Both the film we watched and the Teeter Totter exercise strongly impacted me today. In the film, I was particularly shaken by the massive number of opportunities each person had to notice a failure in the system and still did not. Over the course of the weekend, there were multiple educated professionals who were meant to have the skills and knowledge to identify and intervene accordingly. And they all went in and out of that room. We learn about anchoring and confirmation bias in medical school, but it was a difficult-to-put-into-words experience to watch those concepts lead to a fatal outcome. In a way, the exercise with the Teeter Totter better informed how I felt. When we debriefed after the exercise, right after our group failed to protect one of our egg-cellent patients with the last two people hopping off, the point was made that most “failures” occur when people are stepping off the board. Mistakes happen when vigilance drops. Mistakes happen when the awareness that they could happen fades. In the film, mistakes seem to have happened also because there was failure to remember that life-threatening situations are a very real-life possibility. It’s understandable to want to assume the best especially in situations that could ease the patient. But today taught me that keeping my guard up is not meant to be add anxiety or stress to our days in healthcare but rather means acknowledging all the possibilities including individual and systematic errors so as to anchor me to patient-centered care.
