System Errors or Human Errors

When Errors Happen is it The System?

When I am hired by a hospital or medical facility to speak to the staff about patient safety, my first thought is that this is a facility that cares about safety and patients.  Since my work is primarily about patients and their safety, it must mean they are serious.  Why else would I be there?

Still, there is never a guarantee.  I spoke a few years ago and a hospital.  Once for senior leadership and then for the “hands-on” patient staff.  A double presentation because they are “that serious” I thought to myself.  Unfortunately there is no guarantee no matter how hard they try, that patients will be safe.  I just read an article about that hospital and a patient who died because of the care he received.  Although there may be many others, this one made the news.  I truly believed that this hospital, in another state, was serious about patient safety and though I believe the people I was involved with there were serious, there are so many opportunities for errors to happen.

Most people in healthcare call the errors or unplanned deaths “system errors” not enough staff, distraction by a nurse or pharmacist or any number of reasons a mistake can happen.  In this case, as in many cases, this hospital’s system, in my opinion was working.  Instead someone may have cut corners or not went to leadership about the problems that ultimately caused this patient’s death.

When a family members calls to talk about a bad outcome at a local hospital, I suggest they speak to the hospital leadership.  The people who are running the facility may not even know that an injury occurred or why.  They need to know where the system, or people are failing.  I also looked carefully at this article – without all the facts and saw where a trained family member may have been able to save this patient’s life.  A trained family member may have been in a position to speak up and alert someone that something doesn’t seem right.   They didn’t and the patient died.  If they did, how would that be measured?

Sign up for Family Centered PatientAdvocacy Training at Hofstra University, Hempstead, Long Island.  Register Her:  http://www.pulsecenterforpatientsafety.org/family-centered-patient-advocacy.html 

Listening Skills Learned

Is the Country's State a Practice in Listening?

As a patient advocate, it is my job to be objective and nonjudgmental.  I listen to the patient and their family and listen to the doctor or nurse explain to the family  whatever it is they need to explain.  It is not up to me to make decisions for the family.  It is not up to me to agree or disagree with the care plan.  It is up to me to be sure that information is given in a way that the patient and family understand and that if they don't, they can ask questions.

In my work, I often listen to patients who have special and unique needs to learn what their obstacles are for safe, quality medical care.  People with severe illnesses, families of people with dementia / Alzheimer's, young single mothers to name a few.  I learn from them what it's like to be them, though I don’t pretend to always understand it.   I also get to spend time at the bedside with families and to be with them during this often, difficult time of pain, sorrow and vulnerability.  Advocates who take our training learn the importance of these

skills.

So, what’s my point?  I also listen to conservative radio and liberal news, speak to people who have opposite views from my own and want to learn what makes them think the way they do.  I want to hear what makes people so different in their thoughts and ideas. There is a lot to learn about different viewpoints.   People are angry and frustrated with the way things are in today’s political setting.   

What is concerning is when people use words with no appropriate relationship to what they really mean.  Name calling, making fun of someone’s appearance, or using words not related to the problems being addressed.

As soon as people use, as part of their dislike for someone the way they look, walk, dress, their facial expression or hairstyle it takes away from the important facts that we need to concentrate on.  How boring this world would be if we all agreed.  For those of you who want to moderate, mediate and / or advocate for others, there is plenty of practice opportunities in today's daily conversation.