I have been participating in the Telluride East conference taking place in Washington, DC since August 1. In the whirlwind two days I have been barraged by information, struggled through leadership, boggled by safety concerns, and simply overwhelmed by my own emotions. To put it bluntly, this is the most interesting two days I have spent all summer, and even though I am exhausted, I am beyond stimulated by the experience of this conference. One minute we are hearing from Paul Levy on negotiations and the next we are working on teamwork and leadership in a teeter totter game with 9 teammates, a 2×8, a cinder block and 2 eggs. Suffice to say this is truly a hands on and experiential learning experience like none other.
In reflecting on the past two days I have stumbled upon many thought trains (thanks Cliff), but one that my psyche… Continue reading
Loved the discussion on communication and the different styles. When we were in groups for the case study, it struck me as interesting that the behavior of the surgeon in one version was not “bad”, but it still changed behaviors, and not in a positive way. Also, I was thinking about how I would feel if I were Naomi or Tess? I was thinking it would be hard to “rock the boat”, especially in a time-sensitive situation like an operating room, and especially at the end of a long shift / procedure.
I really like what Cliff had to say about why do we keep trying to hide information, when he was referring to his operation record. It is so true. We are all so egotistical, proud, scared, and a host of other emotions.
I like the thought of looking at the hazards, and not just the extreme cases. I… Continue reading
We had a fantastic talk today by Dr. Terry Fairbanks on the role of Human Factors Engineering in healthcare. It was a very insightful presentation that sparked more questions than answers. Why do we insist, time and again, that people conform to technology and existing systems rather than designing with human limitations in mind? Why do we implement rules based on how work is supposed to be done rather than how work is being done, when we are all aware of the gap between the two? Why do we expect health professionals to achieve perfection when we accept errors from most other people?
It’s frustrating to see how far behind healthcare is compared to most other industries. We are slow to change and slow to adopt technology. It’s even more frustrating to see technology that we have adopted that looks like it was designed by a 10-year-old. As Dr. Fairbanks… Continue reading
Day one reflection–Telluride East
by Scott Emory Moore
“We don’t run in the ER.”
Early in my career as a new graduate nurse in a Level 1 Trauma Center, I remember hearing these words. I do not remember why the nurse said this to me at the time, may not quite be the same reason as it comes to mind now, but it is a valuable lesson none-the-less. In reflecting on my first day at Telluride East, it is evident to me that one person’s hasty actions can have tremendous impacts on outcomes and patient experiences.
Often in the healthcare industry we are quick to focus on speed and time rather than diligent and deliberate precision in the execution of the interventions. Getting caught up in the fervor of the emergent situation does no good for us, rather it is when we slow down and… 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
I wrote the following today on my scrap paper after learning of the story of the tragic death of the young boy, Lewis. The factor that most struck me regarding his death was the failure of the junior team members to recognize that something was wrong over the weekend. It led me to the following reflection:
The scariest part of my surgery rotation as a third year medical student was taking weekend call. It was me, an intern, and a junior resident – usually a PGY 2 covering the entire floor and everyone walking through the ER door. Not one of the three of us had enough clinical experience to have yet developed that sixth sense that helps you tell if someone is “sick” or “not-so-sick.” A good attending physician can look at a patient from across the room and know that something is wrong, but that skill comes with… Continue reading
I am sitting in this room and I can’t help but think, “Oh crap, what did I get myself into.” We all had been asked to introduce one other selected individual. The lists of accomplishments and accolades accrued by the other Telluride scholars sat over their heads like 5 foot top hats. In contrast, as a very green MS2, my head looked pretty bald, maybe covered by a flat cap. Traditionally I would just shut up and try to steal the wisps of wisdom that they utter. Upon conversing with these illustrious men and women however, I was struck by their humility. These people were really listening to what I have to say, as if we were on even playing fields! Truly a testament to the unassuming, non-judgemental nature which is Telluride.
“I cannot believe you played an X!” The objective: Win… Continue reading
Tonight, we were talking at happy hour about the case study presented by Gwen, with Gwen and some other students (some of my fellow UNC classmates). I mentioned I knew there was trouble when the physician “grabbed” the chart. This made me cringe, and I was thinking that we move too fast much of the time. How many pressures do you feel in a shift? It is so hard to not give in to those stresses.
I had seen the Lewis Blackman story previously when I was a training session with a HEN focused on Adverse Drug Events. Something that hit me this time was the administration of Ketoralac in spite of the black box warning. I can hear some of my colleagues saying something like “I didn’t know” or “I hadn’t read that research article, how would I have known?”. My answer to this is: ANYTIME you are about… 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