Making The Rounds – University of Iowa 6th Annual Quality and Safety Symposium

6th Annual Quality and Safety Symposium, 11/15/18

DSC_0293“Facts provide us with knowledge. Stories provide us with wisdom.” Sorrel King, mother of Josie and founder of the Josie King Foundation, shared her story with the attendees of the 6th Annual Quality and Safety Symposium. The presentation began with the gripping story of the medical error that resulted in the death of her young child, Josie. But over the course of the hour, Ms. King revealed the work and improvements in patient safety throughout the healthcare system that her family’s loss continues to inspire.

Ms. King described a number of initiatives that the Josie King Foundation has supported in partnership with institutions around the country. Patient-initiated rapid response teams to “stop the line,” patient care journals in which families can keep track of daily goals and questions they have for their care team, and “hero awards” meant to recognize those individuals who speak up when something does not look right. “Just the existence of these programs,” Ms. King explained, even if they don’t get used all the time, “can change the culture.”

Though certainly Ms. King’s story was the most dramatic of the day, the entire symposium—the sixth since Krista Johnson, MD, MME, and Michael Brownlee, PharmD, MS, first began co-chairing the event—was a day filled with stories. About 35 different speakers packed Medical Alumni Auditorium and small breakout conference rooms around the hospital and the Carver College of Medicine. All of them presented on activities they have initiated or on systems and support available within University of Iowa Health Care designed to improve the quality of care patients receive and to ensure their and their providers’ safety.

Ms. King’s keynote challenged the audience to make changes that will benefit the system and save patients’ lives. But, she cautioned, most calls to action fade in effectiveness within three weeks. “If nothing happens by week three,” she said, “nothing will happen.”

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A Caregiver’s Journal: Helping Family Supercharge Caregiving

On the heels of National Family Caregivers Month in November, which this year carried the theme of “Supercharge Your Caregiving,” here is a way to carry out that charge year-round. And carry it out we must, because health care can no longer ignore these folks. The Caregiver Action Network estimates that there are over 90 million Americans doing this critical work, which is largely publicly invisible, unpaid, and underappreciated.

The Josie King Foundation recognizes those giant numbers and the outsize importance of the role that family caregivers play in the life of patients. The response to requests from non-nursing staff and family members, they now offer the Caregiver’s Journal, a variation of their signature Nurse’s Journal. Their aim is to provide a low-cost tool that can help alleviate some of the emotional stress of serving patients and loved ones with sensitivity, commitment, and compassion.

The journal was created with the help of experts in therapeutic expressive writing and road-tested in several facilitated writing workshops for caregivers. Here’s what participants had to say about their experience:

“I felt stressed at the beginning of writing and relaxed at the end.”

“I felt purged and able to breathe after writing in my journal.”

“I feel like I understand things better after I write them down.”

The Caregiver’s Journal is a 61-page spiral bound notebook filled with helpful content, such as psychological theories about journaling benefits, before and after stress evaluation forms, and suggested resources for those who want to learn more about expressive writing.

The majority of pages are meant to be used for writing sessions, and offer an inspirational quote with perhaps a guided writing prompt. For instance, one is titled guided writing page is titled When Times Are Difficult, with this prompt:

“Things to consider. What are the current situations causing you stress in our work or in your personal life? How can you alleviate these stressors? What steps have you thought about to make this situation better?”

The page ends with a quote from abolitionist Frederick Douglass, “If there is no struggle, there is no progress.”

Some “free writing” pages are empty except for a short quote, with this instruction about how to use them: The following pages are for you to write about anything that you want. Remember to go deep and really explore your thoughts and emotions. Avoid getting caught up on grammar or spelling. Just write.

Many hospitals buy these journals in bulk as a gift for caregivers or to use in staff training and development programs. For more information about the Josie King Foundation and their specialty journals for caregivers, visit

Jebra Turner is a freelance health writer in Portland, Oregon. Visit her online at for more self-care inspiration.

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A Nurse’s Journal: Writing Out the Storm

The Josie King Foundation believes that nurses are leading the charge for a safer, more compassionate health care system. But they realize that in addition to the joys of healing, nurses face many emotional upheavals related to patient suffering, a complex workplace, new technologies, and fear of clinical errors. When personal pressures from everyday living are added to the already heavy load, the weight can lead to nurse stress, anxiety, depression, or burnout.

