I would say The Telluride Experience has continuously kept me motivated and perpetuating towards patient safety. We started the morning with a hike to almost 800 ft. This was quite interesting as it gave us a chance to socialize amongst each other learn our strengths and weakness. After the hiking we showered freshened up, ate lunch and then when to lecture. I noticed each day when Dr. Mayers started his lecture and he mentioned one person that was consistent, that person was Jeff Skiles. I liked the quote that Jeff Skiles used which was, “it is vastly more important to identify the hazard and threat to safety, than to identify and punish an individual for a mistake.” I believe this is a major statement because it demonstrates amongst the healthcare team how individuals act and react. In addition it diffuses that anxiety of always being terrified to do anything because… Continue reading →

“Psychological safety is the felt environment for candor.” – Amy Edmondson

This quote really resonated with me during Kelly’s talk on Speaking Up yesterday because I have had experiences in which I felt both psychologically safe and unsafe. During the times I felt psychologically safe, I felt comfortable speaking up and voicing my concerns/opinions. During the times I felt psychologically unsafe, I kept my mouth shut out of fear that I was potentially wrong or even rude for saying something. Keeping these experiences in mind, how can I foster an environment that feels psychologically safe for my co-workers? And how can I help disseminate a psychologically safe culture on my unit, amongst interdisciplinary teams?

Another eye-opening moment yesterday occurred during David’s talk on Human Factors Engineering. We discussed examples of human factor errors, such as driving away from the gas station with the gas hose still… Continue reading →

I have been an ICU RN for 2 years, a nursing track I never saw myself going into. The first day that I has an ER clinical I knew I would never do anything else. Oh how time changes us all!

In my first year of ICU nursing I had a patient that went into respiratory failure, was intubated, and developed ARDS. Our attempts to recover this patient were proving to be futile, to include paralyzing her to TRY and overcome ARDS. Knowing that we were nearing the end of our clinical intervention course the patient’s family decided to make the patient comfort care the next morning at 10am. The night they made that decision I was in the room and I told them, ‘I’ll take care of our girl.” Around 2am I wanted to clean up the patient. I wanted her bed to face the window so she got… Continue reading →

Before coming out here to Napa for this conference on patient safety, I wasn’t sure what to expect or what I would get out of this experience. I had this preconceived notion that I already was practicing safe medicine and I didn’t think there was too much that could be taught that I hadn’t already learned in school and as a practicing nurse. So coming here I was interested in what we would be discussing, and to maybe feel more validated in myself that I am doing what I am supposed to. But after the first day starting out with discussions about actual medical errors that have happened that resulted in death and then meeting Helen, after watching about her son made me take a step back and think about a time where maybe I had messed up and thought “oh no big deal” because it was such a small… Continue reading →

What I am going to write about this evening is essentially the comment I made last night after watching Bleed Out with Steve Burrows, but I wanted to put it in on the blog as well. First, that film was an exceptional production. It made me so angry – on behalf of Judie and her entire family – and I will remember that anger and frustration moving forward as I try to become a part of the revolution (John’s word) to prioritize patient safety. I plan on recommending the film to my co-workers, family, and friends, whether they practice medicine or not. Bleed Out, along with the other films and discussions from this past week, has lit a fire in me. I hope to use this newfound fire as a means to make change, starting with writing to my senator and representative in Congress about amending our laws to… Continue reading →

What a jammed packed day of emotion! Honestly without prompts it is hard for me to sit down and just begin to write. Except today I was inspired when I was asked by the sweet film crew to record my response to – “What was your Ah Ha moment,”

Through every story I read and watched there is so much emotion; fear, anger, grief. I’ve been in that position as an RN watching something happen KNOWING that I was dealing with the the results of a major medical error.

4 months ago I was called at home by my charge nurse who told me, “Leighann, we need you to come in. We have a rapid response and we need to intubate.” I arrived 20 minutes later, the patient was being settled into her room and I had three doctors at her bedside; hospitalist, pulmonologist and neurosurgeon. The patient was an… Continue reading →

It is crazy to believe that we only one more day left in Napa, California. We started our day with a nice hike up a local trail and experienced some fantastic scenery. I also got to experience some great conversation with my peers during this time. Some other highlights from today included a communication game involving dominos and a great movie showing of “Bleed Out”. We were able to have a great discussion with the creator of the movie, which was really interesting. Finally, it was great to have an aviation discussion with John Nance, the author of “Why Hospitals Should Fly”. He is so knowledgeable and the methods that he was discussing make a lot of sense in the realm of healthcare. I look forward to my last day of the conference tomorrow!

I had many “aha!” moments yesterday, but the one that has stuck with me the most happened after we watched Just a Routine Operation. Chris asked us to close our eyes and imagine the deteriorating patient before us. Then we opened our eyes and discussed what that felt like. But it was the next reflection – closing our eyes and imagining that the patient was a loved one – that really affected me. All of a sudden, I felt so uncomfortable. There’s no way I would want to operate on my family or friends, especially after realizing that they were quickly deteriorating. I wouldn’t be able to stay calm and handle that professionally because I would be too involved from an emotional standpoint. After I mentioned this, Chris asked something along the lines of “why do we leave or forget that connection with the patient? When do they… Continue reading →

Today one of the main topics we covered was effective communication. As long as I can remember I have been a fast talker, fast to the point that many folks often have a hard time catching what I am saying…this on top of all the other difficult factors that lead to misinterpreted messages that Carole taught us today. Listening to my own voice on the Instagram videos of a colleague today while trying to enjoy the festivities hosted by The Doctor’s Company, I couldn’t help but cringe at my pace of my words simply saying “thank you so much for having us.” How much more difficult would I be to understand when trying to explain complex diagnoses or treatment plans?

Throughout my first two years of medical school I have had ample opportunity to be recorded while working with standardized patients, but each time avoided completing a thorough review of… Continue reading →

The power of storytelling is a powerful tool, and I feel like the main takeaway from today was the impact of stories. I don’t think I’ve ever been so moved by so many patient stories than today, and what is more surprising to me is how wrong our perceptions of our patients were. Today we learned that what patients usually feel after a medical error has occurred is shock and/or disbelief, not anger. It was fascinating to hear how selfish it was for doctors to assume that patients would be angry at us and how this was a reflection of how, as doctors, we care more about protecting ourselves than protecting the patient.

Another thing that I found shocking was how different the outcomes were for all 3 of the stories we heard today about medical errors. They were all heartbreaking, but with one showing the extreme end of kindness,… Continue reading →