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.