The Josie King Foundation developed the Nurse’s Journal in 2004, to help alleviate stress through expressive writing. (The journal was a response to results from a research project, Care for the Caregiver, that indicated it was sorely needed.) Created with the help of experts on the topic and specifically for nurses, it is offered by the nonprofit as a tool for self-directed writing or through facilitated journaling workshops.

The Nurse’s Journal is an attractive 61-page spiral bound notebook and is filled with helpful content such as evidence-based theories about journaling, before and after stress evaluation forms, and suggested resources to help nurses cope with work-related stress.

The majority of pages are low-content, with just short guided writing exercises to help you reflect on the stresses of your work life and personal life. For instance, the first one is titled “Guided Writing: Signs of Stress,” and includes the following prompt:

“Things to consider. Do you notice stress-related symptoms in your life? Is there a particular time of day or day of the week in which you feel more stress? Do your stress symptoms affect your job performance or your quality of life? What do you do to combat your stress?”

The page ends with a quote from the Dalai Lama about avoiding the burnout associated with witnessing great suffering.

In between the prompt and the quote, the page is empty so that a nurse is free to write out their own personal thoughts and feelings, as an antidote to workplace and life stressors.

Since launching the Nurse’s Journal in 2004, the Josie King Foundation has distributed them to more than 15,000 nurses. Many hospitals buy the journals in bulk as a gift for nurses during the winter holidays, or to mark Nurses Week, or at anytime for staff training and development purposes. In addition, they offer a companion Nurse’s Journal Guidebook for anyone who would like to facilitate journaling workshops for nurses.

For more information about the mission of the Josie King Foundation and their line of specialty journals for nurses, caregivers, and patients, visit

Creative Nursing
A Journal of Values, Issues, Experience, and Collaboration
Today’s health care institutions need creative and innovative solutions. Nurses need to think creatively, to experiment, to take risks, and to innovate. Creative Nursing is an issue-focused journal that promotes best practices in all aspects of caring—caring for self, patients, families, colleagues, and communities.

Jebra Turner is a freelance health writer in Portland, Oregon. She frequently contributes to the Minority Nurse magazine and website. Visit her online at for self-care inspiration.

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What’s All This About Journaling?

It was my ex-husband who got me journaling again. Our marriage was falling apart, and, on the advice of his friend, he had started to do “morning pages,” a daily journaling practice from the seminal self-help book “The Artist’s Way.”

Though I had kept a diary throughout my teen years and early 20s, somewhere along the way I’d fallen out of the habit. At 29, though, I was deeply unhappy and looking for answers wherever — anywhere — I could find them.

It helped.

Once the domain of teenage girls and the literati, journaling has become a hallmark of the so-called self-care movement, right up there with meditation. And for good reason: Scientific studies have shown it to be essentially a panacea for modern life. There are the obvious benefits, like a boost in mindfulness, memory and communication skills. But studies have also found that writing in a journal can lead to better sleep, a stronger immune system, more self-confidence, and a higher I.Q.

Labeling emotions and acknowledging traumatic events — both natural outcomes of journaling — have a known positive effect on people, Dr. Pennebaker said, and are often incorporated into traditional talk therapy.
At the same time, writing is fundamentally an organizational system. Keeping a journal, according to Dr. Pennebaker, helps to organize an event in our mind, and make sense of trauma. When we do that, our working memory improves, since our brains are freed from the enormously taxing job of processing that experience, and we sleep better.

This, in turn, improves our immune system and our moods; we go to work feeling refreshed, perform better and socialize more. “There’s no single magic moment,” Dr. Pennebaker said. “But we know it works.”

I didn’t know any of this when I started journaling again two years ago. I was in a place where I would have tried anything to feel better; if someone had told me that a daily practice of morning somersaults helped her get through a difficult time, you better believe I would have started rolling.

This is often the first question a budding journal writer might ask him or herself. In some ways, though, it’s the most misguided — one thing journaling has taught me is that the mind is a surprising place, and you often don’t know what it may be hiding until you start knocking around in there.

In other words: Writing in your journal is the only way to find out what you should be writing about.

