Transparency, Compassion, and Truth in Medical Errors: Leilani Schweitzer at TEDxUniversityofNevada
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- เผยแพร่เมื่อ 30 พ.ค. 2024
- The human element can give us kindness and compassion; it can also give us what we don't want- mistakes and failure. Leilani Schweitzer's son died after a series of medical mistakes. In her talk she discusses the importance and possibilities of transparency in medicine, especially after preventable errors. And how truth and compassion are essential for healing.
About TEDx, x = independently organized event. In the spirit of ideas worth spreading, TEDx is a program of local, self-organized events that bring people together to share a TED-like experience. At a TEDx event, TEDTalks video and live speakers combine to spark deep discussion and connection in a small group. These local, self-organized events are branded TEDx, where x = independently organized TED event. The TED Conference provides general guidance for the TEDx program, but individual TEDx events are self-organized.* (*Subject to certain rules and regulations)
As a physician who is interested in the Doctor Patient interaction and ways to improve medicine, I think that this talk should be mandatory for all physicians and hospital systems.
I will share it with as many as possible.
+Sewell Kahn
I had similar issues with my local hospital. I reported a concern about a family member. I was ignored for several months, and then the Hospital's litigator gets angry with me for reporting the Quality Assurance issue, and even fires back simply because she did not like the complaint.
A hospital is supposed to be a place of transparency, honesty, and empathy.
When the CEO of the hospital stomps up and down like a little three year old than there is something seriously wrong with that.
Patients and family members must be allowed to report safety issues without the fear of hospital retaliation.
As a result, I had to seek outside oversight authorities to act on my behalf because the hospital took a vow of silence over the issue--which means it didn't really solve the issue in the first place.
As an RN since 1990, an adjunct faculty instructor for RN to BSN students, I agree that this should be mandatory for anyone who wants to provide patient care.
macellai
my issues had to do with being harrassed on hospital property , they did nothing until i started filing law suits then they turned in false allegations to the BON , ARIZONA STATE BOARD OF NURSING CORRUPTION WATCHDOGS . google there is so much more to the corruption hospitals will do lie perjure themselves !!
@funfunfun405 You are unhinged and have no idea what you are talking about. IF you want to really know who is protecting bad Drs and Nurses it is the Board of Nursing, and Medical Board. Study up , cause your way off the mark. Start with unduly cited on licenses and the trap for those who do report unsafe Drs / and hospitals !!
Thank you for speaking publicly. I hope I will never have to endure what you went through. You are a brave woman, to turn your loss into this motivation to affect change. Thank you again!
I grieve your loss and your pain. Thank you for your openness about this. This talk should be mandatory for all healthcare administrators, policy makers, nurses and physicians in training. We desperately need a culture change. I am a nurse who made a medical error and immediately recognized that I had done it. Fortunately for the patient it was not life-altering. But for me it was. The scathing review that I went through by my organization was revealing. My boss, fortunately, was the exception and very supportive. I use this as a teaching experience for those I work with and train. And I have spoken at length with our risk department about their handling of the situation and the climate it creates to not be transparent. I am seeing slow change, hopefully for the better.
I cannot begin to imagine the amount of time, excruciating process and tears it took for your to write this talk. And then be able to deliver it with the fortitude by which you shared it.
Thank you, Nahed. I prepared for months before the talk & got advice from wise friends. I knew the talk would be part of Gabriel's legacy-that motivated me.
@@TheLeilaniS ❤
First and foremost, I am so sorry for your loss and for all the difficulties you have experienced with losing your son. I can only imagine that losing a child is a level of pain beyond comprehension. I deeply admire how well you have allowed yourself to feel such deep empathy for the people on your son’s care team and how profoundly they were also affected by his death. It takes a lot of strength and courage to set aside your own grief, and anger at the injustice of it all, to see the humanity in the people who were caring for your son. Not everyone who loses a loved one due to a medical error is able to see their way out of the pain and anger to feel compassion for the humans behind those errors, and for the pain that they were undoubtedly feeling as well. In fact, I would imagine most people aren’t able to do that, and as you discussed, many end up hiring a lawyer to try to right the wrongs in some way, however inadequate it may ultimately be.
