By Sarveshwari Singh
On the first day of the Telluride East Summer Camp, Kathy Pischke-Winn and Dr. Joe Halbach organized a game using dominoes. It really showed how miscommunication in health care can happen so easily and how simple steps can prevent it.
We assembled in groups of three — one person role-played a doctor, another a nurse, and the other an administrator. The physician sat with his/her back to the nurse and instructed the nurse how to arrange the dominos according to a prescribed pattern. The nurse couldn’t ask any questions. Not surprisingly, the nurse didn’t arrange them correctly.
This scenario brought home how communication disconnects among clinicians happens so often in health care, and it underscores why a leading cause of errors is failure in communication. Also, informal rules can deter students and residents from asking questions, which can lead to a… Continue reading
Loved the discussions on high reliability. Healthcare can learn a lot of lessons from the US Navy as Dave Mayer pointed out. If you want to see our Navy in action, you only need to go to Facebook. Each vessel has a Facebook page that they post how they do some of their operations. Below is a link to the carrier USS John Stennis. They also share their thoughts on leadership as well. We don’t have to go to far on seeing how to do things safer! Sometimes the answers are in our own backyard.
The day started with Dr. Cliff’s “railmen story”–Listen to the Rhythm. I was deeply impressed by Dr. Cliff’s kindness to, and caring for others, whom he does not know and may never know. Not only did he give extra notice to the things easily overlooked as a passerby, but he also carried out his caring despite the inconvenience to himself. I was thinking to myself what in the world could stop this devoted man from becoming extraordinary? He is so caring to the world outside of his expertise, then what level of caring does he pay to his field? I was also reflecting on myself on how far I am behind him as for the caring heart—-how often I overlook what’s going on outside because I am already quite full with my own business?
A fun thing for today was Teeter Totter Game. This was my first time playing the… Continue reading
By Linda Hunter, RN, PhD Student
I continue to learn from and be impressed with my health professional peers and feel like we are starting to get closer to the top of the patient safety mountain and picking up speed as we move “up and over”. I am thrilled to see the interaction and reflection amongst the multi-disciplinary group we have.
When Rose mentioned that Lewis was with us and watching – it reminded me of when my sister passed away due to a medical error involving morphine. She was 24 yo and legally blind due to juvenile diabetes but was vibrant, intelligent and fun! She died while I was working in Saudi Arabia and when I was coming home on the plane (crying the whole way) I looked out and saw her walking on the clouds and smiling at me. We can never forget the loved ones we have… Continue reading
This week we transport the Telluride Patient Safety Educational Roundtable and Resident/Student Summer Camps to the heart of the nation’s capitol — Washington DC. Dave Mayer MD and Tim McDonald MD/JD along with faculty Paul Levy, Rosemary Gibson, Helen Haskell, Cliff Hughes, Kathy Pischke-Winn, Joe Halbach, Gwen Sherwood and more will educate the young of healthcare, sharing communication skills, patient stories and negotiation training in the spirit of keeping patients safe. The Telluride alumni numbers continue to grow, building that critical mass of voices who can share the wisdom of open, honest communication and transparency throughout medicine.
Student reflections on this year’s camps, as well as last year, are found throughout the Transparent Health blog, on Educate the Young and on faculty member Paul Levy’s blog, Not Running A Hospital. Look for additional reflections from this week’s class soon to come, and follow us on Twitter via #TPSER9. The… Continue reading
One of the most important lessons I have learned from the past three days is the urgency in which we need to act to bring ethics back to the forefront of healthcare systems. Too often the best interests of the patients and their families are put behind financial, legal, and personal factors. It may never be possible to prevent every error, but we have a professional duty to take responsibility and put patients’ and their families’ needs first in the aftermath of a medical error. I wish to express a sincere thank-you to Carole for your courage in sharing your personal story so that future healthcare professionals can learn from it. I hope that each of us will continue this conversation of patient safety to make a difference in patient care when we return to our institutions.
Today I also learned about the concept of anchoring. Anchoring is a… Continue reading
On my way back home from Telluride, I happened to pick up a copy of USA Today from 20 June. I was pleasantly surprised to see that the front page featured a special report, “When Health Care Makes You Sick: Under the knife for nothing.”
Although the article highlights medical errors, interviews Lucian Leape and Rosemary Gibson, and even mentions the story of Michael Skolnik, its tone perpetuates acceptance of medical errors and withholding of valuable information: there is a way to know the total number of cases in which people got surgery that wasn’t needed if honest disclosure is practiced; hospitals are required to report infection and surgical errors to a governing body, but reporting to the patient and family (those who are most affected) may not be required. The article… Continue reading
Wow. I’m not even sure how to reflect on the amazing day we had today. From the horrors of the Michael Skolnik case video, to the excitement of being the first group ever to save Stewie (our egg ‘patient’), to the heartbreaking story that Carole courageously shared with the class, today has been emotional and eye-opening.
So many moments today, as we listened to and became engrossed in the narratives being shared, I found my face scrunched up or my mouth falling open wondering how we could possibly treat our patients and families in some of the ways that we do. I like to believe that people are good and generally do the best they can. And yet, hearing about health care providers who ignore and belittle a mother worried about her child, or administrators who threaten a mother who just lost her child to… Continue reading
In just the first day, I feel refreshed to listen to, and take part in, the unique conversations that develop spontaneously after activities and during breaks. I hope we can discuss results of increased patient safety as a group with regard to medical student training at free-of-charge clinics. These venues often provide care to vulnerable populations, who medical students may “help” by performing common procedures or assisting an overworked volunteer physician. Many procedures have an inherent learning curve in which mistakes are common during the learning stages, and these mistakes may cause undue harm to the patient. There is certainly a fine line between a medical student providing helpful care and learning versus harmful mistakes and discouraging patients from visiting again. Medical students may also overestimate their skills and find themselves in uncomfortable situations without readily available assistance. For example, I am aware of… Continue reading
By Jan Boller, Western University of Health Sciences
Yesterday was my first day at the inter-professional Patient Safety Summer School for medical, nursing, and pharmacy students. I echo the conclusion (by Kim Oates) that the future is brighter. As I listened to the students reflect on what they were learning, it was inspirational. They will reshape healthcare to be safer, more effective, and more affordable. I felt a renewed sense of urgency to spread and sustain this exemplary model for preparing future health professionals. Thank you to David, Tim, Kathy, Gwen and the entire faculty team for creating this exemplary program, and to The Doctors Company Foundation for providing the student scholarships. Brilliant idea!