But when I was just getting started, the first place I went looking for guidance was the book that had inspired my ex-husband: “The Artist’s Way,” by Julia Cameron. Ms. Cameron describes the morning pages as “three pages of longhand writing, strictly stream-of-conscious,” done as soon as one wakes. They are “not meant to be art. Or even writing.” They need not be smart, or funny, or particularly deep — in fact, it’s better if they’re not.

Ms. Cameron encourages practitioners to think of them as “brain drain,” a way to expel “all that angry, petty, whiny stuff” that “eddies through our subconscious and muddies our days.” After years working as a writer and journalist, making my living trying to sound smart on the page, this was a huge relief.

On the other hand, Dr. Pennebaker’s research has found that journaling about traumatic or disturbing experiences specifically has the most measurable impact on our overall well-being.

In his landmark 1988 study, outlined in his book “Opening Up: The Healing Power of Expressing Emotion,” students were randomly assigned to write about either traumatic experiences or superficial topics for four days in a row. Six weeks after the writing sessions, those that had delved into traumatic experiences reported more positive moods and fewer illnesses than those writing about everyday experiences.


Dr. Pennebaker’s research has found that even a one-time 15-to-30-minute session of focused journal writing can be beneficial. In fact, he said he is not “a big fan of journaling every day.”

“One of the interesting problems of writing too much, especially if you’re going through a difficult a time, is that writing becomes more like rumination and that’s the last thing in the world you need,” he said. “My recommendation is to think of expressive writing as a life course correction. As opposed to something you have committed to doing every day for the rest of your life.”

If you’re distressed about something, Dr. Pennebaker advises, set aside three to four days to write for 15 to 20 minutes a day about it. If you don’t find a benefit from it, he says, “stop doing it. Go jogging. See a therapist. Go to a bar. Go to church.”

Dr. Pennebaker is also not a purist when it comes to tools. Techies can take heart in knowing that, contrary to the romantic ideal, typing out journal entries on a laptop or even on a phone can yield effects that are just as positive, particularly if it’s more comfortable and convenient for you. The point is simply to get started.

“Try doing it different ways,” Dr. Pennebaker said. “Some people like writing with their nondominant hand. Others find talking to a tape recorder works too. Experiment.”

Over the years, I have switched up my process here and there, even embarking on an overly ambitious plan involving color-coded pens. The one I’ve come back to again and again, however, is closest to what Ms. Cameron advocates: I write three to five pages every morning by hand.

For her, the timing and frequency are essential to a beneficial practice. “Jungians tell us we have about a 45-minute window before our ego’s defenses are in place in the morning,” she said. “Writing promptly upon awakening, we utilize the authenticity available to us in that time frame.


Journaling may sound hokey to some. But it can be one of the most useful and cost-effective tools we have to forge a better, more emotionally and mentally healthy life. As Dr. Pennebaker said of his research: “I’m not a granola-crunching kind of guy. I got into journaling because I’m interested in what makes people tick.”

Ms. Cameron’s book, on the other hand, is steeped in the kind of earnest spirituality that New Age skeptics will no doubt bristle at. Yet one of the quotations that has stuck with me the most is straightforward and practical: “It is very difficult to complain about a situation morning after morning, month after month, without being moved to constructive action.”

When I started journaling, I felt stuck. I was nearing 30, facing the personal reckoning that always comes with such milestones. I was unhappily married and dissatisfied with my career. Worst of all, I had no idea what would, theoretically, make me happy. I didn’t know what I wanted.

Then journaling provided me with an important outlet for the debilitating anxiety that had come to paralyze me at odd hours each day. And besides, I enjoyed it. It was fun to wake up every morning and spew a hurried black scrawl all over those straight blue lines.

Still, I remained unconvinced by Ms. Cameron’s grander claims about how journaling could change one’s life. And yet, today, as I write this, just two years later, my life has completely changed: I split from my partner of 10 years; began a new, fulfilling relationship; enrolled in an M.F.A. program; rekindled my freelance writing career, and am planning a move to Los Angeles.

