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 →

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 →

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 →

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 →

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 →

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 →

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.