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After a Medical Error, Patients Could Become Hospital Insiders

Cheryl Clark, for HealthLeaders Media, May 22, 2014

Patients who have been harmed by medical errors, and their family members, could be recruited to hospital internal quality review proceedings and their suffering could be used to prevent future mistakes. It's a good idea with potentially disastrous side effects.

Hospital quality expert R. Adams Dudley, MD, was flapping his official UCSF identification badge that hung from a lanyard around his neck. He told the group at a recent patient safety meeting that when a hospital patient is harmed, "maybe they and their families should be given one of these."

The point he was trying to make was this:

It's not enough for healthcare providers to merely be honest and apologize when a patient suffers harm, a strategy slowly replacing the standard "deny-and-defend" practice that persists in most hospitals, he says.

And it's not enough to do the thorough root cause analysis, even offering compensation right away, which some organizations are starting to do to avoid litigation and help patients grapple with the tragedy.

They need to do more if they're truly serious about being honest and preventing errors going forward, and this is what Dudley thinks might be the next step to take.

"What if, when someone is harmed in our hospitals, we say not only, 'we're sorry you were harmed', but 'here's a badge. Now you're part of our team. Now, if you choose, you can be a patient advocate, come to our staff meetings, talk about what happened, [and] attend patient safety conferences. We'll e-mail you the meeting schedule.'"

We want you to help tell us how we can prevent this from happening to someone else, he says.

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3 comments on "After a Medical Error, Patients Could Become Hospital Insiders"


Jackeline S. (5/27/2014 at 1:31 PM)
I like the idea but I don't think it makes good sense nor is it necessary to allow angry grieving people on the inside except as it relates to transparency about their own matter. I think a victim of error and their family would be best served in an advisory capacity to help make improvements but not as insiders of the entire system.

Danny Long (5/22/2014 at 7:45 PM)
First, I was very excited to see one of your articles hit my screen, the title was great.. the idea was uplifting.. then Rick Boothman perspective.. Please consider: After over a decade of the Boothman model, known as the "Michigan Model" of gag orders and strong arm, take it or leave it tactics. If the Boothman model were as successful at reducing preventable hospital deaths as it is at increasing their profit. My question to Mr Boothman: Why has UM post-op death rate remained at or worse than national average of 10%? Improved patient care/safety would reduce death rate? wouldn't it? See medicare data for UM statistics.

bettynoyes (5/22/2014 at 5:01 PM)
This article makes my heart ache.. So many good intention ... Such truth in this story ..potential for such long lasting PTSD for all the stakeholders. But how can we create a better, safer system to allow honesty on the part of all the Stakeholders ? What difference would a crisis clinical facilitator make.??