I don’t how journaling helped me make these changes. Perhaps, as Dr. Pennebaker may suggest, it simply allowed me to purge some of my anxiety, leading to a better night’s sleep and more energy to accomplish the task. Or maybe, as Ms. Cameron would say, it put me in contact with my very own spiritual guide. Certainly, I got to know the dusty corners of my brain better, and, when I did, my true desires became harder to ignore.

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Tim Cunningham column: In death’s wake, the power of The Pause

By Tim Cunningham

He collapsed at school by his locker, just 11 years old. After 9-1-1 was called, the EMTs arrived and began CPR immediately. He was brought to our emergency department and we did everything we could — IVs, ventilation, sympathomimetic drips — but nothing worked. We couldn’t save him. The attending physician declared him dead — calling the code and noting time of death — as we, without a moment’s hesitation, stepped back into the noisy mix of an overcrowded emergency department.

Shaken — as I’ve been after every pediatric death I’ve ever witnessed as a nurse — I emerged into the hall to encounter another child’s livid mother, who’d stood outside the resuscitation room for 20 minutes waiting for a nurse to bring the medication her otherwise healthy child needed to be discharged from the hospital.

Under the hailstorm of her words — I was slow, I didn’t care, this hospital was crap — I felt not even an ounce of empathy. Wordless, angry, I retrieved the meds, administered them, and all but threw the discharge papers at the mother.

No excuses here: It was ugly, unkind, and unfair of me to treat this mother with such an edge. I still regret it.

That is often our world in emergency care. As nurses and physicians, we rush from room to room, family to family, crisis to crisis, expected to immediately let go of what just happened in one room and be present with the patient before us in the next.

And isn’t that what patients have a right to expect? Shouldn’t patients expect that their nurse or doctor is in a frame of mind that enables them to be authentically attentive? But how in the world can we provide the safest care if we ourselves are in tatters? There’s a sad truth here: We are not paid to be present. We are paid to get work done, no matter how impossibly sad, messy, or tragic that work is. And never does there seem to be enough time.


In the years since I moved from working in a trauma center in New York City to doing research at the University of Virginia, memories of that ER stay with me. Now, I’m studying an intervention that, while not a fix-all, may help prevent injury to patients and providers — it may even save lives. In hospitals on four continents, what we call “The Pause” has become a standard of care.

Here’s how it works: When a patient dies, any member of the care team tending him calls out for a pause. They might say something like, “Can we stop for a second to consider this person who’s died? They loved and were loved. They were someone’s friend and family member. Just for a minute, in our own way and in silence, let’s take a moment to honor this person and the efforts we each made on their behalf.”

The group is then silent for about 45 seconds. It’s personal, optional, and simple.

Preliminary results from our investigations have found “The Pause” is a boon to both healthcare teams and patients. Caregivers who practice it report a stronger sense of collaboration with the health-care team in moments of intense stress.

What’s more, providers consistently report that when they pause — no matter what they choose to do during those 45 seconds — they feel more grounded and ready to interact with their next patient or family. They feel more present.

Cited by the Schwartz Center for Compassionate Healthcare and the American Association of Critical-Care Nurses as a tool to elevate quality health care, this “Pause” keeps spreading. In short order (roughly the time it took you to get through the third paragraph of this commentary), health-care providers are finding they’re better grounded, and ready to face what’s next.


Pausing to breathe and reflect is nothing new, but encouraging caregivers to pause to honor a patient and a health-care team may be. “The Pause” may provide a compassionate edge toward better care for all of those involved. I wish to this day that we had paused at the end of the 11-year-old’s life, to honor him, ground our team, and prepare ourselves to face what would come next.

It would have helped me be much kinder to the next mother, her child, and the rest of the patients I treated that day.

Tim Cunningham, RN, DrPh, is director of the Compassionate Care Initiative at the University of Virginia School of Nursing. To read more about The Pause visit:

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10 Things Parents of Pediatric Patients Want During a Hospital Stay

Hospitals cannot improve the patient experience without listening to — and acting on — patient feedback, Peter Pronovost, MD, PhD, senior vice president for clinical safety at Minnetonka, Minn.-based UnitedHealthcare, said in a 2015 blog post for Baltimore-based Johns Hopkins Medicine’s Armstrong Institute for Patient Safety and Quality.

