As I reflect over the last week, I feel re-invigorated from the Telluride Maryland Experience. I am lucky to work at Boston Medical Center – a truly progressive, quality- and patient safety-oriented institution but know there is still much work to be done, both at the organizational level and of course, at the national level. I am particularly fascinated with the rigorous data analytics employed by MedStar (from Kelly Smith’s sessions), highlighting the importance of data-driven changes and the power of quality improvement to transform environments into cultures of safety over time. I will be pursuing a fellowship in general internal medicine where I hope to learn the research skills to process and analyze large datasets to help inform future policy, ranging from the institutional or organizational level to the state or national level; I aim to utilize these skills to help transform quality and patient safety.… Continue reading
Day two was equally as packed and we again started with a very moving yet tragic patient story of Michael Skolnik who lost his life because of a lack of proper informed consent – the medical system designed to keep him alive, failed. I am reminded of the Swiss cheese model of accident causation highlighting the systematic failures that led to Michael’s preventable and unfortunate death. There were so many opportunities during his care that if a proper system check were in place, he may still be alive and well. His story is a painful and humbling reminder that as physicians, and, more broadly, as caregivers, we have an unbreakable commitment to our patients and we must always advocate for them because at the end of the day, the care we provide is for the patient.
Our patients (and/or their families) must make the ultimate and final… Continue reading
What an exhilarating first day at the Turf Valley Telluride Experience! As expected, starting with a sentinel, tragic patient safety story was a very effective jump start to this week. The discussion that followed was powerful and illustrative. I was struck by one of my colleagues here, a preclinical medical student. He responded to the tragic, yet illuminating patient safety story of Lewis Blackman, where system errors resulted in his untimely death. I’ve had many eye-opening opportunities to learn from patient safety events during my residency program, especially through various patient safety and risk management electives, where I reviewed patient safety events and participated in a Root Cause Analysis. However my medical student colleague has not had these experiences yet and his initial response to Lewis’ preventable death was to study harder and expand his medical knowledge even more so he could better… Continue reading