by Vidya Viswanathan

At the end of today’s session with Lewis Blackman’s mother Helen Haskell, I was really struck by her observation during the course of discussion: “Confidence kills.” In the documentary, Haskell also says of her son’s tragic death due to medical error, “He died because he was in the hospital.” As a rising fourth-year medical student, it stands in such stark contrast to the message I’ve gotten in my training, especially on rounds. Rounds often feel like a way to tie each patient up in a nice box with a fancy bow and meticulously ignore the true messiness that we are professionally obligated to address. Even as fresh, inexperienced students, we are taught to make a persuasive argument in our presentations and to always craft our presentation to fit our leading diagnosis. When we list differential diagnoses at the end of our presentations, the team often interrupts… Continue reading →

Today was definitely an eye opening experience for a rising M2.  Its something we can all imagine, yet something that we put in the back of our minds… something that were never going to do. Making a life threatening mistake is something that is possible everyday as a resident or attending.  I think we believe as medical students that its never going to happen to us, yet statistics show that its certainly possible.

Hellen’s story about Lewis is such a wakeup call for us that are soon to be Interns and junior residents.  The loss of her son was almost purely due to the fear and/or over confidence experienced by those young physicians.  I think its something that nobody wants to think about, but something that we all need to acknowledge before we start seeing patients.  Honestly thats my biggest reason for attending this conference…… Continue reading →

Today I was introduced to the concept of premature closure, the practice of latching on to a diagnosis too early before considering all the conditions that should be in the differential. Having just finished my first year of medical school, I’m not surprised to hear that this accidental practice exists, especially after reflecting upon the education I’ve received over the course of the last year. Immediately, I can identify two aspects of undergraduate medical education that contribute to its prevalence.

First, a message that I’ve heard repeated over and over again this year is the idea that medicine is about memorizing disease scripts and being able to recognize them when they present in clinic. At my institution, this is enforced by our examinations: most of our question stems involve a patient case, and to solve the question, the student must recognize the condition the patient is suffering from and… Continue reading →

Having spent the past year as a chief resident in quality improvement and patient safety, I’ve come to the conclusion that QI is at most times frustrating, at many times defeating, and, in sweet but rare moments, enriching. This has been my (limited) experience, at least. Working inside an institution that has been under intense scrutiny for its quality and safety issues, rarely a day passes in which I’m not pulled into a discussion about a recent safety event, near miss, or upcoming meeting with hospital leadership regarding a root cause analysis. Perhaps my sense of disappointment stems from the fact that meaningful, systemic solutions to the problems our institution faces are almost invariably faced with inertia and a lack of buy-in from involved parties.

I maintain hope for the future of quality and safety because it is still a relatively new phenomenon, at least in the field of healthcare.… Continue reading →

Day 1 of AELPS2018: Wonderful, honest, and compassionate discussions today about open communications, premature conclusions, and diagnostic error. I greatly appreciated the personal stories that were shared and the focus on improving communication across a healthcare team, including the patient and family members.

One area that struck me today was a case study about a missing sponge in the operating room and two different scenarios depending upon whether the team continued to look for the item, or if members of the team were unable to speak up and advocate for the patient. Although I agree that this is an area of great concern and focus, it seemed like the conclusion was to change the ability to communicate, but ultimately neither option appeared correct. Yes, overriding protocol and leaving the operating room with an incorrect count is not the best answer, holding the case and leaving the patient in the operating… Continue reading →

It great to be here and to meet this wonderful faculty.
The Lewis Blackman case was really touching to me in a special way and his mum is doing an amazing job by teaching us with this experience.
What was amazing to me was how open and honest communication improved patient/relative- physician trust and reduced the rate of suing by families.

I am excited to know that there are people out there who are passionate about patient safety like I am.
For the remaining days am looking forward to absorbing as much as can
Thank you

Day 1 started with a picturesque background of the Breckenridge Mountains as strangers gathered together for the common goal of patient-centered care. It then continued into a busy day filled with health professionals and students chipping away at the mammoth iceberg that is patient safety (or rather the lack of it) through personal stories and experiences. Finally, the night took a gaggle of us to a local Thai restaurant where it ended with a shebang filled with laughter, introspection, and appreciation for the new friends we were surrounded by.

I think back and wonder how such different walks of live connected so quickly, but I cannot seem to define it by a single instant. Rather, it was an amalgamation of moments. It was the faculty who were in perfect harmony today and whose enthusiasm was infectious. It was the patient-care tragedies we heard of sons, husbands, patients that touched each… Continue reading →

Day 1 reflection (s/p po EtOH): I sit here in this hotel thinking about what it was that I actually absorbed from the day. What sits with me, however, is on how many occasions that I see the medical errors presented in what I observe as well as what I do in my own practice. For the first half of the video about LB, I couldn’t help but think…”what would I have done differently.” Tachycardia and abdominal pain could easily be explained away by postoperative ileus. Nausea could have been attributed to the anesthesia. As I was watching this video, I can honestly say that I wouldn’t have necessarily been concerned until day 3 when the tachycardia proved persistent and continued to elevate. To me, this was a reality check. “What’s the worst thing” is a statement that I have heard in medical school, but I feel that it has… Continue reading →