully capable of making mistakes without strategic system’s safeguards in place.
Over the course of the four years, we tried to expose our students to as many of the complexities of patient care as possible, which included the unfortunate instance of patient harm. As such, we hoped our students left the program armed to face, and openly discuss, one of the two fears they consistently voiced on their first day of medical school–hurting a patient they would vow to care for and protect. And they also moved forth knowing there should be support available in the event they themselves became a “second patient”. Ideally, students should be prepared to ask questions of leadership, residency program directors and future employers before they choose to work in a given healthcare system. Questions such as: 1) What are your serious safety event numbers? 2) What programs do you have in place to manage a serious safety event when it occurs? 3) How do you respond to patients and families when an unintentional error causes patient harm? and 4) Who manages your Care for the Caregiver program, and how long has it been in place?–all should be received well, and openly discussed by those involved in the interviewing and hiring process. If not, students should think twice about ranking those programs in the match, and residents should hesitate when thinking about signing a faculty contract at that institution.
Admittedly, barriers still exist to this curricular approach, but those “Walls of Silence” are coming down, and those barriers are slowly being removed. Many medical malpractice insurance carriers now endorse disclosure and apology when appropriate, as they see the value these programs have on the system as a whole. The Doctors Company (TDC), COPIC and the Committee of Interns and Residents (CIR) provided scholarships so that 70 students and residents could attend this year’s Telluride Patient Safety Roundtable and Summer Camps on Open and Honest Communication (which incorporates many components of the UIC disclosure curriculum) so the next generation of caregivers learns how to do it right. We have to continue spreading the word, and build programs that teach not only “how to” keep patients safe, but caregivers as well.
A number of core themes ran through our four-year patient safety curriculum. In previous posts, I have shared aspects of informed consent/shared decision-making and disclosure of medical errors as two of the themes with patients at the center. It was also our belief, however, that we couldn’t have a patient safety curriculum for medical students and resident physicians without addressing the impact harm can have on caregivers and care teams as well.
A number of years ago, Albert Wu and others started using the term “second victim” when referring to caregivers who unintentionally harmed a patient during treatment. The term was not received well by patients and family members who felt caregivers should not be considered “victims” on par with patients who were seriously harmed, or died from a medical error. A more common term used today for caregivers involved in a medical error is “second patient,” which many feel is more appropriate because of the growing body of research on the impact of medical errors on caregivers and care teams (see below).
During the third and fourth year of our patient safety medical school curriculum we started conversations with our students around the importance of Care for the Caregiver programs. Like other programs across the country, UIC does have a Care for the Caregiver program in place, as it was one of our Seven Pillars. We shared the tenets of this program with all of our students and residents during their training with us, incorporating articles from the growing body of work focused on the impact a medical error has on the care providers involved. Those articles include:
(1) Residents’ Responses to Medical Error: Coping, Learning, and Change. Kirsten G. Engel, MD, Marilynn Rosenthal, PhD, and Kathleen M. Sutcliffe, PhD Acad Med. 2006; 81:86–93. Engel et al concluded that:
“Medical mishaps have a profound impact on resident physicians by eliciting intense emotional responses. It is critical that resident training programs recognize the personal and professional significance of these experiences for young physicians. Moreover, resident education must support the development of constructive coping skills by facilitating candid discussion and learning subsequent to these events.”
(2) The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada. Amy D. Waterman, Ph.D. Jane Garbutt, M.B., Ch.B. Erik Hazel, Ph.D. William Claiborne Dunagan, M.D. Wendy Levinson, M.D. Victoria J. Fraser, M.D. Thomas H. Gallagher, M.D. Waterman et al concluded:
“Physicians reported increased anxiety about future errors, loss of confidence, sleeping difficulties, reduced job satisfaction, and harm to their reputation following errors. Physicians’ job-related stress increased when they had been involved with a serious error. However, one third of physicians only involved with near misses also reported increased stress. Physicians were more likely to be distressed after serious errors when they were dissatisfied with error disclosure to patients, perceived a greater risk of being sued, spent greater than 75% time in clinical practice, or were female. Only 10% agreed that health care organizations adequately supported them in coping with error-related stress (emphasis added).
(3) Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. West et al. JAMA. 2006 296(6): 1071-8. West et al concluded:
“Self-perceived medical errors are common among internal medicine residents and are associated with substantial personal distress. Personal distress and decreased empathy are associated with increased odds of future errors…reciprocal cycle.”
Additionally, we shared that hospitals were not supposed to treat Care for the Caregiver programs as if they were optional – that the National Quality Forum (NQF) has made these programs a requirement. NQF Safe Practice #8 is Care-for-the-Caregiver, and it states:
“Following serious unintentional harm due to systems failures and/or errors that resulted from human performance failures, the involved caregivers (clinical providers, staff, and administrators) should receive timely and systematic care to include: treatment that is just, respect, compassion, supportive medical care, and the opportunity to fully participate in event investigation and risk identification and mitigation activities that will prevent future events.”
Come back tomorrow for more on Care for the Caregiver programs and why there is such a strong need to make these programs mainstream education in our medical and health science schools…