I think there is really something profound in the idea you presented of using truth, honesty, and compassion as a method for healing. Typically, it is the direct patient care providers (doctors, nurses, etc.) who are tasked with upholding the ethical standards of non-maleficence (doing no harm) and beneficence (doing good/preventing harm) to their patients, and by proxy, to their families, particularly in pediatrics cases where the parents or caregivers are acting on behalf of a child who lacks their own full autonomy. The idea you are presenting is putting some of those ethical standards onto the medical facilities and institutions, which clearly was an effective strategy for one hospital in your case, and the exact opposite for the other hospital. It seems like there would be a huge shift in the way providers handle medical errors, and the constant fear of being sued for mistakes, if there were more institutions practicing these transparent, honest, and ethical manners of handling medical errors. The litigious nature of our society isn’t going to magically be erased, but if it became less of a norm for doctors and hospitals to be sued for medical errors, then that may be a place to start turning the culture of fear and truth suppression in a different direction. It’s an interesting idea that the institutions themselves could be the starting point for instigating these changes, and the effects of this that would trickle down through all levels of the healthcare system. I think it would have a profound effect on patient care in general, but also on the mental-health and well-being of providers, patients, and their families, particularly in cases like this where a medical error had devastating consequences.
Leilani, your statement is among the most humane and cogent I have heard in response to medical error - and as a harmed patient-family member, soon to join you as a fellow TEDx speaker, I've heard and read quite a number. Exquisitely concise.
On the off-chance this may interest you, please consider joining a group of citizen activist/advocates in our work. One ringleader, so to speak, is Regina Holliday of DC. The works are The Walking Gallery and Partnership With Patients.
Bart Windrum wad replced by
The same thing happened to me in February. My son Anthony passed away because of a medical error. The md admited immediately! He was quite transparent and contacted me later on and we are awaiting the medical autopsy !still it does not excuse them from liability"! They were directly responsible for his death and all the alarms sounded OFF they just took six minutes to realize the oxygen tube was not hooked up! 12people in a state of the art room! When the code was called I knew like you that Anthony had passed! I also was a nurse with 23 years of experience! A.E
Leilani, you honor Gabriel and all patients so very much. You tell his story with so much dignity, love, caring and compassion!! Everyone should hear his story! May he never be forgotten, and may you continue to educate our hospitals, institutions and care givers.
What a beautiful and compassionate way to tell such a horrifying and compelling story. Your TEDx Talk should be share with all medical schools - this should be taught at the grass roots of medicine. What is so terribly sad is that it has been 5 years since you told your story and we are still in the same boat - medical error continues to be the 3rd leading cause of death in the United States and Canada. As Co-Chair of Patients for Patient Safety Canada (A WHO global patient safety program), I took to the TEDx Stanley Park stage in Vancouver BC on March 3rd this year to talk about the same problem. I pray we don't stop talking about until it has been fixed - once and for all! Thank you for sharing your story and for continuing to work and advocate for patient safety.
Thank you for your kind words, Theresa. Unfortunately, there is still so much work to do to keep each other safe.
It's rare for a victim to be both accusing and forgiving as well as insightful as this mother. A rare gift which makes change possible by opening doors to the heart. Hopefully the medical team who left would see this some day.
First, I am so very sorry for your loss of Gabriel. Your testimony is extremely powerful, articulate and gracious in the face of such profound tragedy. Your compassion for the 'second victims' is compelling & hope the nurse & pediatrician have seen this. Please consider watching and sharing these youtubes: "Medication Errors-Really Smart People Make Really Mistakes"
"Medical Improv: Exploring Learning Experiences...."
"Interruption Awareness..."
