Just before coming to the AELPS conference in Napa Valley, I upgraded my cell phone. As I was setting up my phone, I hastily clicked through the buttons, checking the box to note that I had “read” the Terms and Conditions. Companies have gotten so used to their customers not reading these long Terms and Conditions that they don’t even show it to you during the main set-up; rather, you have to click on a link that takes you to a separate page to read them. Both the customer and company just go through this charade without a second thought.
While watching the film about Michael Skolnik, I realized that the “charade” feeling has permeated into our informed consent process. If healthcare workers minimize the process of informed consent to a mere formality, our patients will not be able to use that time to truly think about the risks, benefits,… Continue reading
This post is a day late in coming, but it’s still a relevant concern of mine.
Yesterday was the first day of our patient safety camp/conference, and we spent a lot of time talking about communication and speaking up if you see something going wrong, especially if you’re lower down the hospital hierarchy. As a medical student, I imagine this scenario as a med student or a resident doing rotations in the hospital. Being the med student who doesn’t know anything or the new resident who’s green, I can easily imagine situations where I might think something’s off with our diagnosis or treatment plan for a patient, and my concerns are brushed aside as the concerns of an inexperienced learner. At some point, hopefully, I’ll be lucky enough to work with an attending who does listen to me when I raise a concern, but the tricky thing… Continue reading
Before coming to this camp, I was trying to explain the purpose of this camp to some of my family and friends, and I struggled to find ways to explain why we shouldn’t just blame health care workers when medical errors occur. Placing blame is such a pervasive method in our society for “solving” problems that I struggled to find ways to frame the issue of medical errors in a new way to help them understand. Over the past two days, we’ve said over and over again that medical errors are not caused by mean people, and I think that is one of the key phrases I will use in the future in trying to explain this experience. Medical errors are not caused by mean people. In fact, the vast majority of the time, the people involved in medical errors were actively trying to avoid… Continue reading
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.
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.
What a way to start a week! I had an idea of what this week would be like, but not to the extent of the material in which it would encompass. First thing this morning, we touched on a subject that hit so close to home: the difference between the thought processes and communication processes between nurses and physicians. The first activity of the day included a video of the Lewis Blackman story. There are so many events/problems that occurred between all interdisciplinary members of the team. One of the issues being that Lewis was not admitted post op to a medical-surgical floor for post-op management/observation; rather he was transferred to an oncology unit. No matter how we are trained, if we don’t regularly treat and manage a certain population, we need refreshers on what we should be looking for, and how to manage their care.
In the video we… Continue reading
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