Today has been an enlightening day in learning about patient safety. My favorite part of today was Laura’s lectures on transparency and just culture, which I found to be really informative. As a medical student, I believe that we find ourselves sometimes in a confusing position because we either 1) believe that because we are on the bottom of the totem pole, we are not free to always share our thoughts or 2) we simply assume our residents or supervising attendings will report events about patients that we have been following. I think back to this one patient that I always lament over. Back in April 2022, I was doing my psych clerkship in a child psych in-patient unit. We were consulted for a 17 y/o female for altered mental status in the ED. When we visited the girl, we soon realized that neurology had not been consulted first, but no ED staff seemed to be available for questioning, and a guardian was nowhere to be found. We proceeded to interview the patient anyways with little to no background information. After listening to her story and seeing how distressed she was, my fellow had a suspicion that the patient may have conversion disorder, but without a neurology consult, the patient cannot be properly given such a diagnosis. When sharing our recommendations with the ER doctor that they should consult neurology, instead they discharged the patient without consulting neurology and without giving her further treatment. I will always think about this patient of mine and regret that we couldn’t do anything more for her, and if anything I wish I could go back in time and report this safety event if only I had known how. But after today, with the newly equipped knowledge, I will endeavor to improve my part in patient care and ensure that I learn how to report safety events back in my community healthcare system so that something like this doesn’t happen again.