You ARE changing the culture. Beth
I am extremely grateful to have been able to listen to Leilani Scheitzer's message. I can't imagine what it would be like to have gone through such an experience, but really love the take home message she brings. Transparency is definitely important in the healthcare field, as patients we try to be completely transparent with our doctors, so they can fully help us heal when ill, I can see how transparency from the other side when errors have occurred can also help us heal in different ways just as Leilani has shared. I agree with her as she explains all the survivors of experiences like this need healing, and how transparency, compassion, and truth about the medical errors that have occurred can begin that healing process. By not disclosing the errors that have occurred, physicians and hospitals violate the patient's autonomy, as well as disregarding the bioethical principle of beneficence. Beneficence means to put the patient's best interest above all, even the physician's best interest. Disclosing medical errors could possibly cause physicians to lose their license, money to lawsuits, as well as loss of reputation. But doing so would be demonstrating this important bioethical principle and like Leilani explains, can induce the healing of everyone effected by these errors and help avoid these errors in the future.
I am so very sorry for the sad loss of Gabriel. Your presentation was moving, informative and echoes my personal views and that of many others. My son, Robbie, died as a consequence of medical negligence in April 1990. However, almost 24 years on the medical cover up continues in the UK. This is what the ECtHR ruled regarding my deceased son's case in may 2000:
"Whilst it was arguable that doctors had a duty not to falsify medical records under the common law (Sir Donaldson MR’s “duty of candour”), before Powell v Boladz there was no binding decision of the courts as to the existence of such a duty. As the law stands now, however, doctors have no duty to give the parents of a child who died as a result of their negligence a truthful account of the circumstances of the death, nor even to refrain from deliberately falsifying records."
The UK Government is refusing to introduce a free standing Duty of Candour for all Healthcare Professionals.
A 20 minute documentary broadcast in January 2013 exposed the on-going cover up. You can access the documentary at:
www.itv.com/news/wales/2013-01-14/robbie-powell-death-report-redactions-uncovered-by-wales-this-week/
The sooner the medical profession is honest and accepts responsibility for adverse clinical incidents the sooner the bereaved families can move on.
Will Powell 13th January 2014
this will make any one cry - our NHS could learn many lessons. A duty of candour would be helpful on so many levels.
Appreciate you sharing your experience. I have experienced the loss of a parent and my partner due to medical errors.
My parent passed November 2016 and my partner November 2022.
With the parent loss; the primary care physician ordered a special corner investigation. This doctor came to the funeral home and spent 15 minutes in front of my father's casket
The error involved Hosptial employees who did not do their patient research and ignored the primary care physician and family who were active participants in my father's healing.
The report concluded definite medical error.
My partner was taken to an ER and incorrectly diagnosed. This hospital ER had past medical records and should have made the correct diagnosis and treatment.
This diagnostic error ended up causing a number of significant problems where my partner took a turn for the worst due to sepsis which could have been prevented. We went back to the same ER hospital. The doctors were all great; however, the first doctor created a roller coaster path which ended in death.
Many, I am certain, have stories like the two I shared. Gabriel's Mother expresses how one hospital did their best and another hospital where their example was the worse.
In neither case for my loved ones did we retain legal counsel. No amount of money is going to bring our loved ones back.
We can only hope, as mentioned that organizations and people respond with compassion and transparency. Like Gabriel's mother I don't have the courage to work in a medical position where the stakes of a mistake are astronomical.
Lessons learned, necessary changes are made and a sincere apology is the standard we would hope to achieve.
For right now I will settle for the ability to forgive those who made deadly decisions or actions which resulted in the premature loss of two people who were my closest relations. With my Father I have reached that point of forgiveness. For my partner where the loss is recent....it may take awhile to workout forgiveness, as I go through the journey of grief.
Every nurse, doctor, health care worker, administrator and health ministers for the NHS should watch listen and learn.
Thank you for your sharing. I will share with other nurses to spread your message. God bless you and your child
First, thank you for sharing your story, and I am so deeply sorry for your loss. Second, I would like to reflect on your comment regarding transparency in medicine having the ability to heal our healthcare system. About midway through your talk, you state, “By being open and honest when the unexpected happens, we can learn from our mistakes. We can find the deadly system failures, and we can act to fix them.” I feel that this is a message that needs to be embraced more by physicians and hospital administrators alike as it mirrors the ethical principle of beneficence, which is the idea that there exists a moral imperative to act for the benefit of others. As difficult as it may be, acknowledging our failures and shortcomings as healthcare providers, and learning from them, is our obligation to do all that we humanly can to prevent harm to our patients.