Dr. Pronovost formerly served as director of the Armstrong Institute and senior vice president for patient safety and quality at Johns Hopkins Medicine. In this role, he worked with Jane Hill, Johns Hopkins’ patient relations director, to compile “patient wish lists” based on the most common pieces of feedback the hospital received from patient letters or surveys.

While the two leaders developed an overarching patient wish list for the health system, Johns Hopkins’ Patient and Family Advisory Councils also created individual patient wish lists to speak to their own patient populations’ specific needs, a spokesperson for Johns Hopkins Medicine told Becker’s Hospital Review.

Here are 10 things the parents of pediatric patients said they wanted from clinicians during a hospital stay, as compiled by the Pediatric Family Advisory Council for Johns Hopkins Children’s Center.

1. Meet our basic needs. Parents want to be oriented to the hospital once their child is admitted. Clinicians should inform parents where they can get food, how to pay for parking, when visiting hours are, etc.

2. Let us see you wash your hands. Parents worry about germs in the hospital. Clinicians can demonstrate they are dedicated to keeping a pediatric patient safe by washing their hands in front of the patient and his or her parents.

3. Introduce yourself before you start speaking. Parents want to know who clinicians are and how they will be involved with their child’s care as soon as they enter the room.

4. Communicate, communicate, communicate. Parents are always waiting for updates from clinicians and want to know as much information as possible. Parents plan their day around the times they get to speak to providers, so clinicians should let them know if they’re delayed.

5. Know my child’s entire medical history. Parents want clinicians to be as well-versed about their child’s medical history as possible.

6. Be present when you are with us. Parents want clinicians to take the time to answer their questions and outline a care plan for the day. They want to be involved in the planning and discussion of their child’s healthcare goals.

7. Tell us when there is downtime. A patient’s loved ones don’t want to leave and miss something important, so providers should inform them of opportune times to get food, take a nap, etc.

8. Answer the call bell. Parents want clinicians to promptly answer their calls and come to their child’s room as soon as possible.

9. Clean our room. Hospital rooms become a patient and family’s home away from home, so clinicians should help them keep the space clean.

10. Recognize sleep is precious. Clinicians should let pediatric patients and their families sleep whenever possible and group medical tasks together, especially overnight, to avoid regular disturbances.




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Why Partnering with Patients is Key to a Culture of Patient Safety

Patient safety is part of the patient experience promise clinicians make. Clinicians must integrate the patient into the care team to deliver on that promise.

patient safety

Source: Thinkstock

 By Sara Heath

 – When a patient visits a hospital, she has the expectation that she will be treated with empathy, respect, and clinical excellence. At the core of each of these elements is the understanding that she will be safe. But all too often, the promise of patient safety isn’t upheld.

Adverse patient safety events and medical errors are the third leading cause of death in the United States, according to a 2016 report in the British Medical Journal. A separate 2017 survey from NORC at the University of Chicago and the IHI/NPSF Lucian Leape Institute found that 21 percent of patients experience a medical error.

To be fair, the US has seen a decline in adverse patient safety events in recent years. A 2016 report from HHS and the Agency for Healthcare Research and Quality (AHRQ) showed that between 2010 to 2015, approximately 125,000 fewer patients died due to avoidable hospital-acquired conditions than in years previous.

But just because fewer patients are experiencing preventable patient safety events does not mean that the job is done, according to Gary Yates, MD, a strategic consulting partner at Press Ganey and patient safety expert. Healthcare organizations must strive for zero preventable patient safety events because patient safety is a foundational element of a positive patient experience.

“Patient safety is fundamental to the promise we make to patients,” Yates told in an interview. “We like to think of the patient experience as being the convergence of quality, safety, and the experience of care.”

READ MORE: Driving Positive Patient Experiences During Patient Safety Events

“When patients come for care, they expect that harm won’t come to themselves or their loved one,” Yates continued. “They expect us to deliver the highest technical quality care, and they also expect us to treat them with dignity and respect, and that care givers will approach them with empathy and understanding. Safety is a fundamental component of the overall patient experience.”

In fact, patient safety is so important that it tends to take up most of patient mindshare. Even when a health system delivers technically excellent and emotionally supportive care, one preventable harm can mar the entire patient experience. The patient will likely not remember any of the positive qualities of the healthcare encounter.

