Adverse Events

In almost all cases, the patient’s perspective is irrelevant as to whether or not an adverse event has occurred. If the patient is aware that a medical mistake was made, it would (of course) be an adverse event. If they were rendered unconscious or killed by the mistake (and therefore unaware of it), it would still be an adverse event. The point is, all medical mistakes are adverse events. Furthermore, if a mistake was made that did not harm the patient in any way, it would still be an adverse event because breakdowns of protocol in the medical industry are always unacceptable and need to be corrected—regardless if the patient was aware of the mistake or not.

There are, however, some cases when the patient’s perspective does affect whether or not an event is considered adverse. In the case of plastic surgery (which is highly subjective), a patient’s outcome may not be what they had envisioned. While the surgeon may think he or she did a great job, the patient might still consider it an adverse event (and try to litigate). Conversely, a plastic surgeon may make a mistake during a breast augmentation (putting in “c” cup implants instead of “b” cup, for example) and the patient ends up happier with the larger size. While the patient does not perceive an adverse event has occurred, a mistake was made and should still be considered adverse by the medical staff.

Once again...in the medical field, all mistakes should be considered adverse events. As future health care executives, we need to take the proper steps and create safeguards that prevent mistakes—keeping adverse events from happening in the first place.

Fish Philosophy

When I was working as a retail manager, one of the training tools we used to create a more productive working environment and a higher quality customer service experience was "Fish Philosophy," from the book Fish! by Lundin, Paul, & Christensen. This book used the Seattle-based Pike Place Fish market as the backdrop for illustrating this philosophy. Even though the weather was cold, the fish were smelly and the hours were long, the fish workers made their jobs fun and entertaining for customers by throwing fish through the air to one another, singing songs, and telling jokes to customers. They turned something miserable into something fun by employing main four principles: Choose your attitude, play, make their day, and be present (Lundin, Paul, & Christensen, 2000, p. 70).


"Choose your attitude" refers to the fact that we all choose the attitude we put out there for the world to see. Regardless of whether we are having a good or bad day, the attitude we choose to put out there should always be positive if we expect positive things to happen for us. "Play" refers to the practice of playing at work (while still getting work done of course). Since we spend so much of our lives at work, why not make it a fun place where we look forward to spending time--as opposed to dreading every morning. "Make their day" refers to involving customers/patients in the fun we are having. This creates great memories that can make someone's day that was previously not so special. "Be present" is being fully engaged with customers/patients by not ignoring their needs.


While I know that these four principles may not work as well in certain areas of health care (acute care, for example), other areas such as children's hospitals could definitely benefit from Fish Philosophy. But even with acute care, choosing a positive attitude and being present for customers can make a huge difference at the end of the day. With the focus of health care shifting to patient-centered care, any way that we can enhance the quality of a patient's experience is a good thing.

Reference:
Lundin, S., Paul, H., & Christensen, J. (2000). Fish!. New York, NY: Hyperion.