What happened-
– today l heard and learnt about:
- The story of Lewis Blackman
- Implications of diagnostic errors
- Premature closure or anchoring
- The importance of transparency in health
- Mindfulness
- Communication
- The importance of open communication with the patient and family
So what?
1. Lewis’s story is so distressing because I have seen this happen multiple times before. The ongoing saga of issues associated with this has lead to multiple reviews and recognisable changes in the healthcare system to provide a “safety net” for acceptable “parameters”. The issue with this is the evidence behind the decisions making processes. Lewis’s story has allowed me to reflect on issues I have observed in the past and the frustration I have experienced as both a junior and senior member of the nursing team. This story demonstrates multiple failures and, with the benefit of hindsight we are able to form a clear picture of the events which led to his death. The focus of the system to heal is person failed as the system failed this person. I am privledged to live in a time where we are open to change, admission of wrongs, and an era of learning. It is essential we learn from his story to communicate to the communities we serve that this is unacceptable. It frustrates me that on multiple times the clinicians failed to recognise deterioration and we’re sure that their equipment had failed instead of looking at the signs and symptoms the patient was demonstrating. This highlights that we as clinical studies do not listen to our patients or families well.
2. The impact of the diagnostic and patient assessment skills of Lewis failed and this impacted and implicated bias into the thought processes of the clinicians on hand. He has chest pain from thoracic surgery, but we must always consider is this normal for the harm we have caused with this surgery or should we reassess? Diagnostic errors can cloud our judgement. In the instance of a patient i was asked to perform a procedure for, the consultant was sure the patient had lung ca, However he asked me to induce a sputum sample because there was a risk that this patient actually had tuberculosis and our administration of prednisone may have resulted in proliferation of the disease. I was asked to perform a procedure to rule out was our diagnosis wrong? Was our interpretation of our imaging wrong?
3. Premature closure, anchoring or tunnel vision biases our thoughts about theoretical diagnosis. The patient must have this disease, this symptom is abnormal but it cannot be related they must have something else. This is often seen too frequently in health and we as clinicians are expected to know, and provide an opinion. This opinion is then communicated to the patient as this must be correct. This is a failure and a falsity of our health system stressing excellence. It is ok to say I don’t know, however this should be followed up by I don’t know but I’m going to work with you to try to figure this out.
4. Transparency is becoming more apparent and vital for Health facilities to maintain standards, and deliver open , honest healthcare. This encompasses openness, honesty, accountability, discision making, reporting, expectations and outcomes. For every action there is a reaction. We have caused harm, however we apologise and are willing to work with you to achieve goals. This open communication however must fit within a SMART outcome measure as without closing the loop, we will never achieve full closure of an event.
5. Mindfulness to me means to never trust and always question. I do this frequently in practice, supported by current literature and evidence to demonstrate, what are we doing and is this the most effective measure we are taking? This needs to be holistic and it is essential to look at the patient as a whole and not focus on one model. I feel that this is something that is missing from healthcare as we are not mindful. The heart issues are fixed move the patient to the next service to manage. What is the answer? A multidisciplinary approach?
6,7. Communication between people and peers is vital. Although only a limited amount verbal we must be aware of all our communication tools at hand to deliver our message. Individuals learn through different mediums and the application of communication and learning theories can allow us to deliver our message coherently, effectively and in a manner which is understood by all participants in said communication. Communication breakdown is evident in almost all reported errors, however evidence is demonstrating that compliance with reporting is poor.
It is essential that the consumer and the provider work together to achieve holistic outcomes which are mutually beneficial.
What now?
The enormity of the task to drive culture change is mind boggling. However through utilisation of cyclic approaches to close the loop of identification, implementation and evaluation, health care can progress. It is vital that people understand the importance of reporting an error. It is vital that communication is open, honest and involved. Why shouldn’t the patient be involved with their healthcare? It’s about them. Partnership with consumers and the identification of focus areas for change is essential to drive change. Leadership plays a vital role. However what style is required? We do not want the laises faraire style as this is not suitable, however a dictatorial style may not work either. We need congruent and situational leaders to act as agents for change. Communication is so vital that without all will be in vain.