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.