We had the opportunity to listen to John Nance, the author of Why Hospitals Should Fly, speak for a couple hours at the end of day 2. This man should be a motivational speaker. He had several great thoughts on medical culture, but one specifically that I thought was pretty profound was the idea of a 3 tier system for reducing medical error. While the concept is simple, it is just another example of how “doing simple better” is a great strategy for reducing error. Medical culture places so much emphasis on making tier 1 (the “practitioner”) infallible, but when you take a step back and think you realize based on everything that we’ve heard this week this seems ridiculous. The vast majority of safety advancements, whether it be in aviation or medicine come from filling the holes in tiers two and three. By placing so much emphasis… 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 →