It seems outrageous to me that hospitals are one of the most unsafe places one can be. Both Michael’s and Lewis’s stories reminded me of stories I have heard from my own family members about poor experiences with the healthcare system. I feel fortunate that none of my loved ones have had as devastating an outcome as the stories of these two young men, but I know that I will fear for them if they are ever in the hospital. I feel like the public is being lied to. I feel like we in healthcare all have a duty to make our systems safer and improve the quality of the care that we provide. Patients deserve to be treated with respect. They deserve to know what we are doing with their bodies and what their options are.

This week has been wonderful and eye-opening so far. I love how… Continue reading →

Looking back at our first day, I’m again overwhelmed with emotion thinking about the Lewis Blackman story.  In the video we are able to see each and every breakdown in the system that eventually led to this tragedy.  My heart breaks for the family.  My heart breaks for the nurses and the doctors and all the members of the healthcare team, who I am sure felt ultimately responsible.  Yet it is the system that is at fault, not any single action or single person.  A system that should be there to serve and protect the most vulnerable, our sick patients, has actually been the what has fostered one of the biggest obstacles to providing safe, quality care: a lack of communication.

As a nurse, I can imagine how that night shift nurse felt when she was concerned about Lewis and attempted to call for help.… Continue reading →

Anyone reading this, follow me on twitter @cjeffrun27 as I’m trying to post a bunch! You’ll also see posts from the SMACC conference in Berlin #dasSMACC and HPRCT conference in Toronto last month #HPRCT.
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Wow, what an incredible group of people in this space. I’m continually stepping back and recognizing how lucky I truly am to be here. And I’m so grateful to Giovanna (2nd yr psych resident at USC) for encouraging the medical students – those with the freshest eyes in the room – to share their thoughts. Those of us with years of experience have undoubtedly developed some beliefs and biases over time, which aren’t necessarily bad (in fact, it’s called experience for a reason!), but… what I wouldn’t give for a beginner’s mind on many things 🙂

I took pages and pages of notes from today’s talks and games. So many ideas, reflections, take-aways. I’d never… Continue reading →

My experience at Telluride began with an intellectual discussion over drinks with a doctor of nursing practice student and a second year resident. It astounded me that I had the opportunity to casually listen to and learn from these experienced medical professionals who held the safety of their patients in high regard. It was great to hear that while we still have a ways to go, there is hope in changing medical practices through the younger generation of doctors and nurses. It set a positive, hopeful tone on the rest of the conference experience.

The quote that stuck with me the most from my first day at the conference was from the Lewis Blackman story. Helen Haskell states that after her son’s death, she was expecting the hospital to call her because she was the only one who knew the whole story. She witnessed the doctors’ premature closure,… Continue reading →

By the end of the documentary, I had goosebumps running up and down my arms. Learning about the Lewis Blackman case and watching the story unfold on screen affected me in an unexpected way. I was obviously devastated for the tragedy Lewis’ mother, Helen, had to endure, but I was also trying to quiet a deep anger within me as well. It wasn’t directed towards any of the medical providers involved in the case, but more towards my surprise at the failure of the system. Although it was really hard to watch Helen describe her pain, I now have a refreshed outlook on how I want to impact the field in my own future. I would hope no one ever has to endure what Helen and her family did that fateful day.

Yesterday, as we were watching the Lewis Blackman film, a question flashed across the screen that immediately resonated with me. It was, “How do we create a culture where calling for help isn’t a sign of weakness but safety excellence?” As a new nursing clinical instructor, I think about this question often. There are only so many lessons or words of advice you can impart to your students in the short amount of time you have with them, but asking for help is one lesson I’m quickly learning is essential to teach. When students approach me with a question that I don’t know the answer to, I’m honest about what I don’t know, but direct them to resources we can use to find the answer. This requires incredible vulnerability and humility. It’s scary to reveal that you don’t know the answer to a question, especially to people who look to… Continue reading →