The teeter totter game was the perfect way to show how 1 small change can lead to an impact in safety. We all naturally in medicine want the best for each patient, but the slightest wrong move can result in a near miss or patient harm. This is something that we all need to be aware of, and instead of trying to assign blame, knowing that we all are working towards the same goal, and any mistake is a mistake as part of a team.
I truly enjoyed the Telluride experience and learned a lot from both the patient stores/videos and even from my fellow participants. It is important for everyone in healthcare to work together to make patient safety of the upmost importance at their institution. As a resident, in a busy situation things can be missed, so our program started sepsis huddles not that long ago, which brought things to both resident and nursing staff attention. This allows us to not miss a sick patient on our radar and to come up with an adequate plan with the residents, bedside nurse and charge nurse and if the patient does not improve to involve other services like calling a rapid response. Small changes like this allow us to continue to work on improving patient safety and I hope to be a part of the improvements in patient safety at my institution.
The story of Lewis Blackman was very effective in showing how important communication is. As a peds resident, I watched the whole video looking at all the errors made from the resident perspective, but when listening to others comments, I heard nurses looking at it just from the nursing view and you realize in any medical error, each profession looks at what they could have done better and it seems that we are always hardest on ourselves in the situation. That ties into Jack Gentry’s story, that admitting your fault helps deal with our own turmoil we experience after the situation. So many times the hospital wants to protect their financial responsibility but in the end, things can go a lot smoother when you are upfront with the patient and their family. Listening to Jack Gentry’s story, I thought if that was my family member I would have been so… Continue reading