Finally got to see this. I hope what she spoke about comes to pass but I doubt it. Nobody admits their mistakes in our society. It's not just the medical people. My heart goes out to Leilani. I hope she finds peace. I can't imagine losing one of my children. If it happened and somebody stonewalled me, they'd regret it. I'd make sure of that.
Wow! What a fabulously human response to something that has been known to destroy other humans - the loss of a child. Wow! What awareness & compassion, exquisitely organized and expressed. Leilani, I'm so glad you did this! May it inspire a whole bunch more humans. I am truly inspired.
I enjoyed this as you have spoken the truth. As an employee in NHS I advocate this and hope someday across the hospitals the administration supports us all in delivering truth and tranparency along with clinical care. Thank you for sharing.😢👏👏👏
“Attempted optimism’s , but their faces betrayed them”.
That is so powerful , all the more so because I have seen it.
I have tried to put a similar description on what I saw the day following my surgery, but I could never find those right words.
The medical mistake and the subsequent surgery disappointment I suffered pales to insignificant against your loss and despair, so sorry, I hope you are ok.
I believe that what this women experienced, although terrible, should be heard and practiced by everyone in the medical field. All to often medical errors go unnoticed or aren't freely admitted. How can we expect our healthcare system to improve if we hide what happens and continue to let them occur. There should be some sort of system in place where medical errors are processed and a way to make sure they don't occur again are thought of and discussed with all staff members. What the children's hospital in the video did was a prime example. Something unimaginable happened but everyone dove in to figure out the problem. Once the answer was found they made sure that everyone, including people at other hospitals, knew about the mistake that was made that day. By doing so, many future incidences were prevented. If every hospital did something similar to this the number of errors would be greatly decreased, and the family members involved could at least have a little peace. For example, I have worked at a veterinary hospital before and whenever a mistake was made that person was required to write it down and come up with a way to make sure no one every did it again. Then at our monthly meetings those mistakes would be talked about and that person would share their ideas with everyone else about how to prevent it. This brought the mistake to everyone's attention and made us be more aware of it for future scenarios. Our practice improved tremendously and almost immediately. I wish our healthcare system could follow something similar, but all too often people try to hide their mistakes because they are embarrassed or ashamed. Instead of getting those feelings they should be glad that they can share it with other people and ensure that the possibility of it happening again would decrease.
Thank you for sharing and I'm so sorry for your terrible loss. May your candor and compassion support you.
I applaud Leilani Schweitzer for speaking out regarding the mistakes made in her child’s care, and I empathize with her loss. I can’t imagine the pain she must have felt, and for her to share her story shows her strength and passion in advancing medical care. The way that her medical situation was handled should set an example for future practice. Physicians try their best to adhere to legal guidelines, but they also have ethical and moral obligations to fulfill. Sometimes it seems like this is a tricky balance, especially when it pertains to having to own up to mistakes they may have made. In her talk, Leilani discusses how important transparency was to her case. The fact that her medical care team made sure to inform her of their decisions, wrong-doings, and the process of events helped to validate her concerns and gave her a clear picture of what was going on. I would argue that this is not always practiced because the act of admitting to your faults could have serious consequences for your professional career. Unfortunately, practicing transparency is a standard principle of medical ethics because it allows patients to feel confident that their doctors are considering and acting upon their moral and ethical consciousness. It leaves little room for false accusations to be made and allows for open communication between both parties. Physicians are responsible for the beneficence of their patients, even after they have made mistakes. The fact that Leilani was treated with these principles in mind shows a good example of how physicians that use their ethical principles to make a positive impact for a patient that did not initially benefit under their care.”
Leilani thank you so much for sharing your story; Gabriel's story. It make in difference in my life and how I practice medicine.
Been there, done that. The medical field lost me after a death and a blame game. My guilt cost me a job. It still affects me today.
Thanks for your perspective Leilani! You are so brave to tell your story!
