Day 2 of Telluride: The Plot Thickens

Our day started with a video about an event in an OR wherein a complex dynamic at play led to an unintended event culminating in hypoxic brain injury and subsequently death.  Since the victim’s spouse was in aviation – another high risk industry who was in a position to provide inputs about the errors made: leadership, situational awareness, support, communication.  Emotional story of a healthy young woman whose had donated her organs for the good of others.   A simple puzzle game drew me towards reflecting on not only the dynamics of team work but also the hierarchy.  While our team had good cooperation there were still voices of frustration from observers who could look at the errors being made but could not voice their opinions.  A highly information packed and an entertaining lecture by John Nance highlighted the similarities between aviation and medicine,… Continue reading

Telluride Day 1 & 2 Reflection

I am not a usual “blogger” so I am using the tactic that Tracy taught us to talk about the parts of this experience that have made me feel. The first thing that I jotted down that I wanted to explore more but we did not have time in the day, was the concept of “The Pause”. I had the pleasure of working alongside Jonathan Bartels at the University of Virginia and have incorporated The Pause into my practice. For anyone that is unfamiliar with his work, I would strongly encourage you to watch this quick 3 minute video that introduces the concept, https://vimeo.com/143628865 as it has really helped me to decompress after some of the most stressful moments in my life.

Another thing that keeps sticking out to me is the story of Lewis Blackman and the fact that his untimely death began with a newspaper article. It… Continue reading

Failure to Rescue: The Story of Lewis Blackman

An Interdisciplinary Viewing

As a surgery resident, I had a different reaction to the the film “The Faces of Medical Errors…From Tears to Transparency: The Story of Lewis Blackman” than some of my fellow scholars. This is absolutely the value of viewing and discussing it in such a forum, as every perspective highlights specific opportunities for improvement.

As our interdisciplinary discussion highlighted, Lewis’ death was the unfortunate result of a broken system.  Lewis was a 15 year old undergoing a new repair for pectus excavatum.  The first systems issue brought up by his mother, who remains a strong patient advocate, was the informed consent process surrounding a new “low risk” surgery.  The pectus repair was technically successful, but issues started intraoperatively.  He was making minimal urine during the case and after.  He received multiple doses of toradol, up to post-operative day #5, with minimal oral… Continue reading

Telluride Day 1 Reflection

“Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective, and potentially dangerous.”

Looking back on yesterday this quote was particularly meaningful to me. It is so true that medicine has made enormous advances over the decades and I am constantly amazed by the complexity of treatments and procedures that are available to patients. However, the more procedures that are performed, the more complex they become, and the more moving parts that are added to each hospital course, the more we experience mistakes and lapses in care.

A few thoughts I have in regard to approaching this issue:

  1. Teams that practice together perform well together. I run into this issue all the time. Even in a setting such as an outpatient medicine clinic, nurses, medical assistants, residents and attending physicians should be grouped into teams that work together each week. The interdisciplinary team can then… Continue reading

En Route to Colorado: A Belated Post

While technically already in Breckenridge, I’d like to share the thoughts and key moments that led me here:

I first heard about the Telluride experience from a classmate of mine from the BU School of Public Health several years ago. The stars never aligned as far as scheduling, but I feel that I have now reached the point in my training where I want to focus my energy on the patient-centered care I entered medicine to improve. I have been exposed to patient safety events since long before I entered medical school and became part of this tribe. A great uncle was the victim of an OR fire many years ago. A close family friend and mentor went with undiagnosed and ultimately rapidly progressive head and neck cancer until persistence and a patient advocate got him to the NIH. I was taken to a urologist/chiropractor/acupuncturist… Continue reading

Day 1 Reflection

As I reflect on day 1, I can’t help but think that so many problems in patient safety can be solved if you remember that the person you’re interacting with is another human who should be treated with respect. This goes for both interactions with patients and between providers. Especially when communicating with patients who have lost a family member, if at the very core of our job is to help people, it shouldn’t be that crazy of idea to help someone mentally and emotionally through the grieving process. I realize that I am coming from a point of view with little clinical experience and as we discussed, there are many barriers to this – fear, reputation, litigation, etc. It’s currently not an easy process, obviously shown by the fact that’s it been a long process to make change, but I can’t help thinking that all this could be much simpler than it is.

Pre-Telluride Post

My patient safety interest started before medical school where I worked in a medical simulation lab. I absolutely loved my job and the idea that one can practice so many skills without coming near a patient. However, I found that craved talking with patients. They often felt far removed and more difficult to get into that direct “I’m truly making a difference” state of mind that one can sometimes get when interacting with patients. This summer, I’m doing research in communication between residents and attendings and, though I find it interesting, similar feelings have come up. In my (very limited) experience, it seems like most patient safety work can feel far removed from the patient despite being a topic that first and foremost is all about the patient.

Since starting medical I can already see from new medical students how quickly people come to forget that the patient is at… Continue reading

You don’t ask for help if you don’t need it.

“There is a strong culture in medicine – you don’t ask for help if you don’t need it.”

That is a quote from today that sticks out to me because as a nurse I’ve seen it in action. There was an instance a few years ago when I was the charge nurse on our pediatric floor. It was a weekend morning around 7:30am. Right away at the beginning of the shift one of our newer nurses called me in for a second opinion on an infant who seemed lethargic and whose vitals were off. We called a Rapid Response and had a team respond within a few minutes led by the PICU fellow, which was pretty typical. She clearly saw that things were not right with this baby, and began calling out request for support teams: lab, X-ray, IV team, etc. After trying to get in touch with a few… Continue reading

Teeter Totters – Day 1 reflections

Day 1 was filled with lots of great conversations and thought provoking discussion.  The most of which was the Lewis Blackmon video.  As I think back on the video, I keep thinking about how many mistakes were made and how many times the medical team could have intervened that likely would have changed the outcome.  First, having a post surgical patient on an oncology floor seems very inappropriate and quite frankly dangerous for patient safety.  I realize that in today’s world of bed shortages (especially at my home institution), this is a very likely occurrence but it is disheartening to see.  Secondly, It amazes me that once Lewis started having increased abdominal pain and his vital signs began to change, there was no discussion of moving him to a higher acuity floor, such as step down or even the ICU where he would be monitored… Continue reading

Safety Moment – Pride for your Patient

I love the expression ‘if you’re a ditch digger, be the best ditch digger you can be”. It sums up that attitude of having pride in your work regardless of what you are doing, and shifts the focus from the work at hand to the bigger picture of self worth and meaning. When thinking about the work I have done in the past and the teams that have been successful for me it has always boiled down to a shared respect for the goal at hand, and a willingness to see the job to the end. Everyone on the team has had responsibility and, in particular, ownership over their parts and ultimately the entirety of the project. With the idea of a safety moment in mind, I think of this expression, because patient safety is only as strong as the weakest link in the chain. Therefore, pride in one’s job… Continue reading