To Err is Human - and we are all human
I recently viewed the documentary "To Err is Human".
This film tells the tale of the Sheridan family and how they were failed by different parts of the US health care system not once, but twice; a tale of heartbreak and fear, resilience and perseverance.
It is a well told story that chronicles the steps and missteps that brought them to their current places in life: Cal is a 23-year-old man with Cerebral Palsy and Kernicterus (and a comedian, by the way); his father, Patrick, died almost 2 decades ago of misdiagnosed terminal cancer; his mother, Susan, works to advocate for changes in the system; and his sister, Mackenzie, is pursuing a career in public health.
What struck me about this film is that it warns us to be vigilant in matters surrounding our own care and the care of our loved ones, while avoiding a strictly accusatory tone. It alternates between the errors that were made in the Sheridan family's care and taking a few steps back to look at the big health care picture. It acknowledges that as humans we all make mistakes, and evaluates the processes, policies, and procedures that allow for those mistakes to lead to harm.
This is a film about being proactive - at both an individual and a systemic level.
"Everybody is responsible."
It has long been recognized that times of transition present the most potential for errors, as they are most often multifaceted and complex. There are many types of transitions as an inpatient: from ER to admitted inpatient, from night shift staff to day shift staff, from hospital to home, from rehab facility to assisted living. Even as an outpatient we transition from one insurance company to another, one provider to another, one medication to another, and the list goes on.
Each person in the health care system (as well as the health care system itself) must accept appropriate responsibility for his or her part in the process, acknowledging the critical role that each plays. Whether mopping the floor of the operating room, preparing meals in the hospital kitchen, administering IV fluids at bedside, or performing heart bypass surgery in the OR, each person's attention to detail is vital to positive health outcomes.
As patients, our role is to be as observant as possible and ask questions when we don't understand what or why.
"You can't solve it if you can't see it."
My takeaway from this comment is that medical providers need a better, more formal, non-punitive way to report medical errors. All medical errors.
It's crucial to our health to develop a program that encourages reporting in all settings, including hospitals & skilled nursing facilities. Diligent, consistent error reporting is required to do an accurate risk management assessment, which will result in a more accurate picture of root causes and systemic insufficiencies. In order for patient safety to change in any meaningful way, there must also be a shift in the culture of medicine, as well as in the way we address malpractice within the legal system.
Our duty as patients is to let medical personnel know as soon as possible if we think there is something amiss. Unfortunately, for now we also need to push this information up the chain of command to be sure the right people hear it.
"You can't manage what you can't measure."
It was very heartening to see this documentary present some of the steps that are being taken to more accurately assess and address medical errors. One such step is using an "OR Black Box". Similar to black boxes of the aviation industry, this device records every detail of a procedure, including who is performing which part of the procedure, and exactly when and how often the door to the OR opens.
Whether or not this particular device will be the answer, I don't know. But it gives me hope to know there are companies developing tools to measure and increase safety.
This is an important film to watch, with many noted professionals offering their insight, thoughts, and wisdom. Let's all work together be part of the solution. Our health depends on it.
More information, including where to view it, is available here: https://www.toerrishumanfilm.com