This also needs to be viewed by management and developers of Health Technology systems and devices!
I've worked in IT' HIT and software development; it's very common for developers and managers@ those companies to have little or no clinical or even healthcare training or experience. This is short-sighted and inexcusable!
At the least they could just spend a week shadowing the workers who will use the systems.
It would save countless hours, many lives and suffering, and of course money.
Thank you for your courage and you have my condolences. Sadly this kind of thing is still happening. A year ago in February I lost my son at age 17 to a Pulmonary Embolism that a simple blood test could have found. He passed out at school on Wed and died on Sat. I can truly Understand the grief the anger that you felt and probably continue to feel. Bless you and your Family.
Thank you for sharing your story!
Sometimes people dare not admit our mistakes, especially when they are sure it is wrong and it hurts others. They don't have the courage to face the consequences of their mistakes. It is time for us to take responsibility of our own mistakes and get relieved from guilty. I think we should rethink the punishment in our education. Does the punishment teach us the right way to face our mistakes?
Blessings of PEACE, Dear Mother of Gabriel. Thank You for Sharing.
Great speach , human erroes, can be so destuctive,my prayers are wth you .
Great talk, Leilani! Thank you for sharing your story.
when you go through such a loss it is normal for anyone to blame the healthcare providers, bt you not only understood their situation with empathy but also shared this to help other doctors (or future doctor in my case) to learn from this, errors in healthcare can be avoided with a good system where there is teamwork to catch one person's mistake, where there is learning, where errors are not punished but reported in a safe space and learnt from, where patients are part of the team. Hoping to carry Gabriel's story with throughout my career. thank you
My condolences go out to Ms. Schweitzer for the loss of her precious son Gabriel. I was incredibly touched by her experience and the courage that she had in sharing her story. I can empathize with her tragedy caused by a series of medical mistakes at the hands of various healthcare workers. I, too, suffered the loss of a very close loved one due to medical errors. As a mother of four, my initial assumption and belief was that the nurse that was at fault should be fired and have her nursing license taken away. The hospital was negligent as described by the three primary elements in Dr. Bernard Lo’s book, “Resolving Ethical Dilemmas: A Guide for Clinicians.” These elements include: a breach of duty to the patient, the patient being harmed, and the breach of duty causing the harm. After further thought and reflection, I realize that healthcare workers are imperfect human beings and not immune to making mistakes. Even though they strive for nonmaleficence, the ethical principle that expresses their duty to protect the patient from harm, errors will still occur. They are often overscheduled, work very long hours with little sleep, and have a lack of supervision due to understaffed working conditions. Ms. Schweitzer explained that medical errors cause over one hundred thousand preventable deaths each year in the United States and it is the third leading cause of death behind heart disease and cancer. Mistakes and errors will inevitably occur, but change needs to happen. All parties involved need to take responsibility and be transparent when these incidents take place. They need to be solution oriented and make every effort to fix the problem so that it does not happen again. Silence is not an option. They should honor the individuals that have been lost due to these medical errors by learning from the mistakes and fixing them. Opponents will argue that transparency in medicine will cause more malpractice lawsuit payouts, problems with insurance companies, and distractions among hospital staff. I can understand why many hospital administrators react to medical errors with deny and defend mentality. They hide behind legal tactics and avoid dealing directly with the family. It is easier for the hospital to blame the person that was at fault, terminate their employment, and then assume the problem is solved. Actually, research shows that transparency will make us safer and save money. The families of these victims do not want money, but they want to know that their loved one did not die in vain. They want a prompt investigation, honest and transparent explanations, an apology, and to see that changes have been made to ensure that the tragedy will never happen again to anyone else. Ms. Schweitzer expressed that compassion and truth are essential for healing. By sharing her heartbreaking journey with others she is honoring her son and helping to change the way healthcare workers handle medical errors in the future.
