Spreading the word about the PFACQS mission—and accomplishments-- is critical to its success. Council members serve as educators and facilitators for change, and understand that the most compelling lessons come from the voices of patients and families.
Two educational forums held during the last year have attracted dozens of MedStar Georgetown associates—and featured two powerful speakers: Jack Gentry and Rosemary Gibson
In November 2015, Gibson, author and senior advisor at The Hastings Center and a member of the MedStar Health PFACQS, made her persuasive arguments for change to a diverse audience of hospital team members. A national expert and advocate, her books include Wall of Silence, which tells the human story behind the Institute of Medicine report “To Err is Human,” and The Treatment Trap, which focuses on overtreatment in health care.
Creating a Culture of Safety
Gibson talked about the importance of creating a hospital culture that is “genetically wired” to safety, and of the proactive steps MedStar Health has taken toward this transformation— major initiatives to encourage both caregivers and patients to speak out if they perceive a problem with care.
The “Good Catch” project is making reporting near-missed mistakes—and acknowledging medical errors—a positive action for the care team. CLER, the ACGME program initiated at all MedStar Health teaching hospitals, is restructuring resident medical education to foster patient safety. And MedStar Health’s Telluride Patient Safety Summer Camp for medical and nursing students and residents is helping to shape the next generation of proactive, safety-oriented health care professionals.
This culture of safety also means that when errors are made, caregivers step-up, speak honestly to patients and work together to find solutions. This was Jack Gentry’s remarkable story as told to a standing-room only crowd of MedStar Georgetown associates—many who were moved to tears.
Turning Tragedy Upside Down
In April 2013, Gentry elected to have surgery to repair two bulging discs in his neck. He was looking forward to years of health and activity after a long career as a police officer in Baltimore City. But during the procedure performed by orthopaedic surgeon Justin Tortolani, MD, at MedStar Union Memorial Hospital an error occurred when one of the surgical implants hit the spinal cord, leaving Gentry with incomplete paraplegia.
But for the physician, Jack and his wife Teresa this tragic incident became a remarkable moment of grace. The surgeon talked opening and with transparency about what had happened. The Gentrys worked with MedStar Health to find solutions through reconciliation—not confrontation or litigation.
The health system stepped up to cover the costs of Gentry’s long rehabilitation—and he and his wife have become national advocates for resolving unintended medical harm through compromise and mediation. In 2016, the Gentrys testified before the Maryland state legislature in support of a MedStar-sponsored bill that would make it possible for caregivers, patients and family members to talk freely and honestly about harmful events, offer apologies, and work toward optimal resolution and out-of-court remedies.
Today, Gentry is an active member of MedStar Health’s PFACQS and a proponent of a no-blame safety culture. “I’ll be honest with you, without Dr. Tortolani and MedStar’s approach to this, I wouldn’t be where I am today,” Gentry has said. “We have settled our differences from a monetary point of view. We never filed suit. We worked it out, and we did it in two years versus five or six or seven years if we had gone to trial. And in the meantime, where would I be?”