Healthcare organizations must set patient safety as a top priority. This will require an all-in commitment across hospital leadership and staff, Yates said.

“In order to prevent harm, in order to really make progress towards the goal of zero harm for patients, it requires an organizational commitment,” he explained. “That commitment includes a tightly aligned board, senior operational leaders, and senior physician leaders, all committing to what some would consider an audacious goal, but the right goal, which is a goal of zero harm to patients.”

That strong leadership, paired with a culture of safety, can help deliver on the goal to eradicate preventable patient harms, Yates said. Once organization leadership has bought into the goal of true patient safety, it is important that they include patients in obtaining that goal. After all, patients have a significant role to play in supporting patient safety efforts.

READ MORE: How Patient Safety Factors into the Patient Experience Puzzle

“The organization needs to invite patients and families into the conversation to help create an environment where they can truly be partners,” Yates stated. “Organizations can provide education on ways that patients can participate and encourage them to speak up, understanding that some patients and families may be reticent to speak up or ask questions to providers.”

Healthcare organizations are inviting patients and families to serve on patient advisory councils (PACs) more and more, Yates sad. Patient and family stakeholders are also being asked to sit on operational committees and some board committees. This is an essential part of integrating the patient voice into hospital improvement efforts.

Although patient and family advisory councils are becoming increasingly common in healthcare, there are some hospitals that have not jumped on board.

“Some hospitals and health systems are still reticent to robustly include the voice of the patient,” Yates pointed out. “There may be concerns that input from the patients might be a distraction for the organization. There may be concerns about confidentiality. There may be concerns just because it’s a change.”

However, those hospitals participating in PACs outweigh those who may be excluding patient sentiment. The insurgence of PACs in clinical and organization improvement are setting a good example for hospitals just beginning to consult the patient voice.

READ MORE: Simplifying Patient Safety Grades for Patient Decision-Making

“The good news is that there are organizations that have successfully implemented initiatives such as patient advisory committees and are continuing to push the envelope,” Yates asserted. “There’s a wealth of experience in how to select patients and families for participation on operational and board committees, how to vet potential members, and how to onboard and educate them so that they are effective in their role and the organization’s comfortable with their role.”

Having a patient in the room is essential for changing the culture of safety. Healthcare organizations cannot properly serve the patient if leadership does not know how the patient wants to be served and which processes could best bring comfort to the patient. Understanding how patients and families need to see patient safety initiatives implemented is key to making programs successful.

“The conversation is just different when a patient is in the room,” Yates noted, quoting his peer Jim Conway, who previously served as the COO of Dana-Farber Cancer Institute.

Incorporating the patient into patient safety initiative goes beyond organizational improvements. Clinicians themselves need to be more inviting and allow the patient to participate in their own care. A patient who is engaged in care can serve as another check on patient safety protocol. This relationship works best when the patient is empowered to participate in care.

“One of the challenges to creating a true culture of safety in healthcare is dealing with the hierarchy gradient,” Yates said. “A hierarchy gradient exists when, in any relationship, one individual perceives themselves to be in a lower position of power than another individual. When the power gradient is large, then it’s unlikely that the person who perceives themselves as being on the lower end will be willing to speak up.”

Patients often perceive themselves on the lower end of that hierarchy gradient, and healthcare organizations are working to change that. The same strategies organizations employ to create clinical teamwork – communication, care coordination – can help integrate the patient as a part of that care team, Yates said.

The onus is on the clinicians to create a welcoming environment in which a patient feels she can participate in her own care and her own safety.

It could be difficult for a patient to ask a provider if he’s washed his hands before an exam. Clinical team members need to create a culture that gives the patient the confidence to do so.

How a care team interacts with the patient, greets her, demonstrates empathy, invites her to ask questions, or invites her to comment on aspects of clinical care are all important things to do, Yates said.

Healthcare organizations can also use various signage to reinforce that notion.

Ultimately, the provider needs to reach out to the patient and incorporate her into the care them. Clinicians who educate their patients, give them context to participate in clinical decisions, and treat their patients as members of the care team will help create a culture of health.

One of the best ways to manage the authority gradient and minimize power distance is when the party that’s perceived as being in the higher power position invites others to participate and welcomes questions,” Yates explained. “It helps to set the tone and helps to create an environment where individuals are more likely to contribute.”

