Put simply a safe culture is one in which those in charge are willing to hear bad news and act appropriately. Developing such a culture is a central element of efforts to improve both the safety and the quality of care provided to patients. Just Culture: A Just Culture is one in which the line…
Author: RRHemphill
I am an emergency medicine physician by training, but have spent much of my career with a focus on trying to improve patient safety and quality of patient care. I have worked in government, military and large academic systems.
A Framework for Safety
Developing safer health systems takes a long time…a really long time. And the terrible thing is that you can spend years building a better system and it doesn’t take much time to tear it all down. A smart person once said that trust is earned in sips and lost in buckets…safety feels like that too….
Where To Go Next With Safety…
When thinking about how to help expand knowledge around patient safety, it’s hard to know where to start. But a recent court case helps remind us what is at risk. A nurse practicing at Vanderbilt University made a catastrophic medication error that resulted in the death of the patient that she was caring for. A…
What Do the Five Stages of Death and Dying Have to Do With Patient Safety – Part 6
This is the final section in this rather old article that I wrote. As I look at it again, I realize that we have continued to make progress, but we still have a long way to go. Acceptance: Despite the difficulty of the task, encouraging work is being done in improving medical quality and patient…
What Do the Five I’ve Stages of Death and Dying Have to do With Patient Safety – Part 5
Depression: This section can be short and to the point. Having exhausted all ability to deny the problem or to explain away the findings, I felt overwhelmed and a bit sad. If, as it seems, intelligent, well intended, and hard working people can still collectively be participants in a system with such problematic outcomes, what…
What Do the Five Stages of Death and Dying Have to do With Patient Safety – Part 4
Bargaining: Finding that denial was no longer an appropriate response to the evidence, I moved onto my version of bargaining. It went something like this – perhaps the poor outcomes being described are true, but even if they are true the type of patients we care for are contributing to these outcomes. The complexity of…
What Do the Five Stages of Death and Dying Have to Do With Medical Error? – Part 3
Anger: Despite my attempts to dismiss the IOM report, the media continued to give it considerable press. Unlike many media events related to medicine, this one did not go away after the initial fanfare. It was repeated multiple times and increasingly the number of deaths was linked to images that the public could easily understand….
What So The Five Stages of Death and Dying Have to Do With Medical Error – Part 2
Denial: I do not want to trivialize how devastating it is to receive a diagnosis of a terminal illness and it may be a sad testimony of how much of my life is identified by my profession that the IOM report seemed to so disturb my world. However, when the report was first released my…
Why Patient Safety is Hard
What Do The Five Stages of Death & Dying Have to Do With Patient Safety It’s Not What You Think. To start, I thought it might be helpful to pull out something I wrote quite some time ago. It was my thoughts on my first reactions to a report from the Institute of Medicine called…