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follow on tumblr ask me anything rss archive silence a commentary | agency for healthcare research & quality » “…patients and families realize no provider comes to work with the intent to cause harm. yet, when harm does occur, and honest and transparent conversations are not conducted, you harm us again, and this is the second tragedy. we can only maneuver through the world in survival mode when we do not know the truth, and we lose the ability to actually live. having these difficult conversations is not easy, but they are paramount to the healing process for patients, families, providers, and organizations. there are four things patients and families want after medical harm has occurred: tell us what happened, tell us how you are going to fix the problem, take responsibility, and apologize.1 first, when we say "tell us what happened,” it means what we need and want to hear, not what you feel comfortable telling us, what you think we should hear, or what you want to share with us.2 it is simply about the truth, no more, no less. second, we need to know that what happened to our loved one is not going to happen to anyone else. if it does, we feel their injury or the loss of their life was in vain…“ source ahrq.gov 1 month ago compassionate care honest communication disclosure pediatrics 2 notes share this the national academies - crossing the global quality chasm: improving health care worldwide » 1 month ago share this apology for the unexpected death of a child in a health care facility » a prescription for improvement by frank gomberg “…i have tried to highlight some of the major issues in order to improve the discourse of apology in the context of unexpected deaths of children in healthcare facilities. i have created the trilogy of tragedy for use as standalone modules in mediation courses, seminars and hopefully in ethics courses in medical schools, in order to advance the pedagogy of apology. as i said in the introduction, my goal was to “add something valuable” to the discourse on apology. i sincerely hope that i have done so. the unexpected death of a child in a healthcare facility is a uniquely horrific event. as lawyers, mediators and doctors we must try to forge some interpersonal connections after these horribly agonizing events. to fail is to lose some of our humanity. to succeed permits us to go on—in the name of something better in the future.” thank you for sharing part of justin’s story in your research! i always debated with myself, which was worse, the not knowing or the not caring? should i focus my advocacy on patient safety or on disclosure and honest communiction followinig adverse medical events? i still teeter back and forth but they are both totally vital in improving patient and family centered care. they work hand in hand. 2 months ago apology disclosure compassionate care healthcare quality communication honesty civility share this this new placque rests beneath a memorial dogwood tree at justin’s middle school beside several of his classmates’ trees. they all left too soon… their legacy for change lives on. 2 months ago compassionate care memorial pediatrics 1 note share this a note from one of justin’s ihi forum scholarship winners! still time to apply for 2018 forum scholarships and learn from the best. good afternoon dale, i was thinking about you today and have a few moments to write to you. since i was last in touch with you i have done many things that were influenced by meeting you and attending the ihi conference. i still work for the same company which is a rural federally qualified health center. our company has 12 clinics and a mobile unit spread out over 4 counties in south mississippi. we provide family medicine, internal medicine, pediatrics, psychiatry, wic nutrition, counseling, dentistry, optometry, obstetrics, gynecology, radiology, ultrasound, and mammography services. i have become the quality improvement specialist for the entire pediatric department. this started with a project designed to reduce errors in the administration of childhood immunizations. since then i have done many such projects. i have designed the templates for the performance and documentation of all of our well child visits for a total of 19 separate age groups. i have written policies to implement standards of care for many of the areas of care we are audited on by many separate entities. i have done numerous unannounced site visits and audits whenever the administration has a concern about quality of care of an individual or a clinic. i test many new ideas or methods of documentation or methods of reporting for the administration. in short, your influence extends a long way here in south mississippi. our clinics provide medical care to 35,000 individuals a year here. our patients are the most vulnerable in our area because they are poor and uneducated, with few resources and options. we see a lot of children who are in child protective custody because of abuse and neglect. all of them receive better care from all of our clinics because of you and your mission to improve safety and quality of medical care. many thanks dale for all you have done for me and for our patients here in south mississippi. ~carolyn ( http://www.ihi.org/education/conferences/national-forum-2018/pages/enrollment.aspx ) 2 months ago justin micalizzi ihi forum scholarship meded ihi compassionate care quality improvement pediatrics share this medical mystery: what caused 11-year-old boy's death in operating room? » can we start the conversation now? 3 months ago ptsafety justin micalizzi ihi forum scholarship trustingagain meded justin's hope project pediatrics healthcare quality anesthesia share this national steering committee for patient safety » overview in may 2018, ihi took the bold step of relaunching the patient safety agenda with renewed energy and focus. in convening the national steering committee for patient safety, ihi is leading the effort to develop a national strategy for reducing harm in the delivery of health care. the national steering committee for patient safety, with members from the health care, policy, regulatory, and advocacy communities, is charged with creating a national action plan to guide patient safety efforts across the country in a cohesive and coordinated fashion. 5 months ago ihi share this quality and patient safety teaching day at albany medical college 2018. what an honor to be asked to present for the amc 3rd year medical students again this year! their enthusiasm and curiosity gives me great hope for the future of medicine. many thanks to dr. jim desemone and dr. mandeep sidhu for their vision in creating a magnificent teaching event for the medical students with a focus on safety, quality, compassion and trust. special thanks to dr. ray walsh, amc picu physician and friend, who joined the discussion sharing emotional thoughts about his care of justin after transport from a neighboring hospital to his unit. we were able to donate several signed books to the schaffer library of health sciences at amc. thanks to the authors for their generosity in sharing real time knowledge with the staff and students. medical students are always my favorite audience-they inspire me to keep going! 5 months ago justin micalizzi ihi forum scholarship justin's hope project albany medical college ptsafety meded ihi the task force for global health share this how to prevent medication errors in the operating room? take away the human factor british journal of anaesthesia define_me_wa> » thank you, dr. ron litman, for telling justin’s story once again. the article was noticed by many anesthesiologists, internationally. they have contacted me vowing to do better. one young anesthesiologist writes: “…i promise you i will always do my best for patient safety! not in the paper or theory, but in reality! i promise you i will always follow all the safety recomendations and best practices. that’s my promise to you, and it makes me in
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