As I sat down to ponder what to write for this blog post, a thousand things seemed to pop up in my mind. Each lesson learned from our meetings, each stop-in-your-tracks quote, each incredible person I met today. I wandered into a forest today, but all I could seem to think about were the lovely trees. Perspective is a grand hand to hold though. As I think through the large themes and broad strokes of the picture painted today, I keep coming back to context. I have studied large-scale databases on preventable medical errors. I have had loved ones experience firsthand the chilling effects of preventable medical errors. Heck, I’ve personally been on both sides of small preventable medical errors at one point or another. How do they happen? Why do we feel like they’ll always happen? What specific systemic problems are in need of proper solutions? Where is the context?
I found that context today. Yes, patients are less safe because we are all human and are destined to fluctuate between our best and our should-be-better. Patients are less safe when one healthcare team member is pre-occupied or short-tempered. These all seem self-evident and, in many ways, easily explained away. We cannot simply explain away the errors of system though. Patients are less safe when the system put in place for the sole purpose of healing their wounds breaks down time and time again. Patients are less safe when a third-year medical student feels scared to question a doctor’s unsafe practices because he/she has gotten three of the doctor’s anatomy-related questions wrong in a row. Courage and ego should not equal altruism and excellence. When put in context, patients are less safe because we allow them to be less safe.
They don’t need to be though. We can’t keep allowing it. Here’s to another day of the fight.