Reflection

Today was quite an experience for me. It felt like an emotional roller coaster and brought back many memories of prior patients that had poor outcomes under my care team. When some of these bad outcomes occurred, I worked hard to disclose potential adverse patient safety events to my attending and program director. Their responses were well intentioned and they said they’d look into it.

Unfortunately, after the initial disclosure, very little info was given to me or other members of our care team about what transpired. To this day I have no idea if all parties involved were made aware of these issue, especially the patient and their families. Hearing todays testimonials made me feel better knowing that others had similar adverse patient events and that I was not alone. It also gave me the strength to want to dive deeper into these issues and make sure we are… Continue reading

Reflection of Day 1

The discussions today were thought provoking and inspiring. There were multiple times today that we discussed how a patient and/or their family would want answers and open communication after an adverse event.  This was the nudge/chastisement I have needed to take action to try to remedy unhealed wounds.

I had a patient, who I was the PCP for, die about 3 months after I had started seeing him. He presented to me in the clinic with vague symptoms that I tried to work up over the next 2 months but failed figure out what was wrong. He was eventually hospitalized and then diagnosed with advanced lung cancer. I saw him in a follow up visit and he was supposed to be starting chemo but miscommunications kept happening between the patient and the oncology clinic. I tried to get involved and help figure out what could be done… Continue reading

Day 1 Experience

Our day started with an introduction to the tragic story of a gifted boy Lewis.  Narrated by his mother it was an emotionally intense documentary of death due to a preventable medical error.  Interwoven in the narrative was the idea of reflection and mindful practice as means of improving our practice.  This gave rise to an interesting dialogue wherein we all inquired our individual emotions, trying to understand how this could have been a loved one.  The faculty engaged the audience in a healthy constructive discussion about how to change our practices once a medical error is identified.  While data backs the evidence that patients and their families are more understanding if a physician admits to an error, it needs to be done because it is the right thing to do.  The highlight of the day perhaps was the teeter totter game. … Continue reading

Safety and quality first

Having been a patient multiple times, going through surgeries and what not, I’m always anxious about what could go wrong. This anxiety sometimes translates into fear, what would happen medically, human or system errors and the outcome for me. These feelings have impacted the way I care for my patients leading to a desire to improve the patient experience by positively impacting treatment outcomes, promoting the kind of quality care I like to receive and mitigating errors that could arise from the process of care. I wanted to attend the Telluride camp to learn more about doing this. I once worked as a quality improvement consultant in a pediatric facility but the view/experience is a bit different when you are providing direct patient care vs non-direct patient care. I’m here to use my past experience and the knowledge from this camp to change my practice and drive change in my… Continue reading

Optimism and Despair

What drew me first to the world of medicine was the sense that stories were essential—even elemental—to the provision of patient care. The paradigmatic provider-patient exchange, that of taking a history, features doctors and their patients working together to weave a narrative, to make sense of pain, and to ultimately address somatic and psychological suffering. Thus in undergrad, before med school, I spent much of my time thinking about what stories we tell each other about how health care apparatuses developed and took shape, how different marginalized communities imagine and experience their relationship to medical institutions, how the American public at large makes sense of medical science and society.

One dominant narrative within this imaginary is that of the infallible doctor—physician not as frail, emotional, conflicted human but as extension of medical science itself, enacting healing in the name of logic, rationality, and algorithm, performed with the precision of a… Continue reading

Day 0

Greetings everyone! I can’t wait to begin this week with all of you. I have been a registered nurse for the past 8 years and I am in the first year of my Doctor of Nursing Practice program focusing on Health Innovation and Leadership at the University of Minnesota. I have served patients at the bedside in both in-patient and out-patient settings, and I also have formal leadership experience managing a busy urban pediatric primary care practice.

In my nursing career so far, I have witnessed a wide spectrum of approaches to patient safety (the good, the bad, and the ugly). At an academic medical center where I worked on a pediatric med/surg and cardiology floor for five years, I got my first real experience with a grassroots approach to shifting toward a culture of safety. I feel fortune to have had the opportunity to participate in this quality improvement… Continue reading

Adverse Events

I chose to attend the Telluride Experience because intern year of my residency program, I was involved in a negative patient safety event. A patient being taken care of by my team was discharged from the hospital with the wrong type of antibiotic medication.
The patient had a community acquired pneumonia. He was responding to our initial antibiotic regimen and we were prepping for discharge. Though improving clinically, blood cultures came back positive. We waited for results and acted when we saw that the cultures speciated. We anticipated a quick discharge, but our patient kept barely failing discharge vitals parameters and we had to keep delaying sending him home. With pressure to keep our patient census low, the plan was to discharge him as soon as he meet safe discharge criteria.
We discharged him approximately a day later with medication for his specific infection. In our haste to discharge, we… Continue reading

The Quest for Zero: Climbing the Mountain of Patient Safety

For my telluride post, I decided to reflect on the activity that impacted me the most, and I realized that a great lesson lies in the hike we all went on. On Wednesday we all went on a hike up a mountain range, which was a fun activity to do. While climbing, all my focus was to just keep going up, hoping not to fall amid the decreasing levels of Oxygen and the increasing snow. However, after we were done with the climb yesterday and went into one of the afternoon sessions. It just dawned on me that there was a clear parallel with what transpired during the climb, and what we have been talking about this week on patient safety.

While climbing we all encountered some slippery slopes and those ahead would always call back to warn those of us behind them about the slippery areas, making us aware… Continue reading

Reflection

I chose to attend the Telluride experience because I truly do value patient safety in all respects, as cliche as I imagine it may sound. As a healthcare practitioner they may be nothing more unsettling when you are unable to answer questions such as ” How do I safely care for this patient or population?”,  “How can I protect these patients from themselves”,”What adverse events are associated with this condition or disease process and what protocols are designed for these situations as they potentially arise?” or ” What situation would be considered a medical emergency?”.  The answers to questions such as these are the foundation from which we guide evidence based practice polices  and approaches.

I believe that this experience will allow me to collaborate with like minds that may bare perspectives that allow me to challenge my own ideals and practices to better provide safe patient… Continue reading

Great feelings to be part of the team.

Patients safety has been my watchword in all I do with my patients, learning how to work as a team to build a culture that promotes patients safety is the primary reason I am attending this Telluride Patients Safety Conference. I have heard so many good experiences from past participants. I hope that my experience during this conference will equip me to be a part of the agent of change in my institution and other places I might find myself in the future.