Insights October 2013

It is great to be on the “balcony of personal reflection” to discuss the importance of family, patient and care provider conversations. Out of nowhere the Ghost of Healthcare Consciousness swoops in and declares:

“Quality healthcare is based on three elements: communication, trust and caring. When one of these elements is missing, patient quality and safety breaks down … If the desire is to reduce patient safety incidents, this trinity must not only be present but vigorous. Only when we are able to stand together – patient, families and provider – will we actualize change.”

How is wholeness defined? A common description of wholeness would normally comprise the words “not broken,” “damaged” or “impaired,” but another meaning of the word refers to “containing all the elements properly belonging.” When this word and its definitions are applied to a patient safety continuum, a dichotomy is created: “broken” on one end and “whole” on the other. We are unsure where healthcare presently sits on this continuum, but we still have some distance to cover before we see “wholeness.”  

If we were able to view patient safety as a large puzzle, with all its pieces laid out on a table, it would provide us a visual framework and greater understanding of the many “individual pieces” needed to construct the “whole.” We must show a willingness to embrace, and support, each and every part of this puzzle, for even the smallest piece has the potential to maximize the synergistic effects of this greater whole. There is also the possibility that our puzzle will never be completed, as the image initially sought continues to morph, requiring additional pieces.

We, personally, cannot claim to contribute in a clinical way, yet our unique perspectives make our offered “puzzle piece” equally as valuable. Our contribution will be a combination of my daughter’s narrative. It will be our voice, now that Jess has none. It will come by way of hard-earned collective insight, using empathy in hopes of inspiring a better plan for post‐error exploration and healing. Our journey has taught us that all involved in medical error suffer, and all are in need of restorative balance.

The post‐error process often finds those harmed and those who have inflicted the unintentional harm on opposite sides of the table, positions that create further anguish for everyone, at a time when healing is needed most.

In addition, healthcare systems are often short-sighted, underestimating the curative nature of forgiveness. A fearful refusal to meet with patients and their families after an incident impedes the healing process.

As a counsellor, I (Tanya) became a mediator because of my daughter’s death from medical error, as it had the capacity to bring mutual understanding and healing to this particular “piece of the puzzle.” It wasn’t until I had a powerful meeting with Jess’ physicians, five years after her death, that I came to understand just how crucial this particular piece is; this process of coming full circle. We talk about a mediated post‐error process, a facilitated dialogue of sorts that would see the mediator meet with family and physicians separately. A series of meetings to hear each side, to understand the details involved and manage the strong emotions attached. Working with empathy, we would create an environment conducive to honest listening, not only with our ears, but our hearts as well. And then, and only then, would we all come together. It would take ample courage, perhaps a leap of faith, to enter into a process such as this, but I am here to tell you that the rewards are transformative. 

We offer the following recommendations:

  1. Staff oriented to share information with patients and families or advocates and to develop a relationship of trust as fundamental to patient-centred care. The role of the patient/family in the process of finding out what happened and how is crucial.
  2. Boards make it clear that patient-centred care, and with it the adoption of quality and patient safety improvement practices, is a core expectation. And they drive improvement beyond the requirements of government and external accreditation, regulatory and licensing bodies.
  3. Patient-centred care progress reports are requested by boards, received and acted upon.

The comment posted by David Cochrane on the essay “Can an Organization Grow if Its People Are Not Connected?” resonates: “… I can not help but reflect on the fact that organizational structures are the first things healthcare administrations focus on. Changing politics, funding, labour relations call for reorganization. We are very good at reorganizing either at the macro or meso levels … Over the years, and throughout all of the “organizations,” the issues of quality in healthcare persist. It seems that the outcomes are independent of the organizational structure, whatever it is. So what is missing? It is not “a” structure; it is a clear definition of the goals that any structure is to deliver. It is the “relentless” pursuit of those goals and transparent accountability to the public. We … have spent so much time on structure that we have failed to define, understand, design and deliver upon the goals our system is to achieve. In fact, in building the artifacts of our health care system (organizational presence, structures, buildings and such) we are protected from having to address quality, sustainable delivery and transformation. … We should be guided by the goals society sets for us and not bow to the structures we have created.”

Using Jess’s motto, “Dare to Dream,” we dare to dream of a future where family and care providers sit together, working to give meaning to someone’s death or harm, and in turn, helping to sow the seeds of mutual healing. Will you help us dare to dream?

It begins with listening. Join the conversation posted today: Three Patient and Family Voices: Dare to DreamListening to Me and Stop Tiptoeing Around What Matters.

Click here to see the First Series of Ghost Busting essays.
Click here to see essays from the Second Series: The Ghost of Healthcare Consciousness.

About the Author(s)

Tanya Barnett, Grieving Mother, Wife, Sister, Grandmother, Patient Safety Advocate. Hugh MacLeod, CEO Canadian Patient Safety Institute … Patient, Husband, Father, Brother, Grandfather … Concerned Citizen.


The Canadian Patient Safety Institute (CPSI) exists to raise awareness and facilitate implementation of ideas and best practices to achieve a transformation in patient safety. We envision safe healthcare for all Canadians and are driven to inspire extraordinary improvement in patient safety and quality. To help address many of the challenges mentioned in the essay above, the Canadian Patient Safety Institute with partners has tools and resources such as: Patient Safety Incident Analysis and Canadian Disclosure Guidelines. In addition, if you would like information about Patients for Patient Safety Canada, please


Cochrane, D. 2013. Website posting on essay: “Can an Organization Grow if Its People Are Not Connected?” Longwoods Ghost Busting Essays.


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