Today has been an enlightening day in learning about patient safety. My favorite part of today was Laura’s lectures on transparency and just culture, which I found to be really informative. As a medical student, I believe that we find ourselves sometimes in a confusing position because we either 1) believe that because we are on the bottom of the totem pole, we are not free to always share our thoughts or 2) we simply assume our residents or supervising attendings will report events about patients that we have been following. I think back to this one patient that I always lament over. Back in April 2022, I was doing my psych clerkship in a child psych in-patient unit. We were consulted for a 17 y/o female for altered mental status in the ED. When we visited the girl, we soon realized that neurology had not been consulted first, but… Continue reading
One, of many, light bulb moments for me today occurred while discussing reflective practice. Through our day patients are reported out to us by colleagues who have often labeled them. To me this can be similar to the picture that we saw and were asked “what do you see”, followed closely by “how many circles can you count”. As a group we already had the bias in our mind of what we originally saw; when asked the second question we could not see beyond our original label to count the circles. This is similar to when colleagues label patients as “drug seeking”, a pain, or a “ringer”. It causes us to sometimes not be able to see past the label to the patient, intentionally or not. As we transform to leaders we need to break these biases down so patients can be seen at face value.
I spent most of the day thinking about limitations to patient care over the weekend shifts, exemplified in the movie from today. What stuck out to me most is the residents were unable to get ahold of an attending during the weekend – was the team afraid to call and “bother” their attending over the weekend? I’d think so. They had no problem walking into an OR to speak to the attending about blood pressure cuffs on Monday.
Inevitably, something you find out during your first week of intern year is who is nice and who is mean when calling consults, specialists, ect. However all throughout residency you’re encouraged to always call with concerns. How messed up is this? It is completely unreasonable to expect new doctors/nurses/med students to feel comfortable calling with concerns if they know they will be yelled at, grilled unfairly, or repremanded. Some of my most… Continue reading
Watching the Lewis Blackman film was difficult. There were multiple instances in my mind where I thought, “Oh maybe now they would call a rapid response” and yet, it never happened; so many caregivers, from the nurses and providers, had let it slip through them.
I’d like to think that the culture of my home hospital makes it safe for nurses to call an RRT without having the nocturnist and ICU coverage come in and shake their heads at the nurse who called it if it was just a false alarm, but sadly I’ve heard stories of the nocturnist yelling at nurses for calling an RRT unnecessarily. Playing Devil’s advocate, I would understand if the nurses were hesitant to sound the alarms. But it seems like even when the travel nurse tried to contact the attending about her concern for Lewis, she didn’t get the best response for Lewis and… Continue reading
Today was exhausting!
We had a PACKED day (preceded by a really great breakfast) in which we discussed the terrible case of Lewis Blackman. We dissected what went wrong and how it could have been avoided. We applied many of the “issues” of the case to our own practice and our lives in general. I came away with a feeling of hope that in discussing such cases, we can prevent them. Who knows how many similar cases have been prevented already just by the mere discussion of medical error prevention?
He then discussed transparency reporting by Laura Lee and I was introduced to the idea of categorizing medical errors ranging from intentional harm to smaller systemic issues the need to be addressed. Christopher Bonk discussed health IT and how it can be both a blessing and a curse. We discussed optimizing EHR systems and quality improvement measures used to do… Continue reading
Today was a great because we established a foundation for seeing things from various perspectives with the staring at a picture exercise and established a simple, but fun way to simulate teamwork and patient care with the teeter totter exercise. Notwithstanding, watching the Lewis Blackman story was incredibly powerful in that I can see how many patients and their families might feel similarly when they enter a hospital and it taught me the importance of listening to family members as well as the patient in terms of being advocates. Lastly, I think the little tidbits thrown out such as using the statement “I have a concern about …” are really powerful, simple tools that can easily be implemented and shared to help improve patient safety.
I thought the Wall of Silence made me cry, but today’s video made me cry just as much; I couldn’t even bring myself to comment or share my thoughts afterwards because the thought of speaking on what we just watched made me tear up even more. Being able to see and hear from the people on the other side of patient safety events is eye opening. Like Carole said, we need to remove some of those labels (i.e. hysterical) that we use or hear our coworkers use.
And being around this group of such open-minded individuals is such a positive experience. I wish I could make everyone in healthcare have such open minds with a concern for the greater good of patients and their families–I guess this is where I need to be the first dancing guy. I love being able to hear from both the nursing professionals and doctors/medical… Continue reading
It was an amazing first day meeting everyone and getting to interact while learning!
After today, it hit me how many people want to make a change in healthcare, but at the same time, we may not always know where to start. Like our discussion after the first video, how to we change the culture to help with the residents and their workload? when should a nurse push more to advocate for their patient or when are they safe to say they agree with the family or patient?
I sit here after today and think, the problem is culture and needing to make adjustments, why is to make healthcare safer for patients, and after this week, I hope to have more tools to invest in helping make strides towards changing and improving for patient safety.
I thoroughly enjoyed the interaction with multiple disciplines. I feel like it really drove the… Continue reading
Today I went in with an open mind not knowing what I would learn. I left with a great sense of new knowledge along with a strong desire know more. When I came back to my room, I found myself looking up random related areas, including how Leapfrog scores are calculated, founding of QSEN, and psychological safety assessment instruments. The Lewis Blackman video was heart wrenching to watch. There were many important points regarding the chain of events and how the situation was handled. One of the things that struck me the most were the comments Cathy made after film. She talked about some of the underlying reasons why the family had decided to go ahead with the surgery (father’s experience with bullying, etc.) along with the impact Lewis’ death had on the family. Lisa also alluded to this point with her personal story. It really hit me of how… Continue reading
Our discussions and training today have me feeling energized about patient safety. As I look forward to implementing what I have learned, I am left with a lingering question. In our readings and the film today there is language that highlights age and training level. In particular, I have noticed references to the “young doctor” in these stories of patient safety, often who has contributed to the failure of the medical system to protect a patient. My question is: how does one balance the task of creating a culture of collaboration and teamwork that fosters group communication and shared responsibility of patient safety with the need to operate within the framework of medical hierarchy based off of years of clinical experience? As a soon-to-be “young doctor” myself, how do I navigate finding (and then using) my voice and the space to keep patients safe while also simultaneously being told that… Continue reading