I’m a firm believer that if we’re still doing things the same way we did 10 years ago, then we are likely doing them wrong. This is why the College is striving to become more of a learning organization, so that we can continue to improve how we guide the medical profession and protect the public.
As you read through this issue of Messenger, you’ll notice that we have approached something a bit differently. Dr. Lakhani is an Alberta physician who recently went through the CPSA complaint process. We asked him to provide his perspective and share some of the things he learned along the way, so we can all learn as a profession.
This was a case that I believe was not best suited for a disciplinary approach, but for a multitude of reasons, it ended up there. I commend the patient for bringing this issue to our attention, it takes a great deal of courage to do that. Unfortunately, submitting a complaint is currently the only process through which a patient can raise concerns about the quality of their care and I believe this needs to change. In the coming months and years, we plan to look at a process where patients can bring concerns forward as learning opportunities, rather than from a disciplinary perspective.
Saying that, we can’t discount the seriousness of the error made and the effect it had on the patient’s health. Did Dr. Lakhani make a mistake? Absolutely, but it was a mistake that any of us could have made and one we can all learn from so it can be prevented in the future.
As we know from the aviation industry, it is rarely one single event that causes an adverse outcome and in that same vein, there is rarely one single thing that will prevent that event from happening again. In Dr. Lakhani’s case, there are many things that could have been done differently, but that doesn’t mean we should set out to blame others for what happened. If we really want to move things forward, we all need to embrace our own accountability when things go wrong, so we can learn.
In his article, Dr. Lakhani raises some important issues that we need to consider. We need to be vigilant and recognize that health care is a complex environment, which can increase the risk of missing things. We all need to work together and improve our communication as colleagues— we can decrease the chance of errors by talking to each other more. And last but not least, we need to give patients more access to their medical information, because they are the ones most invested in their own health.
Finally, I would like everyone to realize that this was a rare event. As physicians, accepting responsibility, empathetically acknowledging the patient’s suffering and approaching the situation ready to learn from it can lead to a successful resolution. We go into health care to help others and a negative outcome can be devastating. When something goes wrong, it takes incredible courage to move past the negative feelings, but we must all try to acknowledge these mistakes so we can all improve.
I commend Dr. Lakhani for agreeing to share his perspective so that others can learn. I hope others will take this opportunity to reflect on their own practices and identify ways to prevent these very same things from happening.
As always, I appreciate your thoughts and feedback.