Some Mature & Wise High School Students on Preventable Medical Errors
Near home in San Antonio, I had a chance to volunteer last Friday, speaking for an hour to a group of high school juniors and seniors who are part of the health professions program within in the Alamo Academies program that prepares students for careers in areas including aerospace and manufacturing (companies like Boeing, Lockheed Martin, and Toyota are sponsors). The students are earning credits that count for both high school and college.
The students are starting to work toward their planned careers, with ambitions including being a NICU nurse, a surgeon, a veterinarian, and other paths. I gave them what was perhaps their first introduction into the types of problems we are working to solve in healthcare — and how they will, thankfully, be more likely to be able to participate in not just doing their job, but also in improving the way healthcare is delivered.
I started by telling the class how much I admired the career path they were choosing and how important their future work will be. I asked them why they want to work in healthcare and, of course, it's all about taking care of patients.
I shared some examples of how “waste” can sometimes get in the way of spending time with patients and how “Lean” is a method (from Toyota) that can help reduce this waste, leading to better patient care and less frustrated employees. I mentioned the nearby Toyota plant and how they teach that “Kaizen” (continuous improvement” and “respect for people” are core principles. I also encouraged the Alamo Academies leaders to take the healthcare students to visit the local Toyota plant, as I have done with MHA students and medical students.
In the context of asking why bad things happen sometimes in healthcare — and not blaming or punishing individuals — I asked them about this headline and news story that appeared last week:
“Brazilian doctors remove the wrong leg of a patient and then amputate his other leg”
A Brazilian hospital says a patient with diabetic kidney failure has been left legless after going into an operation to amputate his right leg and having doctors remove his left… doctors were supposed to amputate the right leg of Antonio Cesar Victorio but instead they removed his left leg.
“When the patient's daughter told doctors they had removed the wrong leg, they amputated the other leg as well.”
The students gasped… they haven't yet had to think about challenges like this. It was really shocking to them that something like that could happen.
I asked the class to think about how something like that could occur — how could you amputate the wrong leg? How could that even happen?
What they said was amazing.
The first student who put her hand up said, “Because they lost focus?”
Another student suggested, “Maybe they were tired?”
I congratulated them for thinking about systemic factors. I thought it was really interesting that a group of 16 to 18-year olds didn't react by saying that people were stupid or they should have been more careful.
I asked the class what types of things you could do to prevent mistakes like this.
One hand went up and a boy said, “Maybe you should have a meeting to see if everything's all right first.”
A girl in the back said, “Maybe you should mark the right spot with an X.”
Again, it was absolutely amazing to me that these kids would, without any knowledge of this, suggest things that are supposed to be part of the “universal protocol” process for having a surgical team huddle (or do a “time out”) and signing the surgical site in advance.
We also discussed, as a class, the pros and cons of marking the site with an ambiguous X, or “maybe you should write ‘not here!',” said one of the students.
I think the students enjoyed hearing some real world perspectives. I wasn't trying to shock or scare them — I was trying to help emphasize how important their life's calling is, if they end up working in healthcare (and I certainly hope they well). I left the class really encouraged about the future, given the kids' responses to a systemic medical error without “naming, blaming, and shaming.”
I hope the cultures in our healthcare organizations change quickly enough so that they don't have that “common sense” drummed out of them when they enter the healthcare workforce.
More on the Alamo Academies program – an article written in The Atlantic.
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Encouraging to read about our future Dr. And nurses. I have a strong belief that lean should be taught at a young age. The changes that could be made in the world in the next 12 years would be amazing. Thanks for sharing Mark and thanks for giving your time to help our future.
Great stuff, Mark. Hopefully these new workers won’t be absorbed into the system and start taking errors for granted as business as usual. Good to get them thinking about these kinds of issues early.
I am new to the network.
Keep the good job.
I feel bad for the patient, the family, the surgeon, the team, the hospital, the system, but it is not that simple.
“Simple solutions to difficult problems sometimes are right, but not always”.
Just saying that the wrong leg was amputated does not describe the problem to me. I need to know the health condition of this patient both legs… more details of this sad case are needed to see what transpired that lead to this undesired outcome.
Good comments from the students, but…
Too much focusing can lead into telescoping hence to miss the forest for the trees. The forest here being the practice and delivery of medicine and the trees, the manuals.
Fair enough… we weren’t doing a true root cause analysis, since we’re not there in the hospital talking with the people who were actually involved.
I do think, however, it’s a good instinct to look first at the system instead of blaming an individual, which is the main point I was hoping they would get.
My other thought is that I think a euphemism like “unintended outcome” sugar coats the problem a bit.
Thanks for reading and for your comment.