Culture of Safety

One of the phrases from Telluride that stuck with me the most was the idea of creating a “culture of safety.” To me, this epitomizes the teamwork that every care team should have to optimize patient care. One of the most difficult aspects of medicine is the rigid hierarchy – as a medical student, I generally feel uncomfortable correcting residents or attending physicians if I notice something that strikes me as odd, such as not adhering to proper protocols. In a culture of safety, the hierarchy disappears – everyone on the team is responsible for the well-being of the patient, and everyone should be encouraged to speak up.

After I returned from Telluride and was working on a project where I was observing hand hygiene in the ICUs, I kept the “culture of safety” in the forefront of my mind. I noticed when students and nurses were encouraged to speak… Continue reading

Gas Hose part 2

I had a startling incident at the local gas station less than a mile away from home that illustrated many of the things we talked about. As I was bringing the gas nozzle over to my car, it suddenly spewed gasoline like a fountain at high pressure and some of it splashed on a person who was filling up her car on the opposite side. I never had any idea this kind of thing could happen as I tried to replace the gas nozzle as quickly as I could without slipping on the large puddle of fuel on the ground.

After that I was in a state of shock for a long time. The first thing I did was to go inform the station attendant, who came outside and determined the cause was due to the previous person keeping the latch lifted. But ultimately he blamed it on the previous… Continue reading

True North

A story resonated deeply with me today was that of Melissa Malizzo, a young mother of two who died while under anesthesia for a liver shunt at the University of Illinois. The event was unquestionably a terrible tragedy, and errors in monitoring and staffing while under anesthesia undoubtedly contributed to her death. However, unlike many hospitals, University of Illinois did not confound the family with obtuse language and communicate only through a bevy of lawyers. Instead, Dr. Tim McDonald, one of our faculty members who was the hospital’s chief safety and risk officer for health affairs at the time, was honest and forthright with the family. The U of I had adopted the CANDOR model of communicating, which is used when unexpected events cause patients harm. The model focuses on communicating in a way that is timely, accurate, transparent and just. The hospital took ownership of the error and made… Continue reading

Why this is my battlefield

My hope in joining the Telluride Summer Camp was to hear more patient safety issues from clinicians. How do they respond when something goes wrong? What functionalities do they expect if health information technology may help? What technology do they not like? – As poorly designed technologies may become a burden instead of being helpful. How do they learn from lessons? All of these questions mean a lot to me because I am on my way to becoming a medical informatician and a researcher who commits to improve patient safety and quality of health care through data science and information engineering.

 

A lesson I learned from the past three days is empathy. I told Dan the second day that ‘I am now learning to stand in a nurse and a physician’s shoes to think.’ How did I make that? I sit with fellow students and faculty watching films where… Continue reading

“Nothing about me without me”

This is my take home message from the third day at the Telluride experience. This is the essence of patient centered approach. When health care providers assume the paternalistic approach, it comes to the level that the provider designs the care/ management in the way the provider wants it to be. The expectation from the patient is to accept it. So the decision maker is the provider. Patient is forced to agree with anything and everything asked by the care provider without even knowing what is it for or how it is going to affect the patient or what are the alternatives or choices available. In other words, irrespective of patient’s choice, the patient becomes forced to say yes. In this process, patients do not receive the required information. Medical language, rushing providers, lack of consistency and continuity of care , patient’s feeling of uncertainty about the outcome and their… Continue reading

Save each other while saving patients

 

I was shocked to learn the CDC report on the suicide rate among nurses (0.11 deaths per 1000) as opposed to general public (0.07 per 1000). Nurses’ health has recently caught my attention. Their burn out, emotional distress, fatigue, physical- psychological- safety concerns related to shift work etc. For the past two years, I had been talking to groups of nurses about minimizing the effect of shift work. American Nurses Association and American Association of Critical care Nurses are working towards healthy nurses and healthy workplace.

Recently there have been discussions on resident’s distress and the need for caring for care provider. Suicide rate of med students also is alarming. There also, increasing demands at workplace, inability to come in terms with emotional challenges, lack of support and compassionate approach from the healthcare leadership make the individual either leave the profession or stretch oneself till it breaks!

As a… Continue reading

Notes on consent form

I learned from today’s film that how conversation can save a life. Later on during the discussion section, consent form became a hot topic as it supposes to help patients making better decisions. Below I would like to share some information and thoughts that might somewhat help with the discussions over consent form.

1. Information representation and exchange

1.1 Problem statement

Data largely depends on paper-based instruments, which constraints data management and information exchange. My team members, during the discussion, expressed an interest in electronic consent; but view accurate electronic capture of informed consent data as a challenge.

1.2 Solutions

We need a medical coding system to define terminologies and semantic relations that are used in consent forms. This system can be something like Unified Medical Language System (UMLS, https://www.nlm.nih.gov/research/umls/). This system should be computer accessible and should be able to link to any existing medical language systems in… Continue reading

Communication: not a script, but a process

Today I appreciated reviewing and learning more about communication. I have always believed in the power of sensitive word choice, and it is here for the first time in my medical education that there has been emphasis on that. It is a big deal to learn about how patient and family voices can become heard through patient safety advisory councils. Seeing members of this advisory council here shows me that patients and families do want to be involved, and we should support and welcome that in healthcare. The presence of such councils exemplifies putting the ideal of patient centeredness into action through a changes in infrastructure that officially give voice to patients and families once kept largely in the dark about their loved ones cases. I really appreciate that the learning experiences today reflect patient/family-centered attitudes by hearing directly from people who can… Continue reading

Is zero possible?

Can the goal of zero errors ever be achieved in the medical field? High risk but complex industries such as aviation and nuclear power set a precedent of admirable safety records, that approach that zero mark.

But is this an attainable goal in medicine? To me, certain aspects of this goal feel manageable, while other feel as though they could be insurmountable. With technology as an adjunct, medication errors are reduced via the use of bar code and electronic versus hand written orders. EMRs can also be designed to prompt reminders if a dose is well beyond the typical limits or the drug interacts with another of the patient’s medications. Similarly, the path to reducing complications from typical procedures also seems clear. Standardized bundles of supplies, clear protocols for the procedure, increased adherence to maintenance of a sterile field all contribute to decreased risk for the patient.

Eliminating medical error… Continue reading

Day 2. Carole

Carole’s story was nothing short of powerful. When she first mentioned Paul Harvey, I had an idea there may be a twist at the end. However, in no way was I expecting what we ended up hearing.

All I can say is WOW!!! What a brave person. What an amazing person. What a selfless person for doing this over and over, giving us a chance to learn from her tragedy. In thinking about future healthcare provides, and what they’re about to experience as residents, nurses, and attendings, I hope as many people as possible are able to hear Carole’s story and others like it. Sharing of this information could possibly help ease some of the heartbreak and after effects families experience after losing a loved one.

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