Day 2 Reflections after Michael Skolnik

An emphasized topic during the Case of Michael Skolnik Video revolved around informed consent. I appreciated our conversations around this topic and couldn’t help but think of a good friend and an issue she encountered in her health care recently. She had been having intense lower abdominal pain for months that had gradually worsened. She recently moved to a new state and hadn’t gotten a new physician yet but eventually sought one out for her pain. When the imaging results were in it was discovered she had multiple ovarian “masses”, one of them the size of a melon. The physician walked in, dropped the diagnosis on her, and then told her she would need to have both of her ovaries removed. He told her that was the standard of care for dealing with this and wanted to move forward with scheduling surgery.

Luckily she is an educated, intelligent person… Continue reading

Day 1 Reflections following Lewis Blackwell

I was moved to learn more about patient safety after my mother had an adverse post-operative event in December. To make a long story short (anyone is welcome to talk with me about this in person) she had an internal bleed that was caught late, and then once caught was mistakenly not addressed. She bled in her hospital bed for nearly 2 days, her blood pressure dropped to 75/59 and her hemoglobin was 5.2 g/dL before nurses overstepped the physician and took action themselves. She received 8 units of blood during her recovery. Watching the case of Lewis Blackman I was struck by how many similarities were between his case and my mothers:

  • Lewis case occurred over a weekend, my mother’s over Christmas break
  • she suffered an internal bleed in the hospital, missed right in front of everyone
  • They minimized Lewis issues as “just” constipation, I had a surgeon… Continue reading

Day 2 Reflection

A few weeks ago, I asked a physician, “what are 3 qualities that you feel make a great doctor?” He answered with clinical intelligence, being able to apply the clinical intelligence, and being an empathetic communicator. Today, we talked a lot about empathy and the importance it holds for the physician-patient relationship. I learned that empathy is being able to feel with people. Meaning we listen, we connect, and we share in pain with them. One of the things I want to implement in my life in order to become a more empathetic person (within and outside of the healthcare setting) is to be a better question asker. I want to be able to have conversations that revolve around others and help me get to know others, rather than just talking about myself, so that when I find myself in a conversation about a medical error, I am… Continue reading

Day 2 – The Teeter Totter Game

I have never played the Teeter Totter game, but I found it to be an amazing learning experience and group activity. My team did a wonderful job deciding on a well thought out plan from the beginning, watching the first group and adjusting the plan as needed, communicating throughout the process, taking our time during the exercise, and when needed physically embracing each other to ensure the weight was kept mostly in the center. Our leader did an amazing job staying calm and reminding us to be patient. He also answered all of our questions and did an overall great job being our calm center that we could balance on and rely on. There are so many things I learned and so many situations where I can apply them in the healthcare setting.

I would love to see this activity held among interdisciplinary staff of all units at my hospital.… Continue reading

Day 2: interest and well being of our patients

Paternalism in medicine continues to perseverate and this should be questioned and re-examined. Physicians go through many years of education and apprenticeship to gain experiences and expertise. I believe knowledge-based value judgement is necessary practicing medicine; however, it should not be a sole method, generalized or inherited practicies, or considered as a norm when it comes to treating our patients.
Any encounters with our patients involve informed consent, which is a process that multiple parties are involved to achieve benefits of patients. Making mutual decisions should include ethical standards: autonomy, fidelity, beneficence/nonmaleficence, veracity, and justice. Competency would also be crucial to provide our patients with best possible options treating their illness. Ultimately, this will lead to ethical integrity of healthcare providers to provide safe and quality patient care.

Day 1 Reflection

I was so excited to begin my 4-day dive into patient safety and quality at beautiful Turf Valley Resort. One of my goals as a medical student this weekend was to be a sponge – absorb as much information as I can from both the organized program as well as connecting with medical student, resident, and nursing peers attending. Since I haven’t seen any patients in real life yet, I just wanted to hear stories and appreciate others’ experiences to best prepare myself for when that time comes.

One of the most memorable things I learned about from the first day was how to approach bringing up issues to and reporting higher authority figures in the medical hierarchy. I really appreciated learning about tangible things that can be done by even medical students: calling a hospital hotline, framing concerns as questions, and shedding the fear of “career risk” over “patient… Continue reading

Reflections of Day 1

One of the questions that kept coming to my mind as I watched the Lewis Blackman story, was why didn’t anyone second guess their diagnosis. As medical professionals we have a tendency to form anchoring biases which restrict us to specific diagnoses but I felt frustrated watching the film because Lewis’ signs and symptoms did not match the diagnoses he had been given. We should all be open to reassessing our patients and refining diagnoses in order to not make another catastrophic mistake such as this. I remember in medical school, in Barbados, our attendings would insist that we had a list of possible diagnoses for all of our patients just to ensure that we considered all likely alternative diagnoses. From that list, we would exclude unlikely diagnoses until we found the one that fit. Something like that would have saved Lewis.

One of the many useful things I learnt… Continue reading

Day 1 Reflection- Advancing Communication

Why are health professionals not listening to the concern of the patient?  A major theme from yesterday was advancing communication to prevent harm and address harm. We often take for granted that we have the ability to use effective communication. We started the day watching a video about leadership, which I thought was pretty powerful. I had not thought much about the following as I have thought about leadership styles. To lead, you have to be on the level of the follower or there will not be a movement. We continued on to watch the Lewis Blackman story. Diagnostic errors ignited my passion for patient safety when my mother in law passed away from a missed pulmonary embolism. As I continue in my medical journey, I want to always remember the phrase “What is the worse it can be?” to avoid premature closure and conformational bias. From the video,… Continue reading

Telluride Experience – Day 1

Lack of communication/false assumption leads to errors:
In learning about the Lewis Blackman case, an event that directed a conversation toward communication’s ability to either prevent or impose a drastic medical error in a clinical setting, one of the events that stood out the most was the idea that nobody asked, “What is the worst thing this could be?” I work for a home health care team that aims to improve the quality of care and the patient experience by communicating patient alerts. Effective communication in my organization is essential to the effectiveness of our team. Thus, the lack of coordination and communication that was exhibited in the Blackman case struck me because, as these nurses assumed that Lewis was fine, it was these false assumptions and the lack of communicating alerts that predisposed the patient to a detrimental error resulting in the patient’s death. When you assume that the… Continue reading

Day 1- Reflecting on Interprofessional Relationships

As an RN in a, small, 20-bed ED I have the opportunity to work side be side, and have face-to-face communication with, the attending physicians (including the ED chair), physician assistants, residents, multi-functional techs, nursing supervisor, charge nurse, triage nurse, unit secretary, environmental services, X-ray technicians, CT technicians, US technicians, and transporters. The importance of open communication between all parties involved in patient care has been stressed since the first night I stepped onto the ED floor. During my orientation I was encouraged to, respectfully, question physician orders which did not make sense to me and now when I precept a new graduate I encourage the same. In our department we are able to question such orders without push-back from physicians, residents, or PAs. They are typically grateful when a nurse has caught a medication order which was meant to be ordered on another patient. Generally, they will take accountability… Continue reading