Friday, January 23, 2009

Flying Trapeze as Therapy?!

We recently read a piece written by a young woman named Megan who had experienced a medical error and lives each day with the emotional fallout. In an effort to heal mentally, physically, and spiritually, she has taken up quite an unusual activity – the flying trapeze! We were moved by her insight and inspired by her tenacity and courage. We were also quite surprised to learn that the trapeze flying business can actually show healthcare a thing or two about safety! We are grateful that Megan has allowed us to use this space to share her story:

In April 2008, I experienced a medication error during an elective outpatient hospital procedure. While there were several factors that contributed to the error, the primary cause was a decision by a doctor that my previous adverse reaction to the medication was not significant enough to warrant deviation from the “standard protocol”. I was given the medication against my wishes and without my knowledge. Upon being informed of the error, my attending physician, in an attempt to be helpful, told me steps I could take to prevent the error in the future. Even though the error was not my fault, the implication was that I was expected to take responsibility for it.

As often happens with medically-induced trauma, I lost the ability to trust others and found that I could also no longer trust myself. I had put myself in a situation at the hospital where I thought I would be safe, but ended up being harmed by it. I blamed myself for my lack of foresight—for not knowing the “magic words” that would have protected me. I became stagnant with the fear that I did not have the judgment to avoid another painful mistake.

After several months, I decided that I could no longer live with the constant fear and self blame. I knew that I had to do something to rebuild my confidence and trust. It was at this point that I happened to see some information about a local flying trapeze school ( I decided that this would be a good way to challenge my fears. I used a simple risk assessment, “Do you think you could get hurt worse doing this than you already have been hurt this year?” “No.” “Well, OK then.” I signed up for a class. What I experienced in trapeze class was the polar opposite of what happened to me in the hospital:

Safety First—The entire trapeze system is designed around keeping the participants safe. There are redundant systems so that if one fails, a backup will be in place. The systems are checked on every swing, making sure the rigging is working properly. Because all the class participants are at different levels, the instructors always ask the student before each swing to make sure they have the details correct. The instructors always “spot” each other, pointing out if someone forgets a detail without any feelings of blame or embarrassment.

It is OK to be scared—Even experienced flyers get a little nervous their first time up on the platform. Fear of heights is part of human nature! The instructors will help you get up the courage to take that first step, and nobody will think you are a baby or a wimp if it takes a while. Even if you decide not to take the leap, your choice will be respected. Being able to acknowledge fear and take the leap anyway is very empowering.

Trusting others—Much of flying trapeze goes against intuition. If you can do what you are told when you are told, the tricks will work. One example of this is that you need to stand on the starting platform with your hips pushed forward. This feels very scary at first, until you realize that the instructor is holding the back of your belt and the resistance makes you safer. Another example is how the timing of the trick is essential to being able to do it correctly. Too early or too late, and you need to work against gravitational forces instead of letting them help you.

The Catch –For the last part of the class, students get the opportunity to throw a trick to the catcher. The person who is going to be the catcher watches the students do their last round of tricks “to the net” to figure out the time it takes each individual to do the trick. This is important because each person is unique in his/her reaction time to the calls, and swing speed. For the catch to work correctly, the catcher needs to plan for this and time the trick appropriately. Students are not told, “you need to adjust to your catcher’s timing.” It is the catcher’s job to adjust to them.

Trusting yourself and having others trust you – The first trick you learn on trapeze is fairly simple and the catcher pulls you off the bar for the catch. After that, you learn tricks where you must release the bar on command (a.k.a. Wait for the Hep!). The instructors will only allow you to throw these tricks to the catcher when they are confident that you can wait for the command. It is very easy to anticipate and let go too early. If that happens there is risk of injury, mainly to the catcher, as you go flying into him. You need to be able to trust yourself, and also know that the catcher trusts you to follow the commands.

Taking responsibility – If a trick doesn’t go as planned, which usually results in a missed catch, the instructors always discuss with the students what went wrong. If it was a timing error, the instructors take responsibility. If the problem is the student not getting into the correct position, that is explained as well. After every missed trick, you will hear someone say, “that was me.” The goal is to improve the process and the student’s experience, not to point fingers and assign blame. Everyone on the team is willing to take steps to make that happen.

