Day 3- We Can’t Fix What We Don’t Know!

My “aha moment” today was when Crystal mentioned that administration only knows about 4% of adverse events which occur because they are only being made aware of the events which are really catastrophic. However, if they had been made aware of every single adverse event, regardless of level of harm, there could have been strategies, plans, and policies put in place which may have prevented much of the 4% of catastrophic events.

This is a point that I intend to share with my team to encourage them to report patient safety events. I think many of my co-workers are only reporting the events which actually reach the patient, I am guilty of this myself. However I am realizing that it is of great importance to report the good catches so administration is aware of potential safety issues.

Reflection on QI initiatives at my institution

One of the most powerful tools that we have in raising awareness for quality improvement and patient safety are the stories that patients and their families have. When listening to these stories, such as the Lewis Blackman story, I can’t help but think of the numerous QI initiatives at my institution that could have potentially saved his life.  Such initiatives include sepsis huddles, PEWS (the Pediatric Early Warning System), and a streamlined rapid response system. Even in the short amount of time that I have been there, great strides have been taken to both implement and improve these systems. Of course, it is relatively easy to lose sight of the big picture and feel annoyed sometimes when interacting with these systems; I distinctly remember on more than one occasion, nurses apologizing to me in the middle of the night about triggering a sepsis huddles, or calling me about elevated… Continue reading

Learning from the Telluride Experience.

Getting to know the histories of Lewis Blackman and Michael Skolnik, showed me how an error can affect the life of many and the wound that despite all treatments and solutions is there for the rest of their days.  Transparency, since day 1, is an important stone to set a good relation with patients and their families.

Nobody deserves a wall of silence when there is a father, mother, son, sibling, any human been involved in a medical error as Mrs. Gibson stated in our visit to Arlington Cemetery. Every soldier that rest in this place had a history well known by their bothers in arms and their families, every patient and their families deserve to know without delays all the details regarding adverse events.

The experience of Mr. Gentry, as a former negotiator, was very illustrative when comparing his former job with the effective communication tools that we… Continue reading

What I learned from the last four days..

The Telluride Patient Safety Experience served as a venue for me to assess my patient care practices from a different viewpoint. It helped me fo find ways I can improve the quality of care that I provide for my patients as a part of the health care team. Small changes in the ways I communicate with my patients, health care team and my patients’ families can have significant impact on my patients ‘ outcomes and satisfaction.

Significance of transparency, empathy, embracing our mistakes and turning them into an opportunity to learn from them to improve the outcome as well as avoiding them in future.

Errors are inevitable. To develop a culture that accepts changes and implements those changes regardless of who suggested the changes rather than a culture of shame and blame is the foundation on which our patients ‘ recovery lies.

This conference also introduced me to some concepts… Continue reading

Day 2- Reflecting on Self Reflection

As healthcare professionals, I truly believe that the vast majority of us have the desire to provide safe, quality care to each and every patient. Our facilities push us toward reaching our goals of decreased safety events and increased patient satisfaction scores. Often, during particularly busy or complicated shifts in the ED, I find myself thinking “how can they expect us to reach our goals and keep our patients safe and satisfied under these conditions?” This question may enter my mind because there is a lack of resources, or acuity is high for all 4 of my patients and they are all priority but I am only 1 person, or I am boarding an ICU patient who really requires 1:1 care but I still have my other patients to care for, or one of the many other things that occur which are concerning to me. I have an amazing team but on nights like this they are equally busy and unable to assist. During these times I truly do not feel that my patients are as safe as they should be. I accepted the opportunity to be involved in this experience  because I feel it is my responsibility to become a key factor in finding solutions.

So that’s the WHY in my story.

In general, I  am introverted and not a conversation starter. I know this about myself. I have been this way for as long as I can remember. For the most part it has not negatively impacted my path in life. However, I am discovering that to truly be an advocate for my patients, for safety, or for anything, I have to change that about myself. I have to start the conversation, offer my opinions, voice my concerns, and get others on board. Before I can feel truly comfortable in doing so, I need to be well prepared. During this experience I hope to collect a box full of tools to take with me back to my department so I am prepared for this challenge.

So that’s what I want to take with me.

