A Patient Safety Conference; About Patients But Not For Patients
I sat on zoom for hours
today to attend a patient safety conference. A PATIENT safety
conference. The first one I went to was in 1999 when I heard healthcare
professionals share their stories of their own lost loved ones. Some,
over the years, have even shared with me in secret what they have gone
through. The pain, the anger, the struggle, and grief of losing a loved
one because of the system they worked for. I don’t even know how many I
have gone to since then.
Today I heard about
human factors and how we all make mistakes. A nurse makes a
mistake and the patient dies. Should she be fired? What should
the punishment be when a doctor injures a patient because of the wrong
diagnosis? The popular Swiss Cheese Model that anyone can plug up a hole and
keep the mistake from reaching the patient. Yes, there was talk
about family involvement, but extraordinarily little, and only after the patient
arrives at the hospital. Who is teaching the patient or family about
plugging up that hole?
We will keep blaming
hospital staff when they get it wrong because no one is even suggesting that
the PATIENT needs to take some responsibility for their own
safety. Sharing their allergies – accurately - prepare your symptoms
- accurately – full medical history – accurately – list of medications –
accurately and yes, even demand that the room is cleaned, and hands are washed
to avoid infection. This is not rocket science.
One speaker brought up
the airline comparison that when there was a bird strike, as annoying as it was
to be delayed, they played it safe and changed planes. The pilot, he
said showed concern for the passenger’s safety first. Well – go
figure, maybe it was the pilot’s own safety that concerned him….
Two more days.
Maybe something good will come out of all this.
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