Although organizations should be working toward zero preventable patient harms, there will be missteps along the way, Yates acknowledged. Most healthcare organizations see some adverse patient safety events annually. The key is understanding how to interact with the patient following one of those adverse events.

“It’s important for hospitals and health systems to do a good job with disclosure and apologize as appropriate,” Yates advised. “Establishing an atmosphere where we’re transparent with patients when things go wrong is critical.”

Transparency is not only important for engaging patients and doing right by them when something does go wrong; it’s also important for the purposes of overhauling the culture of safety, Yates said. Being apologetic when appropriate is important for the patient-provider relationship and also important for clinical quality improvement.

“It allows for us to engage patients in helping us understand how we can improve going forward,” Yates concluded. “Being honest with the patient about what happened, apologizing as appropriate, and communicating with them about actions that are taken helps to assure patients that the underlying causes of what might have affected that patient or her loved ones is something that the organization is addressing to prevent it from happening to another patient.”

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To Err Is Human, Even If You’re A Doctor

In 2002, my then 55-year-old father went to his doctor because of a severe headache. He was diagnosed with sinus infection and was given a nasal spray and sent home. His headache worsened into “the worst headache of my life,” and so the following day, he went back to his doctor. He was again diagnosed with sinus infection but this time he was prescribed with an antibiotic before being sent home.

After two days, my mother saw my father crawling on the floor. He could barely move or talk. He was rushed to a local emergency room where he was correctly diagnosed with a ruptured cerebral aneurysm, or a bleeding artery inside his brain. He was airlifted to Barrow Neurological Institute in Phoenix, Ariz., where a renowned neurosurgeon successfully performed an emergency brain surgery to stop the bleeding. After a few weeks in the ICU and rehab, he was discharged home. He survived and regained his health. Many patients, however, are not as lucky as him.

According to the Armstrong Institute Center for Diagnostic Excellence at Johns Hopkins, up to 12 million Americans are misdiagnosed every year. Among these patients, around 4 million suffer from some type of injury and up to 80,000 die as a result of misdiagnosis.

In fact, a quarter of a million people die each year as a result of medical error, which includes misdiagnosis or delayed diagnosis, improper or delayed treatment, inadequate monitoring of treatment, medication administration errors and improper surgical technique. It’s the third leading cause of death in the U.S. To put this into perspective: More people die as a result of medical error than the combined total 2015 deaths due to diabetes (79,535), influenza/pneumonia (57,062), suicide (44,193), and motor vehicle accidents (32,000).

The issue of deaths due to medical error has been an elephant in the room at least as early as 1999. That year, the National Academy of Medicine released the now famous To Err is Human report, which found that “health care in the United States is not as safe as it should be — and can be” because of preventable medical errors.

To Err is Human concluded that majority of medical errors “do not result from an individual recklessness” but are caused by “faulty systems, processes, and conditions that lead people to make mistakes.” The report’s recommendations thus focused on strategies for improving patient safety at national and hospital levels. These strategies included creating mandatory and voluntary reporting of medical errors and raising medical provider performance standards.

However, almost 20 years after To Err is Human was released, at a time when the U.S. has the most advanced technologies in medical care and arguably has the best quality of health care in the world, thousands of people are still dying not because of their medical condition but because of the medical care they received — or didn’t receive.

Patients can help prevent medical errors by being vigilant about their own medical care. If you have been diagnosed with a medical condition, ask your doctor about other medical conditions that could explain your signs and symptoms. Ask your doctor what’s the worst-case diagnosis and why it isn’t the diagnosis in your case. Ask questions about the medication you have been prescribed or are about to be given to make sure it’s the right one. Follow up on your lab or imaging results. Don’t assume that your test results are normal if your doctor didn’t call you. And know that doctors can make mistakes; they’re only human.

Dr. Michael Vinluan is the medical-legal consultant for The Law Office of Barry R. Glazer. You can reach him at

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Researchers: Medical errors now third leading cause of death in United States

“A new study by patient safety researchers shows common medical errors may be the third leading cause of death in the U.S., after heart disease and cancer”.  (Deirdra O’Regan/The Washington Post)

May 3 at 6:30 PM


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