I was honored to participate in an extraordinary meeting tonight at Jeroen Bosch hospital. Hendrik Brink, head of the medical staff (seen at left), wanted to hold a session for doctors from various disciplines to discuss issues surrounding medical errors. I recommended that he use
The Story of Lewis Blackman, a video produced by
Transparent Learning, Inc., as a way of stimulating and focusing the discussion. The video features Helen Haskell, the mother of this 15-year-old boy who died as a result of a series of medical errors after elective surgery. The story is powerful, and you could have heard a pin drop as it reached its sad conclusion.
After the movie, the 50 or so staff doctors and residents broke into three discussions groups and then reconvened for a plenary session. They considered questions like the following: Was the situation in the movie recognizable? Could it happen in our hospital? What would you teach your residents to help avoid these kind of events? What are the obstacles to discussing mistakes--personal obstacles, those related to the patient and the family, those coming from the colleagues in your own discipline, and those coming from colleagues in other disciplines in the hospital?
Hendrik was assisted in facilitating the discussions by medical education dean Hans Hoekstra (seen above) and JBZ patient security officer Marjo Jager. They helped elicit comments and observations that were thoughtful and heartfelt. It was a very good evening.
At the closing, I asked them what messages they would like me to relay to Helen if I happened to see her in the coming days and weeks. Here they were:
Please tell her that we deeply appreciate what she has done in permitting this video to be made and in contributing personally to it with her extensive appearances on screen.
Please tell her that watching her make us feel that she understands the issues we face and that we therefore consider her to be a real partner with us in the medical community.
Please tell her that we will think about Lewis' story often and will do our best to make sure that this kind of tragic event does not occur in our hospital.
6 comments:
Thank you so much, Paul. I am really humbled by this response and by your thoughtfulness in conveying these messages to me.
Today is the 12th anniversary of the events in the video. It is comforting to know people are thinking of him.
All the best,
Helen
Wonderful! There could be no better compliment to Helen and all of the work she has done through the years. She is a highly respected mentor and friend of patient advocates around the world. It is nice to see her recognized.
Barb
This is way too intellectual-most Medical Errors are caused by a lack of supervision. I am an ex Healthcare Administrator. But I found out about Medical Errors the hard way.
Now I'm becoming an expert on neurotransmitters because my elderly mother "caught" dementia OVERNIGHT. A nurse gave her a benzo sedative in her IV.
I now care for my mother 24/7. She always had a high IQ... which allows her to remember that a nurse poisoned her and caused severe brain damage. It's one of the few things she remembers. But she forgets my name.
I immediately detected that something was very wrong when visiting my mother the next morning. My sister and I made all the arrangements for an fast transfer to a university hospital.
The new hospital saved her life. She was originally hospitalized for a sprained knee.
My mission now is to warn the elderly and their families about the dangers of benzo sedatives and the unqualified nurses and physicians who dispense them.
I regularly tweet warnings about benzo Rxs for the elderly.
My yahoo article is at http://voices.yahoo.com/learn-benzodiazepines-gaba-neurotransmitters-10973308.html
Ditto what Barb said. And Helen, my heart goes out to you on this sad anniversary. Thank you for your generous help to those of us newer to patient advocacy. Lewis lives on in your work.
“Please tell Helen…” I can’t count the number of times I’ve heard people start a sentence with those words. They then go on to describe their gratitude for all they have learned from the tragic death of Lewis, and with the depth of her loss, her exceptional resolve to use this tragedy to take all of us in healthcare to a very different place and better place. In the process Helen has taught us and shown us the power of a networked community, as well as respectful, forceful, well executed process with Lewis, the patient, always “in the room.” Paul, thanks for this highlight and Helen my thoughts, prayers, and gratitude are with you on this 12th anniversary. Jim Conway
Helen,
My thoughts are with you today. Thanks for all you are doing to save other lives and to teach clinicians about safe and effective care. We owe you so much.
Maureen
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