by David Mayer, MD
Last week was the first of three annual Patient Safety Summer Camps for graduate resident physicians in 2017. Each year, I learn from the resident scholars who attend about the current safety challenges and barriers they face on a daily basis as they both try to deliver safe care to patients, and learn to become good physicians. Over the last few years, however, I have noticed a growing concern among our Telluride Scholars, a theme that centers on the overall well being of resident physicians in the healthcare workplace.
Last week, discussions around resident well being reached an all-time turning point, during an interactive presentation on Care for the Caregiver programs led by Crystal Morales from MedStar Health. During the presentation, Crystal asked the residents to think back, and remember the first patient death that happened while under their care—not from a medical error, necessarily, but… Continue reading
Being in the Air Force myself I really appreciated John Nance’s ending story about his time flying C-141’s. I can appreciate the A1C’s fear in speaking up against a Lt Col, especially since he has no actual flying experience. Co-pilots in the AF constantly struggle with correcting senior officers during flight. Like surgeons they to embrace the god-like aura and often think they are above criticism. I agree with John in that the AF is making a great commitment towards true leaders. They’ve also started 360 feedback which is a way for these senior pilots to get feedback from everyone they fly with.
Day 2 was eye opening! The Skolnik’s story introduced the concept of informed consent- an essential part of shared decision making. This stressed the importance of clear communication and patient involvement in medical decision making. It was fun to apply what we learned in group breakout sessions. The day shifted in focus and the talk by David Claussen peaked my interest. The talk dissected EMR systems and I learned that the rush to implementation and false advertising by vendors has led to many of the frustrations that surround use- particularly the lack of human factors engineering considerations which ultimately have led to significant patient safety issues. To close off the day it was insightful to hear John Nance speak of his experiences in patient safety and inspire future healthcare professionals to make a commitment to change the system!
by Libertad Montoya
I was raised, at least for part of my childhood, by a single mom, who was an actor/director. She would often take me to work with her, and afterwards, our household was the site of what could probably be described as a salon–many artists of varying disciplines gathered to discuss and share their art. Visual artists (painters, sculptors, etc.), musicians, actors, orators, photographers, philosophers, and other artists would gather to eat, drink, and share their art with each other in a setting that was safe, open, and welcoming. People were supportive of everyone’s art and often would spontaneously collaborate via giving feedback or even active participation.
Many years later, when we had moved to the US, my mother wanted to facilitate my learning of the English language, so she enrolled me in various extracurricular activities offered by the city. First it was swimming lessons, next it… Continue reading
by Steven Peretlakto
The first day of the Telluride Experience was inspiring! Communication was emphasized throughout presentations and discussions.
Beginning the day with Lewis’s story evoked emotion and set the importance of what was to be discussed. His story resonated with me, and made our patient safety activities real. Things that I took away from our first day include: There is no “I” in team–that a team of health professionals benefit from open, nonjudgemental communication; That family members are an essential part of the team and not to discount their input. Additionally, when working up patients it is important to avoid being pigeon-holed into a diagnosis, and to be mindful of serious life-threatening conditions that must be ruled out. Overall, I am looking forward to the rest of the conference, and continuing to work collaboratively with a passionate group of individuals at the Telluride Experience!
by Anne Gunderson, PhD
In its 1999 report, To Err is Human: Building a Safer Health System, the Institute of Medicine (IOM) concluded that medical errors, particularly hospital-acquired conditions, may be responsible for as many as 98,000 deaths annually, at costs of up to $29 billion. Suddenly, quality healthcare and patient safety became central, public concerns in the United States. According to the Institute of Medicine (IOM; 2000), medical errors accounted for between 48,000 and 98,000 deaths annually in the U.S. At that time, medical errors were considered the eighth leading cause of death in the U.S.; more prevalent than deaths from breast cancer, AIDS, or motor vehicle accidents.
I started my practice in medical education in 2000 at Southern Illinois University College of Medicine. At that time we were creating a new and robust, medical curriculum. Similarly to other medical schools, however, we had just a few lectures… Continue reading
I was blown away today with the humanistic approach that showed the human side of medical error from clinicians. It immediately got me thinking about situations where I had tried to hide mistakes or weakness in my own skill set and how this could potential contribute to patient harm. Discussions about CQI projects also had me asking myself why I hadn’t done anything about the safety incidents I have observed. I am interested to see what tomorrow brings…
As many of us begin our regular summer pilgrimage to Telluride, Colorado, it is hard to believe that thirteen years have passed since a small group of passionate healthcare leaders came together in Telluride to design a comprehensive patient safety curriculum for future healthcare leaders. As a result of that work, many wonderful and highly committed patient advocates and safety leaders will once again convene in Telluride the next two weeks to continue our mission of Educating the Young. For those not from Colorado, summertime in Telluride may be one of the best kept secrets in the United States. Be it the old west feel of the town, or the hypoxic “magic” that happens at an elevation of 9,500 feet, Telluride has always been an educational mecca for everyone that joins us during these memorable weeks of high altitude learning led by the MedStar Institute for Quality and Safety and… Continue reading
My time spent at the Telluride Patient Safety Summer Camp was enlightening and life-changing. It was life-changing for me and my future patients. In my application essay I spoke about how “I want to be part of the solution and enhance patient safety by figuring out how to prevent nosocomial infections, lower remittance rates, and develop better communication strategies between health professionals”. I learned this and much more.
The statistics presented to us were powerful. I cannot believe I was never informed about the infamous IOM report in my first year of medical school. The Hippocratic Oath says we must do no harm; it would be wise if we learned how to actively not do this in medical school. However, this patient safety conference has educated me and I plan to spread awareness to my class. Medical errors account for the third leading cause of death in the U.S.; 100,000… Continue reading
In addition to the interprofessional communication lecture and breaking out in small groups to discuss the case of the missing lap sponge, I really enjoyed the Domino game! That game was my one of my favorite parts of the day. It did an excellent job of highlighting the errors in communication within healthcare. For the first round I played the role of the doctor and I became a little frazzled not knowing how to properly tell the nurse how to place the dominos. I tried to use a systemic approach by first listing the type of domino and then the numbers and colors on it. I also expressed the vertical or horizontal position of the domino. I thought I was explaining my thoughts clearly but when I saw the pattern laid out, I knew I was definitely not. My group members told me I forgot to describe directions such as… Continue reading