Learning from medical errors

As an empowered patient I’m willing to go to the ends of the earth to help the medical community get beyond the famed “culture of blame,” so everyone involved can learn from errors.

Boston’s Beth Israel Deaconess Medical Center had a wrong site incident, and responded by discussing it quite openly on the CEO’s blog. (See The Message You Hope Never To Send. As often happens in a good blog community, the extraordinary comment thread is more valuable than the post.)

I’m heartened but not surprised to learn today that Dartmouth has already made a case study of the incident.

I’m moved almost to tears by the extraordinary bravery and integrity of the people involved in the case for their willingness to openly share what happened. Were I in that position, I might fear that it could end my career. But as the comments on the original post show, a superb culture can be built in which people are willing to even be interviewed on camera about what happened, what went wrong, and how it might be prevented in the future. The world can only benefit.

My hat is off and my heart goes out to people who are so committed to building a better world, no matter what.

I suspect that the new world of participatory medicine will require much greater openness and trust all around. Praise be to the pioneers who are making it happen.

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Posted in: hc's problem list | positive patterns | reforming hc | trends & principles

 

 

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3 Responses to “Learning from medical errors”

  1. Ted Eytan says:

    I’m here at Dave’s suggestion to see how the live comment preview works – slick! And you also converted to WordPress, congratulations!

    While I am here, I want to say that I agree with your sentiments and hope we will push them further into everyday care processes.

    What would happen if a patient said to their personal physician, “I have some suggestions for improvement for the doctor who saw me when you were away” and the personal physician said back, “I would love to hear them and convey them to my colleague. Your feedback is a gift to help them be a better doctor,” and then provided the feedback in that spirit.

    As it is said, it’s better to improve 1,000 different proceses once than one process 1,000 times. Doctors and all care providers in the world of participation don’t have to feel on their own – everyone is on their team, and vice versa. Do you agree?

    Nice preview, e-patients!

  2. [...] Dave deBronkart of e-patinets.net admires extraordinary bravery and integrity of the people from Boston’s Beth Israel Deaconess Medical Center who performed a procedure on the wrong body part and openly shared what happened on their blog. [...]

  3. [...] Indeed. We should be doing our best in preventing medical mistakes and, should they occur, learning from medical errors in a transparent manner, to minimize the chance of repeating them. [...]

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