Critical Reminders from Day 1

Reflecting on our first day of the Academy for Emerging Leaders in Patient Safety and I am feeling blessed for the insights, the lessons and for the reminders.

Yesterday morning we watched the Lewis Blackman Story – we were fortunate to have Helen Haskell with us, Lewis’ mother, who graciously and bravely answered our questions, provided more insights and shared the reminder that this November marks the fifteen-year anniversary of the death of Lewis.

I’ve seen this video more than a few times and to be honest was thinking to myself that there was not much more to “learn”. How wrong was I?

Re-watching this emotional story I was abruptly reminded that the stories of communication failure, mis-diagnosis and poor communication are as real and relevant today as they were fifteen years ago, and that being reminded of the work ahead is critical to this effort of making patient care safer, more just, and more transparent.

I watched the video again, took new notes, re-read those notes, and listened to the story and the discussion. I heard things I hadn’t heard before, heard perspectives that I hadn’t paid attention to in the past, learned new lessons, and was left with a re-galvanized commitment to this difficult, rewarding, and necessary work.

In the work that I do with healthcare leaders to change culture, I hear and see a lot of conversations, interactions and exchanges. Having the ability to reflect on what I have heard or seen, either from reading my own notes, re-remembering my experiences, or having the story interpreted by someone with a different perspective, provides me renewed energy, fresh insights and ideas about alternate solutions.

Day 1 reminded me that re-visiting the stories, notes, videos, conversations and perspectives are some of the most powerful reminders of the work still ahead to change the world of patient safety.

Thank you Helen for the reminder.

Numberless diverse acts of courage

Yesterday afternoon the faculty and students at the “Telluride-East” Patient Safety Summer Camp visited Arlington National Cemetery.

As we paused for some reflections from our leaders Paul Levy and Dave Mayer I was overcome by the scale of what presented itself in the form of field upon field of white grave markers.

Poignant words reminded those gathered that we were indeed standing on hallowed ground and that many have given, and continue to give, the ultimate sacrifice. A sobering reality is that there are between 25 and 30 new burials every day at the cemetery.


Arlington Cemetery


Following our time of reflection I took a walk to reflect on the sacrifice, loss, and scale of what lay beneath me. 400,000 markers of lives once lived, now at rest.

In a recent piece of research published in the Journal of Patient Safety it is estimated that more than 400,000 hospital deaths are attributed to preventable harm. Put another way, since August 2013 more than 400,000 mothers, fathers, brothers, sisters, sons and daughters are no longer alive as a result of harm that could have been prevented with better designed systems, more situational awareness, and other proven human factors and safety science approaches in health care.

I think these numbers are becoming “noise” for many leaders in healthcare, we have heard the numbers and yet still choose not to make the different decisions and the difficult choices. We disassociate from the difficult reality because we don’t “see” the totality of what we are doing.

The grave markers stopped me in my tracks, a visual reminder of what we are doing every year in healthcare by tolerating variation, blaming people, doing the same things over and over and expecting different outcomes.

My walk took me to the Kennedy family grave site. Off to the side of the eternal flame is a Robert F. Kennedy quote that really resonated with the work we are doing with the faculty and students at Telluride-East:

 JFK Quote

It is from numberless diverse acts of courage and belief that human history is shaped. Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance.

Robert F. Kennedy, South Africa, 1966


This quote captures what I will leave this time of learning and sharing with, and what I urge the students, residents and faculty to find the courage to continue doing…

  • Lean in and keep speaking up to improve safety; these are the “numberless diverse acts of courage”
  • Believe in yourself and the difference you can make
  • Stand up for what you know is right and stand up for those less brave and courageous than yourself
  • Speak up, even when your voice quivers and your hands shake. Speak up for patients, the ones you care for, know and for the one’s you dont…
  • Most of all, send forth a “tiny ripple of hope”. These ripples will build to a current. These ripples will make care safer
  • By thinking and acting differently, by bravely speaking up and taking a stand we will sweep down what often feels like a mighty wall


I commit to making ripples and I urge my new found colleagues and friends to do the same.

Make ripples. Ripples save lives, ripples make care safer.


Re-learning the lessons of distraction and over confidence…

My wife and eldest child are out of town; my youngest child is at a sleepover. I decide that this “free” evening is an ideal time to get some things accomplished around the kitchen.

Its 8pm and I decide that while catching up on televised network news, I will also check emails while cooking some meals for the week (following a recipe on the iPad), and prepare myself some dinner.

By means of background, the task I am about to undertake is one for which I am well-trained, and have a plethora experience with, after all it is the simple task of chopping an onion.

Chopping Onions

I learned to cook in the kitchen of the Savoy Hotel in London, where I was extensively reminded of the importance of knife safety, and repetitively trained and retrained on the appropriate technique for dicing, slicing and chopping of said onion.

With the first slice of the knife I removed the tip of my left pinkie finger…

What followed was a relatively calm elevation and compression exercise, while putting away all the dinner and meal ingredients, turning off the TV, laptop and iPad, and then determining what to do…

Over the next twenty-four hours, I heard from my OT, RN and MD friends that this was a reminder of some of the basic tenets of distraction, safety science and human factors. This was, after they cared for my injury, treated me exceptionally well, and suppressed the giggles and smirks of “funny that the guy that talks about reducing distractions and putting error prone humans into safe systems doesn’t seem to heed his own advice…”, a somewhat painful and rather bloody example of to err is human.

The loop was especially well closed by my friend and colleague, David Ring MD at Massachusetts General Hospital (MGH). David is the Chief of the MGH Orthopedic Hand and Upper Extremity Service, someone I have known for several years, and someone whose willingness to talk openly about his own humanness and natural tendency for error has been an inspiration. Check out his mea culpa:

David took a look at my finger within 24-hours of the accident, and recalled the fact that there is a human tendency to take the routine, habitual, oft repeated task, and stop paying attention to the risks associated with it. He shared that when driving long distances his wife will take the wheel; for him driving has become routine and habitual. He, and most likely she too, are aware of the fact that he is not paying attention to the small variations that could ultimately lead to a harm event.

I had undertaken my routine task so many times that I believed I could simultaneously safely perform other tasks at the same time, while taking in the noise of the digital world along with TV images. This over-confidence resulted in a missing fingertip. This over-confidence in healthcare environments can result in care providers putting themselves, and their patients, in unsafe and potentially deadly situations. While still dealing with the discomfort (and embarrassment), I am kind of grateful for the reminder.

Now – how to break this news to my wife…