I will never forget the moment I sat facing an experienced and shaking general surgeon as a young Chief of Staff for a large regional hospital. The surgeon told me he had just cut the common duct! Showing my age, this was in the very early days of laparoscopic surgery. The surgeon had recently taken a short course on laparoscopic cholecystectomy, and this was his tenth case or so.
As I sat there, my thoughts were torn between the devastation to the patient and their family, and the impact on my colleague in front of me. But most importantly – what had we done to prevent such an incident?
Who cut the common duct that day?
I would maintain many of us were holding the instrument:
- The company that provided the short course and “certification of competence” had a role.
- We as a hospital had a role in providing the privilege to do that surgery.
- The entire system had a role in our limited capacity to monitor the implementation of medical or surgical innovation.
But for sure, the patient was harmed, and the surgeon was alone on that day!
For me, this launched a major, lifelong clinical and academic interest in patient safety, and how the safety of all – patients and healthcare providers alike – is essential in our work.
Fast forward a few years. A trusted colleague and I were doing a workshop for PGY1 FM residents on coping with adverse outcomes in our careers. Towards the end of our session, one of our best residents tells us the story of the first night on call in clerkship on Medicine.
In keeping with the “Swiss cheese” model of medical error, a scheduling error and an illness resulted in two clinical clerks (JURSI’s here) and one PGY3 Medicine resident to cover the entire tertiary hospital for the night. The resident was busy in ICU, and after some delay, the JURSI’s are sent to assess a patient who is short of breath. They recognize the diagnosis of congestive heart failure (the admitting diagnosis), but given their limited experience, fail to recognize the gravity of the situation. As things deteriorate, more calls to the resident by the nurses ensue.
As anyone who has done this in the middle of the night knows well – the patient arrests before the JURSI’s get any help.
So what happens next?
The resident arrives, runs the futile resuscitation and says to the clerks, “there are two more admissions to do – let’s go!”
And now, in the workshop two years later, I am supporting the resident truly processing this traumatic event for the very first time. For the first time for this resident, we are teaching both the signs of impending arrest, and how we deal with our own frailties as providers.
So now let me take you to the launch of the Patient Safety initiative at Saskatoon Health Region. If you have not already had the chance, I suggest you watch this short video about Logan.
I have had the privilege of being invited by the CEO of SHR, Dan Florizone, to participate on the Oversight Committee for this incredibly important initiative. We have been meeting with a talented group of colleagues every Tuesday morning at 7:30 for over a month. Our group is ably led by Petrina McGrath from SHR and Susan Shaw from SHR and the CoM.
While I believe SHR is very brave in the open and transparent approach to such an important initiative, I can also state unequivocally that the approach is overwhelming supported by everything written about patient safety since the publishing of “To Err is Human” in 1999.
For me personally, it is tremendously exciting to be back in the “system” and contributing directly to an initiative improving patient care.
More importantly, I believe this is where academic medicine is meant to do its greatest work – enhancing patient care. I am particularly impressed at the work of our department heads and our faculty on this initiative, and look forward to the opportunities for our residents and learners to participate.
As my examples illustrate, it is absolutely essential for the CoM and our health education systems to be part of this initiative. While our education programs must incorporate the latest in patient safety, this is also a tremendous opportunity to do research.
My own personal interest is now diagnostic error (stubbornly sticking around 7-11% despite modern diagnostic tools) and how we teach diagnostic reasoning in medical education. This is a subject for another whole blog.
What SHR is truly doing is changing the culture here on patient safety. And that is a journey health education and healthcare must travel together.
As always I am interested in your feedback and my door is always open.
Preston
I applaud your initiative, and SHR’s. I would encourage similar work in Regina, where a good percentage of your learners are, well, learning. We are at a time where the public system partners with private providers in the interest of capacity. In this time we must ensure that quality control, staffing standards, and a culture of safety-first is upheld whether our patients are being cared for in a regional/public setting, or a contracted for-profit facility. Expectations and liability remain exactly the same whether we practice in a hospital or a private facility, resource quantity, and quality, should also be the same.
-J.
This is Informative and highly relevant. Fostering a culture of safety beginning in medical school will gradually imbue health care with a redefined culture of safety. In patient clinics, and associated clinical teaching sessions, I advocate that each patient have a named patient advocate in the event of medical emergency. Thank you for sharing your enthusiasm.
Pertinent and interesting comments.
In psychiatry, the suicide rate has not changed in 40 years. Despite all the commissions, research etc. there is little evidence that psychiatric assessments or therapeutic interventions affect the suicide rate. I think that our research points us in a promising direction. It is an uphill battle against accepted knowledge, organized psychiatry and the pharmaceutical industry, however. New ideas are accepted slowly.
I am gratified that Patient Safety is being formally recognized by SHR and the COM for its pivotal role in health care delivery. An essential element in promoting patient safety is moving away from the lamentably traditional model of ‘shame and blame’ in dealing with medical errors and near misses. We need to foster a culture where physicians and other members of the health care team feel safe in highlighting their own medical errors and patient safety concerns, with the focus being on quality improvement and positive systemic change.
Very timely issue for me as I have just interviewed 2 residents about several shifts where the patient care burden was almost overwhelming for the housestaff avaiable. This was related to a retreat where all residents from one service were gone and despite attempt to provide further ‘bodies’, the patient load for 2 consecutive days was too much for true patient safety, from what I hear.
I will try to address this issue with several other administrative people.
I work in SHR, this is very encouraging to read, both because SHR recognizes we can’t do this without doctors and also because doctors are so keen to participate.
When my father was hospitalized due to cardiac and other issues, he experienced two adverse events within one hospitalization, unfortunately the events were not dealt with in a transparent manner. As both an employee and a daughter, (although my father has since passed on) I applaud any initiative that will improve patient safety both within my own work and that of others.
Great blog post. I am truly excited for this work being done in the SHR. As a patient who has had several safety issues and harm happen both to me and family members. I am encouraged that the work is being done with the patient and family in mind. Bringing them in and being part of the team to find answers to make sure patient families and healthcare providers are safe and are in a no blame environment. That we will find a ways to continue to find answers and new ways of working together.