August de los Reyes calls it “the catastrophic moment.“ It was also the moment that launched his desire to develop new and innovative patient care processes through design.
In The Seattle Times article, “Paralyzed by errors, this Xbox designer is taking on hospital safety,” writer JoNel Aleccia tells how the former Xbox designer took a medical mistake and turned it into an opportunity to improve patient safety.
It all began after injuring his back from a fall. August went to a local hospital for treatment. Early on, he let his doctors know he suffered from a brittle spine, the result of a rare inflammatory disease. But through a series of communication errors and missteps, August wound up with a severely broken back.
“I went into the ER and while I was there, my back broke,” de los Reyes said. Multiple surgeries and other treatments couldn’t change the truth: He’d never walk again.
He spent months in rehab, learned how to navigate in a wheelchair, and eventually returned back to work. At the same time, he was working out a settlement with the hospital where he originally received treatment. And then August had a revelation.
“In the design world, when we see a problem, we analyze those problems deeply,” de los Reyes said. “I saw this as an opportunity to innovate.”
Aided by his lawyers, he . . . demanded that the hospital investigate and evaluate the circumstances that led to his injury—with his participation. Within days of signing the settlement, de los Reyes met with [the hospital’s] CEO.
Now involved with the hospital where he was injured, August is applying his technical design skills to analyze and improve clinical practice. He’s also in contact with the Spinal Cord Injury Association of Washington and other advocacy groups.
De los Reyes doesn’t know yet what changes would help prevent similar injuries. Experts who focus on mistakes caused by miscommunication have found that taking specific steps to improve handoffs among care providers reduced such errors by 23 percent, according to a 2014 study in The New England Journal of Medicine.
As August works to improve the tools and processes that will aid communication between caregivers and their patients, he’s also thinking about the future: sharing those findings with others so they can learn from his work.
“I’m not letting my condition hold me back . . . At Microsoft we had a saying, ‘Think universally, but act personally.’”
Read this article in its entirety online at The Seattle Times.
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- Tracy Romoser is a communications officer and the blog editor at PATH.