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Medical Group Management Association

Insider: An anatomy of errors — a healthcare executive's experience as a patient

Podcast - May 7, 2019

Patient Access

Patient Engagement

Practice Efficiency

In this special edition of MGMA Insider, we speak with Barb Davis, Senior Vice President of Client Success at CipherHealth. Although Barb has experienced more than 30 years as a healthcare professional, she's here today to share her experience as a patient.

While on the snowy slopes of Colorado in December 2016, Barb suffered a tibial plateau fracture. During the course of multiple surgeries, Barb experienced what she now calls, "a number of near misses" and she identified numerous "opportunities for improvement."

Her article about her experience as a patient appears at…s-my-patient-story

Key points from this podcast:

  • The burden of communication should not lie with the patient
  • A simple misplacement (of Barb's clothes) led to tremendous distraction
  • There are plenty of opportunities for improvement of patient care at a systems level
  • It's easy for a patient to experience "the Swiss cheese model" of falling right through the holes in the system

As Barb reflects on her experience, she has a newfound empathy with patients and the experiences they have in the healthcare system. As she writes, "I am sharing my own experiences to highlight the gap that still exists in patient safety, even when care teams have the best of intentions and when the patient is a knowledgeable healthcare consumer... After 30 years of experience working with physicians, nurses, and care teams, I didn’t call when I suspected that something wasn’t right... I accept responsibility for my own lack of action and can’t help but think about others: What about patients who haven’t worked in healthcare? Would they have fallen through the 'cheese' and experienced system errors that resulted in harm?"

If you have a healthcare story — professional or personal — that you'd like to share with us, please send us an email at

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