Many things stood out yesterday but I shall just make a note of a few things. Some of the things that resonated with me yesterday was listening to people’s lived experiences that resulted from a cumulative effect of system errors, such that when aligned can be tragically fatal. Take for example the story of Helen’s son in the USA. I was just squirming in my chair with discomfort watching it, and at time unbearable to watch how the situation unfolded. Yes, there is the power of hindsight, but rather than have a punitive view of the individuals, it highlights the totality of errors when they align and have flow-on effects. Rather, it allows us to reflect on the system we work in and how those actions and cognitions could have occurred in our workplace. So it was a learning curve and this is a film that needs to be shown to us in pre-clinical years as students, during clerkship and even when we are working in the health force, serving as a reminder of what are primary goals are working in health care, which can easily lose its place at its core as we become task oriented as part of the work we do routinely. To be told of the concepts relating to patient safety among lecture slides when removed from such real experiences can sometimes lose its meaning. The power of this message was reinforced when Carole told the story of her daughter. The message was truly powerful. Her story was able to be strengthened by its delivery and the way she changed perceptions from beginning to end. It provided greater meaning to a patient’s ability to open their trust to the health system again, something we can easily take for granted and should not lose sight of.
