Third Adrienne Cullen lecture on openness about medical incidents
Dialogue and openness: two terms that formed the common thread during the third Adrienne Cullen lecture on Friday April 16 at the UMC Utrecht. During this annual lecture, the UMC Utrecht discusses with various speakers from inside and outside the hospitalhow we as a hospital learn from medical incidents. Due to corona measures, this year’s lecture was given in the form of an online webinar.
The Adrienne Cullen Lecture is a public lecture that anyone interested can attend. Attendance was high again this year. 350 interested people listened and asked questions. The lecture started with a video from 2018 in which Ms. Cullen, who died that year from cervical cancer as a result of a medical error at the UMC Utrecht, explains what went wrong with her, how we as a hospital subsequently dealt with this and how it affected her and her loved ones. After this poignant video, moderator Hans van Delden, professor of medical ethics, talked to Anouk Vermeer, member of the Executive Board of the UMC Utrecht, about why a lecture like this is so necessary. “Openness about medical failures is incredibly important, we need to learn from each other. And not only we, but also other hospitals in the Netherlands,” says Anouk Vermeer.
Listen to those involved
The UMC Utrecht offers patient and peer support in case of medical incidents with the aim of providing patients and staff involved with proper guidance after an incident and to ensure that we, as a hospital, learn from it, and hence prevent repetition. This subject was amply covered during the lecture. One of the speakers was Marcel Albers, director of quality of care and patient safety. He said: “In the case of medical incidents, the needs of a patient, loved one or relatives are sometimes really different from the systematic procedure that we as a hospital are legally required to go through. That’s why it’s important that we continue to stand by the patient. If we lose sight of them along the way, we’re doing it wrong.” Kitty Bloemenkamp, professor of obstetrics and chair of the sentinel event analysis committee, adds: "That's what I've learned in recent years. Keep listening to everyone involved, both patient and healthcare professional."
“If something goes wrong”
In order to learn from incidents, research into them is also very valuable. Cordula Wagner, director of Nivel and professor of patient safety at the Vrije Universiteit Amsterdam, led the study “If something goes wrong”. She spoke with patients and relatives and looked into the consequences of incidents and their disclosure for them. This also showed that the formal procedures are often intensive and frustrating for patients and their relatives. The main recommendation from the study is: keep the dialogue with the patient going. This also enables you as an organization to make adjustments where necessary, because the questions and needs of a patient can change during a course of treatment.
Listening and learning
With this, Cordula Wagner touched upon an important issue, which Michèle Huisman, coordinator of patient support, and Marjel van Dam, intensivist and coordinator of peer support, also endorse. Counseling patients and healthcare professionals requires a tailor-made approach Everyone has different needs, which should always be borne in mind. By listening to both the patient and the healthcare professional, it is possible to properly investigate how the incident could happen. Marcel Albers: “And then it’s important to prevent repetition. We continue to assess whether agreed improvements are still working or whether adjustments are needed. We need to make sure that the change lasts.”
That is why this annual public lecture is so important. The third Adrienne Cullen lecture of the UMC Utrecht ended with a closing word of thanks by Hans van Delden.
About the Adrienne Cullen Lecture
The “Adrienne Cullen Lecture on Open Disclosure After Serious Harm” is held annually at the UMC Utrecht. The first lecture was held in 2018 when Ms. Adrienne Cullen and two of her doctors spoke openly about the medical error that led to her end-stage cervical cancer. Ms. Cullen passed away on December 31, 2018. This lecture is named in her honor so that as a hospital we can learn from things that go wrong and, through openness, prevent similar mistakes from being made again. Read more at our website.
View the full lecture here.