It has already been a week since my time in Napa came to a close, but I find myself continuing to reflect on all that I have learned. I was speaking with Helen on our last day when I told her that the Telluride Experience was truly life-changing. Although that may sound dramatic or hyperbolic, I believe that I will practice medicine differently now that I’ve attended the Academy. I am so fortunate to work at MedStar Georgetown where patient safety is a priority, full disclosure is encouraged after a medical error, and safety initiatives are being implemented continuously. The biggest change I anticipate moving forward, therefore, is within myself. Having met Helen, Jack, Teresa, Carole, and Steve – hearing their stories and speaking with them afterwards – I can no longer be complacent about patient safety because I can now place a name and face to medical error. The… Continue reading
“Psychological safety is the felt environment for candor.” – Amy Edmondson
This quote really resonated with me during Kelly’s talk on Speaking Up yesterday because I have had experiences in which I felt both psychologically safe and unsafe. During the times I felt psychologically safe, I felt comfortable speaking up and voicing my concerns/opinions. During the times I felt psychologically unsafe, I kept my mouth shut out of fear that I was potentially wrong or even rude for saying something. Keeping these experiences in mind, how can I foster an environment that feels psychologically safe for my co-workers? And how can I help disseminate a psychologically safe culture on my unit, amongst interdisciplinary teams?
Another eye-opening moment yesterday occurred during David’s talk on Human Factors Engineering. We discussed examples of human factor errors, such as driving away from the gas station with the gas hose still… Continue reading
What I am going to write about this evening is essentially the comment I made last night after watching Bleed Out with Steve Burrows, but I wanted to put it in on the blog as well. First, that film was an exceptional production. It made me so angry – on behalf of Judie and her entire family – and I will remember that anger and frustration moving forward as I try to become a part of the revolution (John’s word) to prioritize patient safety. I plan on recommending the film to my co-workers, family, and friends, whether they practice medicine or not. Bleed Out, along with the other films and discussions from this past week, has lit a fire in me. I hope to use this newfound fire as a means to make change, starting with writing to my senator and representative in Congress about amending our laws to… Continue reading
I had many “aha!” moments yesterday, but the one that has stuck with me the most happened after we watched Just a Routine Operation. Chris asked us to close our eyes and imagine the deteriorating patient before us. Then we opened our eyes and discussed what that felt like. But it was the next reflection – closing our eyes and imagining that the patient was a loved one – that really affected me. All of a sudden, I felt so uncomfortable. There’s no way I would want to operate on my family or friends, especially after realizing that they were quickly deteriorating. I wouldn’t be able to stay calm and handle that professionally because I would be too involved from an emotional standpoint. After I mentioned this, Chris asked something along the lines of “why do we leave or forget that connection with the patient? When do they… Continue reading
This morning, our group had the opportunity to watch a film about Lewis Blackman and the medical errors he endured as a 15-year-old following a procedure for pectus excavatum. Afterwards, we were able to speak with Lewis’s mom, Helen Haskell. As Helen walked to the front to field our questions, I felt the mood of the room shift. I had never met anyone who knew a victim of medical error before, let alone a parent of a victim. This was such a profound experience in that I can now picture Helen’s face when I think about medical errors and the lives they affect – something that is so important, because it will always remind me of the humanity behind these mistakes and the reason we want to face them head on. I truly felt as though Lewis was standing beside his mother today.
The biggest takeaway from this morning’s film… Continue reading
Attending the Telluride Experience is important to me because I pursued a career in nursing in order to help my patients rather than hurt them. However, throughout my nursing education, I was told that I will make a medical error in some capacity at some point in my career. It was not a question of whether it will happen but when it will happen, and this never sat right with me. I always assumed that if I were to stay diligent and thorough in my work, then strong work ethic alone could prevent errors. After reading The Wall of Silence, though, I know that this is not true. Hard-working healthcare providers with the best of intentions still committed life-altering errors, and I believe that the amount of pressure we place on ourselves to prevent these errors likely causes exhaustion and burnout, especially when we fail in some way.
Patient… Continue reading