After my last column describing communication missteps in treating a patient, Change received complaints for publishing such frank illustrations of our shortcomings. When people don't like the message, I guess they want to shoot the messenger.
I have only one purpose in writing about lapses in patient care: to make Johns Hopkins Medicine the safest and best system of health care in the entire world. No patients should ever have their care (and even their lives) jeopardized by errors, mistakes or lapses in communication. Yet, every day, we are at risk of doing just that. I wish it were not true, and I certainly don't enjoy writing about our foibles.
Case in point: Since the last Change article was published, I found out that we had a new sentinel event, one in which an operation was conducted improperly—most likely, I am told, because the surgeon failed to follow some simple steps that had been established specifically to reduce the possibility of that error occurring.
In the same meeting I was told about the attending on one of our ICU's who refused to follow our new communication of daily patient goals guidelines—procedures that have been shown to reduce errors and length of stay in the ICU. The truly encouraging part of the story is that rather than confronting this doctor and requiring compliance, people said instead, "Don't worry, he will only be attending for another two weeks and the next person is willing to follow the guidelines."
This situation is totally unacceptable. Like the Bob Dylan song, "How many deaths will it take 'til we know that too many people have died?"
The answer, my friends, is blowing in the wind.
