I absolutely appreciate that Telluride not only educates us about medical errors in healthcare but also empowered us with the tools to manage events when they do occur especially how to have crucial conversations with families when a medical error has occurred. Showing the impact of medical error on both families and caregivers highlighted the need to have a comprehensive response approach to medical errors that include critical components such as GO-Teams to initiate event reviews and care for the caregiver programs to support the medical team member(s) affected. As was clearly shown today, family members deserved to be listened to, provided with honest answers and not to be subjected to the old way of deny and defend, which does not benefit healthcare nor families. I think one key thing that has manifested in most of the videos that must be given greater attention to in training healthcare providers is knowledge of health literacy. We saw in more than one of the videos how highly educated individuals did not understand health information that was conveyed to them – for example, the lawyer having to google information conveyed to him. Every day we literally speak a “foreign language” to patients and families and expect them to make critical life or death decisions. How we convey that information has implications. As noted, we use medical jargons and provide informed consent forms that are written at the level of scientific journals. Greater efforts must be made to emphasize communicating simply and clearly as well as creating patient education materials that are written at a grade five/six reading level.
Managing Error Events and Communicating Clearly – Day 3 of AELPS, NAPA
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