Thursday 26 January 2012

Medical Errors: Breaking the Culture of Silence

Every doctor makes mistakes. But, says physician Brian Goldman, medicine's culture of denial (and shame) keeps doctors from ever talking about those mistakes, or using them to learn and improve. Telling stories from his own long practice, he calls on doctors to start talking about being wrong.

In his recent TEDX talk, Canadian physician and radio personality, Dr. Brian Goldman, called for a revamp of the culture of medicine. He made a compelling argument to reinvent the mores in his profession that currently prohibit health care providers from admitting errors and most importantly, learning from those errors.

Last week, one of Nicholas' doctors made a medication error that caused our family to spend an uncomfortable night in the emergency room. She apologized. I drafted a suggested change in protocol that I thought might help to prevent any future errors in Nicholas' (or others') care, which she accepted graciously. Perhaps this battleship of error denial is slowly beginning to turn around in the river.

Today, Louise Kinross, editor of the special needs parenting blog/magazine "Bloom" shared with me the latest apparent turnaround in the Amelia Rivera case. (Details of the case can be found in my previous posts.)

Today, the Rivera family posted an update on the Wolfhirschorn Awareness facebook page:

Over the weekend, a meeting took place between a number of the key leaders of the Children's Hospital of Philadelphia, the Riveras and The purpose of the meeting was to get an understanding of the chain of events that led to the Brick Walls posting. The meeting lasted a little over 90 minutes and the Riveras had an opportunity to tell their side of the story and the related concerns about Mia's needs and how CHOP handled the situation. CHOP agreed that the system is broken and that they are taking steps to fix the process. In addition to addressing Mia and the next steps with her transplant discussions, a few suggestions were made to CHOP about their involvement in a more macro-view of awareness around transplant rights for the disabled, and public and medical community education around the "mentally-retarded" phrase. CHOP agreed to follow up and communicate their action items by the end of this week.

Mia and the Riveras are planning a visit to CHOP in the near future to determine CHOP's role in her transplant and her ongoing medical care. Once that meeting takes place, we will issue a statement on the status of Mia, her care, and CHOP's involvement moving forward.

Nicholas has been on the receiving end of too many human errors in hospitals to list here. The fact is that doctors and nurses ARE human. Often, they are sleep deprived. Mistakes happen. But errors really do offer the opportunity for learning and changing, even if those errors lead to loss of life. I'm with you, Dr. Goldman, because patients and their families can be team players too.


Anonymous said...

When you said "I'm with you, Dr. Goldman, because patients and their families can be team players too. " I agree with you 10,000%

There were many times that I had problems and told doctors what it was, and they laughed. like Stomach muscle spasm - they never heard of it but I knew it and they laughed. So I bought the strongest muscles relxant in a non precription section and took them and the stomach muscle disappeared


I only need doctor to get me pills, not advice.

Anonymous said...


Has Nick experienced more medical errors as an adult?

I humbly thank you for your time.

Matt Kamaratakis

The Caregivers' Living Room said...

Hi Matt, No Nick has not experience more medical errors as an adult, but that is only because the majority of his time spent in hospital was before he turned 18. He is very medically complex and has had over 70 hospitalizations. The likelihood of medical errors goes up with the time spent in hospital and number of procedures undergone. So, when things get hairy, at the same time as nursing/doctor shift changes, on a weekend....that's when mistakes happen. Medication errors are all too common. Once Nick received 15micrograms morphine per hour instead of 1.5, another time he double dosed badly on morphine in ICU because when the pumps were changed, the doctor forgot to disconnect the first one, so two pumps ran for four hours before anyone noticed (that was post major surgery). That's the sort of thing I am talking about.