So while my recovery from my medical error continues, I am very happy to have found an activity that I can enjoy and feel safe doing. One of the school slogans is “Forget fear, worry about the addiction.” This has certainly been true in my experience. Friends say to me, “I don’t know how you can do that, I would be terrified!” For me, I am trying to limit what I am willing to fear. I don’t know if I will ever get over my fear of hospitals, but at least I can scratch “Fear of Flying” off my list.

Wednesday, January 21, 2009

Keynote Speaker Videos Now Available!

As promised in a previous post, videos from the MITSS 7th Annual Dinner and Fundraiser are now available. If you weren't able to be there, or if you would like to experience these amazing presentations again, go to the MITSS homepage and click on Margaret Murphy and Paul Levy's pictures.

Margaret Murphy, a Patient Advocate and Member, Patients for Patient Safety of the WHO World Alliance for Patient Safety, pays a loving tribute to her son, Kevin, who died from a series of preventable medical errors. It is a moving, heart wrenching story of one family's tragic experience with a healthcare system that failed them. It concludes on a hopeful note, though, because of one woman's strength, courage, and determination to find some meaning from the death of her son.

Paul Levy, President and CEO of the Beth Israel Deaconess Medical Center in Boston, provides the second keynote address outlining his own institution’s commitment to creating a consistently excellent patient experience. He shares that BIDMC’s Board of Directors recently adopted two audacious goals: (1) by January 1, 2012, to be in the top 2% of hospitals in the country; and, (3) to eliminate all preventable harm by January 1, 2012. Paul speaks candidly, with wisdom and wit, about the BIDMC’s journey thus far in pursuit of these seemingly unreachable goals.

Two amazing people -- two unforgettable presentations!!!

Monday, January 19, 2009

Apparently, It's Just Not That Simple!

In our previous post regarding surgical checklists, we asked the question "Can it really be that simple?" The answer is -- apparently not!

For a lively and informative discussion, see Paul Levy's blog post (including the comments) on the same topic. Barriers to change include a "broken" medical education system, a physician culture that resists "standardization," and a lack of consumer/patient input. Also, it seems that if the medical community cannot adopt such system changes (like the use of a surgical checklist) relatively soon, the likelihood of further burdensome regulation and legislation is very real. While the exchange is fascinating to read, I found it quite dizzying trying to sift through the differing perspectives and important issues raised!

I guess the appropriate question then would be -- Are we making any real headway or just continuing to spin our wheels?

Thursday, January 15, 2009

Simple Checklist Can Make Surgery Safer

A Harvard School of Public Health study indicated that deaths and complications from surgery dropped by one third when operating room teams used a simple 19-step checklist. While the results of the study are certainly promising, doctors, nurses, and institutions may still be reluctant, for various reasons, to adopt the entire checklist.

As with any patient safety initiative, the authors of the study note that a strong commitment by hospital leadership is required to effect this kind of change. Check out the full text of the article in today's Boston Globe.

Can it really be this simple?

Thursday, January 8, 2009

Obama is going ELECTRONIC!

In his economic policy statement today, President-Elect Obama reiterated his goal of electronic medical records for the country. He stated that this is fiscally responsible, as it alleviates the cost of maintaining paper records, and will reduce medical errors and their subsequent cost. Here is a quote from his statement transcript, taken from the Wall Street Journal website:

To improve the quality of our health care while lowering its cost, we will make the immediate investments necessary to ensure that within five years, all of America’s medical records are computerized. This will cut waste, eliminate red tape, and reduce the need to repeat expensive medical tests. But it just won’t save billions of dollars and thousands of jobs – it will save lives by reducing the deadly but preventable medical errors that pervade our health care system.”

Does this seem feasible? Will electronic medical records produce this kind of financial and patient safety change? Does it have a privacy cost? Should patients have access to these records?Any thoughts or discussion on this issue is welcome.

Erin O'Donnell
MITSS Support Team Member
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