I still remember it clearly. It was the beginning of my 2nd month of intern year. An elderly gentleman was admitted with a heart failure exacerbation. We had adjusted his medications and were able to successfully diurese him back to the point where he was comfortable discharging home. Two days later he’s back on our hospital team. I went and talked with the patient and said “What happened? We had a good plan in place to keep you thriving out of the hospital?” It turns out I was the problem. I had made a mistake when reconciling his medications in preparation for discharge and he tipped back into heart failure. I was so embarrassed but my attending at the time said “You can make mistakes and still be a good doctor. But you need to go and be honest with the patient that this is on you.” So I went and did exactly that. Fortunately, the patient and his family were gracious about the episode, no serious harm occurred, and he was back out of the hospital in 2 days. I learned a very important lesson from that encounter, and it has impacted how I approach medication reconciliation to this day.
Attending AELPS is important to me because as physicians we are stewards of our patient’s wellbeing, and that trust deserves to be honored. Our healthcare system is complex with many moving parts. I think from a historical lens, physicians have been viewed as a “captain of the ship” in terms of mustering together the right talent to yield a favorable health outcome. Far from the days of old where independent providers would bring care into the home and the interventions were limited, the modern patient has many more people involved in their care than they could ever realize.
As a hematologist I treat aggressive leukemias when people are hospitalized. What kind of team does it take to accomplish that? The visible components include the physicians, phlebotomists, nurse aides, advanced providers, nurses, and the housekeeping staff. But the invisible components include laboratory staff and pathologists to ensure I have accurate data to guide my treatment. The pharmacists who triple check to make sure the right dose of chemotherapy is prepared and administered. The administrative leads who safeguard that we have adequate staffing so that individual team members are not stretched too thin, and patients get adequate care. And there are so many others.
As the complexity of delivering medical care has increased, so has the opportunity for mistakes to occur and undermine our best efforts/intentions. An individual member of the team can do absolutely everything right and patients can still suffer harm. Our healthcare system is full of well-intentioned people where despite these good intentions, we still see patients get harmed. I have been the nidus of numerous near misses and I wholly understand that natural instinct to want to shy away from wanting to understand what went wrong rather than embrace the question “how we can change things to avoid these opportunities for harm in the future?”
I hope this week at AELPS will help me learn several things. How to be a leader in developing a culture of patient safety at the health system I am going to. How to recognize opportunities for error before someone ever gets hurt. How to put into place processes for addressing problems with patient safety. The organization I am joining after fellowship has given me the opportunity to be a leader in organizational safety. I’m excited to see what additional learning I can taker away from these sessions to be a better advocate for the safety of my patients and all patients across our system.