When I first went to medical school, I was interested in all of the factors that impact a person’s health besides what I was seeing in the exam room. Little did I know that so many of those factors may end up being things done by myself or by other members of a patient’s care team. Progressing through my training, there were countless instances where mistakes were caught, either by built in safety nets or by pure luck in catching a near miss. As I learned about patient safety and I started to identify all of the room for error that exists in day to day medical care, I started to get more interested in what I could do. However, the patient experience that really pushed me into getting involved in patient safety was a relatively simple one.
A patient I was caring for was diagnosed with C difficile diarrhea. The results came back overnight and the cross-cover resident started treatment in accordance with our hospital’s algorithm. In the morning, I confirmed with the algorithm and continued treatment. The patient was hospitalized for a quite a while, and after completing the full treatment had a recurrence of symptoms and found to have a recurrent C diff infection. After reviewing the algorithm again, we found that she actually should have received a different initial treatment due to a high risk of recurrence. After realizing that two of us had followed the algorithm to the wrong conclusion, it seemed that maybe there was a problem with the algorithm rather than with us. My attending encouraged me to submit this event through our safety reporting system, and I described how the algorithm was misleading and what I thought would be better. In just a few weeks, I got an email that they had updated the algorithm in accordance with my suggestion.
I felt like with this change in the system, the error we had made would be less likely to occur again. Not only that, I had fun working through the problem solving to identify and address a system error. With that, I wanted to learn more about patient safety and quality improvement and how to become a leader in making change to the systems we work within.
