I was honored to participate in an extraordinary meeting tonight at Jeroen Bosch hospital. Hendrik Brink, head of the medical staff (seen at left), wanted to hold a session for doctors from various disciplines to discuss issues surrounding medical errors. I recommended that he use
The Story of Lewis Blackman, a video produced by
Transparent Learning, Inc., as a way of stimulating and focusing the discussion. The video features Helen Haskell, the mother of this 15-year-old boy who died as a result of a series of medical errors after elective surgery. The story is powerful, and you could have heard a pin drop as it reached its sad conclusion.
After the movie, the 50 or so staff doctors and residents broke into three discussions groups and then reconvened for a plenary session. They considered questions like the following: Was the situation in the movie recognizable? Could it happen in our hospital? What would you teach your residents to help avoid these kind of events? What are the obstacles to discussing mistakes--personal obstacles, those related to the patient and the family, those coming from the colleagues in your own discipline, and those coming from colleagues in other disciplines in the hospital?
Hendrik was assisted in facilitating the discussions by medical education dean Hans Hoekstra (seen above) and JBZ patient security officer Marjo Jager. They helped elicit comments and observations that were thoughtful and heartfelt. It was a very good evening.
At the closing, I asked them what messages they would like me to relay to Helen if I happened to see her in the coming days and weeks. Here they were:
Please tell her that we deeply appreciate what she has done in permitting this video to be made and in contributing personally to it with her extensive appearances on screen.
Please tell her that watching her make us feel that she understands the issues we face and that we therefore consider her to be a real partner with us in the medical community.
Please tell her that we will think about Lewis' story often and will do our best to make sure that this kind of tragic event does not occur in our hospital.
