Friday, July 24, 2009

I'm so very sorry

Tomorrow is National Patient Safety Day, a time to remember people who have been harmed while seeking care or cure. It's also a time to consider how people--patients, providers, and those who have been or will someday be patients--can improve the care delivery system and eradicate preventable harm.

Patients are infrequently the target of professionals who intend to harm them. But people, millions of them each year, are nevertheless harmed. I'm sorry for preventable harm that has occurred and sorry for preventable events that loom.

I was a hands-on clinical nurse for a long time. I don't think I've been the last person in a chain of events that resulted in harm to a patient. But I could have been, any healthcare provider could be. Clinicians frequently fly without safety nets, and it's often grace--not structure or safeguards that come when hearts, minds, and wallets open to achieve and sustain reliable processes--that distinguish clinicians with pristine records from those who err. I'm sorry for errors I may not have seen, known to report, and for near-miss events I didn't see as valuable in the fight to eradicate errors.

This morning, it didn't take me long to find a credible account detailing what patients and front line clinicians face each day. In A Nurse's Very Bad Day, New York Times health blogger Teresa Brown, leaves readers with an unflinching picture of what good people who work in, and depend upon, our well-intended but unreliable system regularly face. I'm sorry that a strong, competent nurse cries like a soldier at the end of a battle in civilian territory. I'm sorry for the risks her patients face.

The answer to how millions of people are harmed from preventable medical errors each year lies in all the tiny details that went wrong in Teresa's Brown day. These answers are not easy, cheap, sexy, or full of star power.

People, like me, who are sorry about the harm that has occurred--particularly those who seek to reform healthcare--should harness this sorrow and transform the system into something that's not so regrettable.

In the meantime, let me just say: I'm sorry. I'm so very, very sorry.


Trisha Torrey said...


Thanks so much for this post. It is heartfelt and appreciated.

You might be interested in my post about apologies. From a patient who experienced one and believes it's important for providers, too.

WWWebb said...

I just got the PICC put in for six weeks of IV Vancomycin for yhe MRSA they cultured out of my ortho wound...and nobody's telling me anything beyond the bare minimum at this point, much less apologized.

And as an ex-EMT, I'm of the mindset that gives my providers the benefit of the doubt, although this is starting to change.

Reality Rounds said...

It is the culture of medicine to believe that saying "sorry" is admitting to a mistake. But for me as a human being, if I was a patient and an error was committed, I would appreciate any apology. We are all human beings for crying out all loud.

Sean said...

While saying sorry can be enough for now, the hope is to create an environment where we don't have to worry about saying sorry.
A continuing work in progress. Ever forward. Ever forward

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