I really would like to say thanks to all those who made my week learning about patient safety possible. Certainly David Mayer and Tim McDonald need to be thanked for all of their work in setting up this past week, but all the faculty and facilitators need to be commended. Thanks again, Shelly, Ric, Allen, Barbie, Jill, Paul, Bruce, Carol, Harry, Tracy, Bill, Jeff, and anyone else I may have left out!
I’ve been think a bit more about the role of technology in patient safety. I am certainly of the mindset that technology ideally serves us to make the world we live in a bit more manageable, to make our lives easier, and to provide solutions to common problems. This blog is a useful example of how information can more easily be transferred to a larger audience who share common interests. I was struck… Continue reading
On my trip home from Telluride, I kept asking myself what would have been different if the session on respect and humiliation was covered earlier in the conference? These two concepts and processes are so central to the work we do and the work we want to achieve.
Throughout the week we saw, heard and felt what stories can do for the way we think, act and make decisions. But telling stories demands trust and it also demands humiliation because it exposes our natural limits as human beings which can be incredibly uncomfortable. However, these moments of discomfort are often some of our most powerful learning tools because we open ourselves up temporarily to the possibility of change and transformation, whether we are the story teller or the listener.
During the negotiation session, for instance, what would have been different if we underscored the importance of respect and humiliation during… Continue reading
If I had spent the last four days locked in a library researching the patient safety literature non-stop, I would not have walked away with as much knowledge, enthusiasm, and support as I acquired participating in the Transforming Mindsets: Patient Safety Summer School for Resident Physicians in Telluride, Colorado. The collective efforts, shared experience, and mutual support of everyone involved made for a special atmosphere (in the already special atmosphere of nine thousand feet) that allowed each of us to rise above our prior potentials. Within an hour of resuming clinical duties today, I was already championing our collective cause, walking a fourth year medical student through an incident report about a delayed dose of nevirapine in a newborn; her initial grimace at the optional “name of reporter” question eventually morphing into an enthusiastic smile as she entered her name following our discussion about the benefits of reporting… Continue reading
I dont think that I’ve ever thought so much about informed consent as I did today. I’ve always had the self-perception that I communicate well with patients, especially around planned procedures in the emergency department where I work. After today’s discussion, I recognize that I am doing a fine job, but I can also do so much better.
Informed consent is a shared decision making opportunity between patient and physician. At its core, informed consent is a conversation with the goal of allowing the patient to ask questions and hopefully come away with a clear understanding of the procedure to be performed, as well and the risks and benefits of the procedure. Procedures, diagnostic tests, and medications can all be conversations that are pursued with patients under the vigilance of informed consent.
While the conversation is the essential element of informed consent, the informed consent paperwork can serve… Continue reading
Day 3 at the Telluride Patient Safety Educational Roundtable and Resident Summer Camp started with the annual hike up to Bear Creek Falls–an excellent team building exercise that always leads to relaxed and enlightened discussion about the work to be done and the knowledge gained from the week. It also provides yet another opportunity to get to know colleagues on a personal level, and build lasting relationships that will provide a support system for quality and safety efforts once everyone returns to their respective institutions.
Coincidence or not, we started the day near the top of the San Juan mountain range, and throughout the day it was reinforced that to achieve meaningful change in healthcare, it is imperative that hospital leadership not only supports, but leads the charge. Jill Prafke led a thought-provoking workshop on how to build effective teams with the ability to institute change during the afternoon session.… Continue reading
Our second day in Telluride finished with the residents watching the award-winning film The Faces of Medical Error…From Tears to Transparency: The Story of Michael Skolnik”. The educational film addresses the importance of informed consent versus shared decision-making conversations – an important aspect of open and honest communication in healthcare that is still lacking in many health systems. The film asks the question – Can a conversation change an outcome? Can a conversation save a life?”
After the film, the residents engaged in a two-hour conversation with faculty and safety leaders on issues related to informed consent and shared decision making. When Paul Levy asked the residents how much training they get on this topic, every resident in the room acknowledged this three-hour session on informed consent/shared decision making was more education than they have received during… Continue reading
Shelly Dierking is leading a workshop in conflict resolution today at the Telluride Patient Safety Educational Roundtable and Summer Camp. Residents are using role play of cases to highlight where conflict management breaks down and how best to build it back up.
What is coming to light is that there is variance that needs to be managed on a daily basis, and without teamwork and systems in place to manage and support those at the front lines, it’s only a matter of time before a tipping point is reached and the patient suffers. Not to mention the care providers who have the best of intentions, are human and who suffer along with their patients when an error occurs.
Today was enlightening. Never before have I heard terms such as “early closure” and “normalization of deviance”, words that define the daily flaws of medical care. Narcissism and mindfullness are concepts that I’ve always associated with people I know but never thought of in relation to medicine
At the core of all the activities today was the concept of open and honest communication. The team caring for Louis Blackman had many opportunities to admit that they didn’t know the cause of his symptoms. However, they chose to downplay his symptoms and close the case wothout a clear diagnosis. Narcissism was at play with senior residents, who did not involve their attendings at critical moments.
In medical school we are expected to answer multiple choice questions to demonstrate our knowledge. However patients don’t come in with A through E on their forehead. Its critically important to know that you don’t know.… Continue reading
Please check out this blog post over at Not Running a Hospital about how a new category of medical errors can arise as clinical innovations are introduced. In the cases discussed, use of robotic gynecological procedures created their own cottage industry of opportunities for patient harm.
Dave Mayer and Tim McDonald opened the 8th Annual Telluride Patient Safety Educational Roundtable and Summer Camp. This being the eighth year the pair have taken time away from busy academic appointments, clinical responsibilities and family to continue to push forward in educating new physicians along with faculty on the just culture they know will make healthcare safe for all of us.
The residents and faculty were introduced to one another, and then we quickly moved into the week’s agenda starting with all viewing From Tears to Transparency: The Story of Lewis Blackman — a striking example of why we are all here and why there is still so much work to be done.
The residents kicked off the week sharing how some of their current environments were aware of the need for open and honest communication, yet failed to provide the support when an opportunity to have that conversation… Continue reading