Thank you for your excellent, thought provoking talk. I think the idea of transparency is key to allowing the medical system to move forward. Compassion and empathy as well - we do put a lot of expectations on a system that is often overburdened, with a lack of resources -it’s tough for those working in it. The fact that medical error is the third leading cause of death is important to be aware of. How do we solve for this? Firstly, know that the health care system is complicated, be our body’s own advocates and aim for transparency. I just did a TEDX on the topic of being your body’s own advocate because of medical error - so I truly appreciate your talk! Thank you!
Thank you. That's all I can say. Thank you
The newly accepted number of deaths by medical errors is 440,000 per year in the U.S. There is many more left disabled.
Excellent talk
I'm here bec our topic is about medical error, the 3rd leading cause of death in USA trailing just BEHIND heart dse and CA. I have watched the Lewis Blackman case too. Just tragic =( =(
Leilani, please accept the warmest hug from this old nurse. You honor Gabriel by being outspoken and intelligent, and having the spine to call it as it is. What shocked me was your tremendous compassion for the caregivers: the doctor and nurse who left healthcare. That turned my head, I have never heard anyone express with such clear headed wisdom, what it means for a healthcare professional to leave, never to participate in healing ever again. The hole that is left there, it IS huge, and a waste as you said. And a shame...but again just as you said, I understand it, too. I wanted to leave when we had an incident on my unit. Not my fault, but I FELT like it was. I drove erratically for weeks, endangering myself and people around me. I couldn't sleep. I punished myself in so many ways only I can ever know. I finally went to Employee Assistance for counseling only to be told "it's normal" and that I needed to decide if I would stay or leave. I stayed. I try to forgive myself everyday. Bless your heart, dear.
Speaking as a self confessed ‘perfectionist’ I can relate to your pain. Even though we are inclined to blame ourselves for things that go wrong (even though we are not directly involved) we tend to apply that way of thinking both in our professional and personal lives. We are perceptive, sensitive, kind and mostly put other peoples needs (those we care about) before our own. And when things do go wrong with those we care about, we wonder why we couldn’t predict this and protect them when they needed us most. I salute you Shawni and the many health professionals like you who also wrestle with forgiveness of self when things go wrong. We do what we can and thats all we can do. Cliche yes, but we find it hard to believe, because we care so deeply for those we are there to protect and I think that makes us good at what we do. I hope this helps in some small way. I’m glad you stayed btw as I’m sure many of your past and present patients would also agree. Hugs.
Video no longer available? Why am I not surprised?
This is the first time a Tedx talk has value. She is 100% right. The US needs to step away from third party payments, remove insurance companies and lawyers from the scene almost entirely. Otherwise this mess will never be fixed.
YES!!!!!!!!!!
deny and defend...exactly....
Thank you. And exhausted parents and carers will always need sleep; noise cancelling headphones would help.
Why did she not get a standing ovation?
It’s heartbreaking to be “gaslight” by the very people that you “entrust” with your care or the care of those you love. Being gaslight into believing your “wrong”, on the attempt of a shifty provider protecting their own “rep”...
Revictimization. By the people you trust and who also have the power to “wreck your credit”...and threaten your healthcare.
Abuse. All it would take would be for these “providers” to show some HUMANITY
True..it IS abuse.
Why this video feel like a border in TH-cam?
I wonder if the typical response of the hospital administrators is due to years of conditioning or plain fear?
That’s horrible. I will not even change the parameters of my patient ‘s alarm .
We should think of Nurses and Doctors as being like Priests, most are great, but a small percentage should be removed and prosecuted for their actions.
Alessandro Machi did you even watch the video? As she said, health care professionals are human. With being human comes making mistakes. The whole point of the video was to accept that mistakes happen and to learn from them. And to NOT blame and prosecute
...when wrong are right ? ... Economics saying the cliche " NO WANT MONEY " tell the fact to look back in compassion are not to EGO say ... mean a lot to me to have matter ." SOMETHING " Death as to be see as part of life like dust that was swiped out and clean our path ... let's stat up for EUTHANASIA ... and evolution to better economics !
I am a biologist. I am tired too.
Then they wonder why people want to keep turning to holistic medicine....
No, i cant side with you. 7 screens turned off. I hope you did file
with an insensitive POTUS such as trump expect more problems in health care