Reflections from Telluride

Through the lectures, activities, and patient stories at Telluride, I left completely recharged and ready to work on QI initiatives at my institution. I was particularly impressed by the Caring for the Caregiver Program, as, while we have an institutional-type employee assistance program, we do not have a program particularly geared towards residents and fellows. I was also impressed by the Go Teams and PFACs. The patient stores resonated most with me, however – patients are so frequently left out of these discussions when really they should be at the center of them. As I start to work on QI projects this year, I will remember the lessons learned at Telluride and am appreciative of the network of support and resources that I gained from attending this conference.

Post Telluride Reflection

Less than a week after completion of the course I am amazed how I have began to look at situations at work in a new light. As I see a safety issue that has occurred, individuals are often quick to look and point fingers. I am able to look past who did it but rather dig deeper into better understanding the system and how the system failed. It truly will take a great deal of time to change current outdated RCA process at our hospital. Furthermore, it is important to inspire the entire healthcare team to look and study all aspects of a safety event prior to drawing up a single cause.

During this new academic year I plan to become a resident member of the current RCA team. I hope that with small changes I can make strides to revolutionizing the RCA process into an event review process.

It… Continue reading

A New Way of Thinking

A few weeks ago, I overheard one of the interns worrying about accidentally prescribing a medication and giving to patient the wrong dose frequency. The error was picked up by another resident who is on the cardiology consult service as the medication was felt by the cardiology team to be contributing to the patients presenting issue (symptomatic bradycardia).

I will admit that at the time I was only concerned with reassuring the resident that he would not lose his residency spot due to this error, as the patient was still alive. When the resident was consoled I forgot about this issue. Until attending this conference.

You guys made a very good point that if we do not report errors, we lose the opportunity to learn. Because when I disclosed this error with my workmates, who also attended this conference this weekend, we developed some questions which we lost the opportunity… Continue reading

Day 2 reflection

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.

Reflection on whole experience

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.

Compassion and Hope

There are so many memorable moments from these past few days, but the video we watched this morning in particular stands out. This is my second time watching the MedStar patient care and compassion video, but it was still so meaningful. I love the juxtaposition of what the doctor and patient are thinking about, and knowing this is an actual patient and not an actor makes it even more meaningful.

In a field that is all about compassion, I feel we so often lack compassion for those around us. When you have a difficult patient in the middle of a busy day, it can be difficult to take a moment to understand where their questions or concerns come from. We often lack compassion for those in other fields within medicine. I know as a pediatrician we often roll our eyes at the care our patients receive in emergency rooms. Like… Continue reading

Collaboration

After a wonderful 4 days, learning about Patient Safety through the Telluride Experience, I now have a chance to sit down and reflect. I really enjoyed our prereading by John J. Nance, Why Hospitals should Fly. The most profound passage in this book still sticks with me…

” Nurses are in crisis, and with a low professional self-esteem and a national paradigm of discounted worth, inadequate staffing and senior nursing leaders typically far too disconnected and powerless to change things, nurses act like rats in an overcrowded cage and turn on one another” (P. 39).  (Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other).

As a DNP-HSL Student, this book and this experience was exactly what I needed to be a better leader. On Saturday, I started to think about a few things said by one of the faculty members. “You can not fire… Continue reading

Day 3: Medical errors

We loose 400,000 lives of our patient per year due to preventable medical error.
Medical errors occurring to our patients can lead to mixture of feelings including apprehension, decreased confidence, doubt, and self-blame. Our instinct is to become defensive and try to externalize our problems. These behaviors and emotions can drive us away from the very important lesson which is how to build and deliver better and safer quality healthcare.
Having a supportive and nurturing environment that healthcare providers are welcomed and embraced when error are reported would be the initial step to achieve zero preventable harm.
“Don’t be afraid to make mistakes, just be afraid of not learning from them.” Without learning, errors will repeat over and over again.

Reflection on Telluride Experience

During the past week my eyes have been opened to patient safety in health care.  Through actively listening to the lectures and taking part in the activities, I have realized that there are numerous issues with the way healthcare is currently practiced.  Some of the most powerful experiences were watching the videos of poor outcomes. In the case of Lewis Blackman,  it was clear that the healthcare staff needs to  Think outside of the box, speak to the patient’s family in more detail, and further investigate issues that may seem benign. In the case of Michael Skolnik, It is clear that there needs to be a more detailed informed consent process, even if negative consequences seem much less likely. I believe that Residents should get multifaceted training in order to become the best physicians possible  and as such would benefit from viewing the aforementioned videos… Continue reading

Day 3- We Can’t Fix What We Don’t Know!

My “aha moment” today was when Crystal mentioned that administration only knows about 4% of adverse events which occur because they are only being made aware of the events which are really catastrophic. However, if they had been made aware of every single adverse event, regardless of level of harm, there could have been strategies, plans, and policies put in place which may have prevented much of the 4% of catastrophic events.

This is a point that I intend to share with my team to encourage them to report patient safety events. I think many of my co-workers are only reporting the events which actually reach the patient, I am guilty of this myself. However I am realizing that it is of great importance to report the good catches so administration is aware of potential safety issues.

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