I absolutely appreciate that Telluride not only educates us about medical errors in healthcare but also empowered us with the tools to manage events when they do occur especially how to have crucial conversations with families when a medical error has occurred. Showing the impact of medical error on both families and caregivers highlighted the need to have a comprehensive response approach to medical errors that include critical components such as GO-Teams to initiate event reviews and care for the caregiver programs to support the medical team member(s) affected. As was clearly shown today, family members deserved to be listened to, provided with honest answers and not to be subjected to the old way of deny and defend, which does not benefit healthcare nor families.
I think one key thing that has manifested in most of the videos that must be given greater attention to in training healthcare providers is… Continue reading
Normally when flying I like to be seated at the window to watch the mechanisms of the wing and observe the scenery. This time I decided to apply some mindfulness to my flight home. As the plane got closer to Chicago-O’Hare, I noticed a United airplane lateral to us also descending. I thought how near they were, yet relatively incident free on a daily basis. I observed the United plane land on a runway adjacent to ours at no more than say a minute before us and thought what great communication had to have taken place to prevent the two airlines from colliding. Moreover on landing, there were multiple other planes entering the airport. There are so many opportunities for things to go wrong and thus mechanisms had to be in place at a systems level to prevent these in addition to individual level interventions. It is this greater emphasis… Continue reading
The story of Michael Skolnik drove home the importance of informed consent and the need to move from informed consent to shared decision making and having meaningful conversations with families. As noted, informed consent is written at the level of scientific journals! Time taken to have meaningful conversations to engage patients in developing their plan of care can can prevent unnecessary procedures that are life altering in so many ways. Shared decision-making incorporates the elements of an informed consent; moreover, it includes identifying patients’ needs, preferences, values and goals, as well as discussing uncertainties and costs. It is a two-way conversation between patients and their health care providers. Time must be spent to engage with families and not see the consent process as one more thing to do on the to do list of our busy days as we are asking patients and families to make really serious decisions that… Continue reading
There were so many take-aways from Day One of my Telluride experience in Napa. We played a Domino game that taught my team members and I so many lessons regarding communication that is applicable to the clinical setting. The importance of practicing mindfulness in communication was noted. One could miss an important piece of data especially in a busy healthcare environment. For example, a physician receiving a call from a nurse who is not mentally present and is considering other tasks to be done. Key information could be missed that would possibly support a change in a patient’s plan of care. With the occurrence of any event, as a leader/ administrator, you most likely do not know all the pieces and it is important to talk to all parties involved to capture as much data as possible about the event. Clear communication between nurses and physicians is vital to… Continue reading