Now I ask myself, what am I willing to invest in achieving the purpose which brought me here? I am completely willing to jump out of my comfort zone to be the one who brings the collective concerns of my team to management and recommend solutions. Often in quiet conversations between staff we complain to each other. “Something has to be done about this pump issue. I’m so tired of delaying patient care because I’m searching for a pump, only to discover that they are all in use and I have to go call another unit to beg for a pump. I don’t have time for this.” Or “I don’t understand why we only have 1 attending physician from 2am to 7am. Hasn’t management picked up on the trend of longer wait times during those hours? I have a high priority patient who arrived by ambulance who has not yet been evaluated by a physician and he has been here for an hour.” I hear these types of complaints and even partake but I always assume that management is aware because “someone MUST have informed them already.” Right now I am willing to commit to throwing out that assumption and taking these collective concerns, along with our recommendations for possible solutions, to management.

Answering these questions for myself and really reflecting on them has brought me a great deal of motivation to get started.

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Big Picture Thinking

It is important to not only be mindful, but to also take action. We can recognize something isn’t right, but if we do nothing to change it we become complacent. Regarding informed consent, it is important to keep patient centered care in the forefront instead of just another checkmark to complete. The physician should also go over the risk, benefit, and alternatives. I would like to implement “What is important to you now?” and asses my future patients needs, preferences, values, and goals when I provide treatment. I really enjoyed the art of empathy video. I feel that I am guilty of trying to silver line people’s problems–trying to cheer them up, but I learned yesterday that being present in the moment and honoring their feelings is a more valid response.

Telluride Reflection – Day 2

Today’s discussion around the informed consent process was really enlightening. A common thread amongst both doctors and nurses was that there was extremely minimal education related to the importance and weight of informed consent before starting in the field. When I was a new nurse, I remember MDs coming up to me asking me to “witness” a consent even though I had not been in the room. Even now, I have seen some doctors place a communication order over EHR stating “Nursing, please witness consent in chart” (which also ties into the discussion from Day 1 about how EHR can hurt communication with MDs and RNs). Reflecting after the discussion, I now don’t think this was oversight by the MD but more of a product of lack of education related to informed consent during training. If informed consent was emphasized in nursing and medical school as a “shared decision-making process”… Continue reading

Day 2

The state of Michigan, Department of Human Health and Services, (2015) state that “A consent is executed when it is in writing and signed by the appropriate individual or when a verbal agreement of a recipient is witnessed and documented by an individual other than the individual providing treatment”.

We talked today of how people were scared to obtain informed consents, especially for procedures they would not be participating in. In MI, it is legal for someone other than the doctor to obtain consent, and it frequently occurs. There is not law that states consents are a two person job, at this time in the state.  It’s best to be aware of your states practice laws to ensure that you are legally obtaining consents in your area of work.

Reflection Day 2: Informed Consent

Every story of patient harm from medical error has broken my heart, but the story of Michael Skolnik hit home.  As a neurosurgical operating room nurse, I have both circulated and scrubbed numerous neurosurgical procedures.  I have met the young, the old, the mom, the dad, the child, and more but ultimately we place a sterile drape over the patient and our attention instantly shifts.  We can become so focused on an intervention that we can lose sight of the big picture.

It had never occurred to me that a witness is not required on an informed consent form, or it is institution or state specific.  When I learned that information this morning, my mind was blown.  I can think of numerous situations where having a witness has been a critical step.  Not only can a witness stop the line if there is… Continue reading

Telluride Reflection – Day 1

Though we started the morning of Day 1 with a “safety story,” I really feel like the critical importance of quality and safety wasn’t anchored until the group watched the Lewis Blackman story. In my notes, I underlined  “calling for help when uncertain is an important characteristic of safety cultures and empowers MDs and RNs to reduce medical errors.” The idea of “calling for help” or, stated better as “calling for guidance,” is something that as an older nurse, I love to teach to new graduate nurses and am never ashamed to say I do every day at my job. Where I currently work, if new nurses are not asking questions, then we get worried! Asking questions (or better phrased as “asking for guidance”) is a cornerstone of transparency. The ability of a new nurse to be transparent in saying “I am admitting I don’t… Continue reading

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