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Posts tagged ‘quality improvement’

Doctors make mistakes.

TED posted this powerful talk today about the toxic culture of perfectionism in medicine. This shows the importance of acknowledging mistakes—not only for patients, but also for quality improvement efforts and for physicians’ well-being.

It takes a lot of courage to do what this doctor did: to get up in front of a crowd and trot out a laundry list of personal mistakes. Most doctors seem to have one story they’re willing to tell, usually about a mistake they made during residency. So is Dr. Goldman just a terrible doctor? Maybe. But he felt it was important to speak on this topic, which tells me he’s probably a great doctor. And if great doctors make mistakes like this, what does that say about the mediocre doctors? So many errors and near misses go unreported and unacknowledged. How can we fix the system and care for our doctors when we don’t know the whole story?

Trust and disclosure of medical errors

Last week I attended a discussion about the disclosing medical errors to patients. The discussion was structured around an example case in which a patient was given the wrong medication but fortunately experienced no complications as a result. As with most hospital errors, this represented a failure at several steps of a complex process, with mistakes by multiple people/departments. When the nurse realized the error, the nurse asked a member of the medical team to write a prescription for the medication the patient actually received (i.e., a prescription for the error).

In high-reliability organizations such as healthcare, aviation, and law enforcement, trust is vital. Errors could cause deaths, so workers must carefully coordinate complex actions (e.g., airline travel). High-reliability organizations prevent catastrophic errors by fostering strong relationships, honesty, and trust. For this trust to develop, there must be psychological safety. When teams share a sense of psychological safety, they feel safe admitting errors, challenging others’ views, and engaging in other types of “interpersonal risk taking” (Edmondson, 1999). Psychological safety plays a role in whether providers disclose errors within the organization—to fellow team members, to other teams, and to administrative personnel.

But what about the patient? Read more