This is a club I never wanted to be part of, but oh how much these videos are helping. Thank you Julie. This is a must watch. (If you have less time, just watch Julie tell her story from 7.45)
Some key points I took away (basically the bits where I had to pause the video, have a good cry and drink a glass of water)
9.49 –
“There will never be a point when you have achieved enough skill, experience, knowledge, vigilance, prudence, awareness, or carefulness, to be able to fully control whether you commit an error or not, or overcome the human condition.”
11.39-
“This error did not occur because of who I was, it happened in spite of who I was. ” (ok, so I’m still working through this, and whether I can accept that, but a very intense statement, crying my heart out right now..)
14.43 –
Talking about the need for a response team to help the caregiver in the immediate aftermath.
15.36 –
“Others may have a delayed reaction of despair”. This was my experience, it took me 18 months to begin to face the facts. See Spinach in my teeth.
18.50 –
Talking about the rapid focus shift to the victim and their family and their (valid) desire for staff to learn from the error, and make sure it never happens again. Legal proceedings and a culture of blame and punitive measures prevents transparency and apology. (So true. I’m still not sure who I’m allowed to tell or contact and whether correspondence with the family is a good idea or even permitted during legal proceedings, but more on that later. I should note, that with anthing else in life, I would have found this out by now, clarified the boundaries, but I suppose that’s avoidance for you.)
25:50 –
“Suggest ways in which you can help this person. as in, can we get together again after work, and talk more together. Don’t just say if there’s anything I can do, just let me know. This person has no idea what he or she needs.”
If there is anything I can do just let me know, was almost word for word what my supervisor told me over the phone after notifying me. Granted, my memory is somewhat patchy due to the shock, so I can’t say without a doubt this was the case. But from memory there were no practical or sequential steps offered to assist me in the days weeks or months following. Not one follow up conversation after the initial call notifying me of the error and its fatal outcome. In hindsight that is terrible. I had no idea (and still don’t) if my university even knows.
24:40-
“When and if we fail, we fail together… ”
Final words.
24.59-
“I came here today because I can guarantee that in every organisation you represent, there are or someday will be, people who have unintentionally been involved in an adverse event. I ache to reach them. I can’t. But you can. Please take my hands with you, take my heart with you and together let’s seek them out. Reach out to them and let them know that you are open and interested in how they are doing and feeling, support them whatever way you can. Suggest ways in which you can help this person. As in, can we get together again after work, and talk more together. Don’t just say if there’s anything I can do, just let me know. This person has no idea what he or she needs. Share with them what you have learned here. And let them know that this happened not because of who they are but in spite of who they are. Let them know that to you, this person is still all he or she was before this occurred, that you’ll always remebr them for that, not for this event and that this event does not define who they are.”
Amen.
Mama I killed a man 