Remembering the fundamentals

Day 1 at the Telluride patient safety experience was a good refresher course for me to reinvigorate and bolster myself to persue the same goals and ethics that I wanted to work with in my career when I started my psychiatry residency journey.  During the past two years as I went through the rigors of my residency training, I  felt that  some of the most crucial principles taught to us during our orientations had lost their sheen abraded by the stress of getting things done as an assignment to deliver rather than  a passion to heal another human body and soul.

There were multiple instances during the sessions today where I found myself to be critically  analyzing my own communications with the interprofessional team that I had during the last two years. I am glad that I will be taking home with myself some helpful… Continue reading

Reflection Day 1: Normalized Deviance

This first day of education has been a whirlwind of information, but nothing can compare to the personal stories of harm that has led to adverse outcomes.  Most of us as medical professionals have gone through an educational journey that teaches the importance of patient safety and quality, but it becomes so much more real when we listen to honest experiences shared by those who have lived it.  We could all speculate and say we would do things differently in that situation, but the truth is that medical errors are usually committed by good people with good intentions.

After reflecting on the movie that featured Lewis Blackman’s story, I began to wonder if a contributing factor to the critical error could have been a normalization of deviance in his vital signs.  If Lewis’ heart rate had shot up unexpectedly, or there was a sudden change in blood… Continue reading

Day 1: Transparency

Today was very eye opening and inspiring. I learned so much about patient safety issues and ideas from the stories told, data presented, and patient experiences shared. There are a lot of lessons and information that I will take back with me after this experience, but for this blog post I will just focus on one that stood out to me.

The way MedStar handled the medical error case of Jack Gentry was incredible. I was so impressed to hear the steps taken by the surgeon and hospital to acknowledge the error from the beginning and ensure they did the right thing for the patient and their family. It was during the post discussion piece that someone mentioned the importance of asking how an organization dealt with their last serious medical error. I had never thought of asking this question before during an interview or as an employee of a… Continue reading

Overcoming Defensive Medicine

  1. As a healthcare professional it is extremely important to always look towards improving the delivery of healthcare. As a senior resident there is often resistance when feedback is given to coresident. It is in human nature to become defensive when ones actions are being challenged. However, as healthcare professionals it is important to foster a culture of embracing feedback and change. At my training hospital residents are encouraged to join and become active team members of many hospital committees. This allows us to become active members to help bring about change in the entire hospital. As a member of the High Value Care committee I have been able to work closely with hospital administration to create quality improvement projects focusing on improving patient safety.

In the last few weeks, as a chief resident I have found it extremely hard to deliver feedback to some residents who become fixated on defending… Continue reading

Medical Error

Today Jack Gentry’s story resonated with me on a personal level. My father had terminal diagnosis of stage IV A laryngeal squamous cell carcinoma and went in for placement of a PEG. Subsequently, there were complications from the procedure. The team that placed the PEG refused to return phone calls or answer any questions about concerns. Nothing was done until my dad ended up in the hospital on a ventilator. At that point, multiple people from the team were calling my family back and rounding on my dad in the hospital. There was never any apology for the lack of communication or the lack of concern. This experience was the polar opposite from what we strive for when errors occur or things go wrong in patient care.

Premature Closure

During this first day of the Telluride Experience, the main theme was communication. One specific aspect that I want to focus on is premature closure. I have seen so many residents have conversations with nurses on the phone and make assumptions and cut off nurses–sometimes due to their own egos, feeling burnt out, or busy and not knowing how to prioritize. But I know that there are many instances that nurses were truly instrumental in saving patient’s lives, and if I would have ignored their concerns, I’m not sure where those patients would be today. One recent instance that stands out in my mind is when I was called by a nurse about a patient was POD1 from an abdominal hysterectomy (who had been rounded on that morning and was doing well). She told me the patient’s hands were very pale and her blood pressures were low (100s/60-70s), even though… Continue reading

Day 1

Many things to unpack and think about from today but…

Today while playing the domino game I had a bit of an epiphany about communication and intent. While playing the role of the “nurse,” I was determined to perfectly interpret and execute the intent of the doctor’s instructions. When the finished product wasn’t quite right, my first instinct was to blame myself for not interpreting the instructions correctly. When the roles reversed and I was the “doctor” giving the orders, I again blamed myself for not giving more clear instructions when there was an error in the final product.

In both roles, my intent had been good, if potentially unattainable: to perfectly execute the task at hand on the first try. My partners in the game were similarly focused on achieving success. As such, I knew that any errors made in the translation of the task were not due to… Continue reading

Day 1 Reflection

After watching the Lewis Blackman film, I was surprised when I learned how many mistakes were made during his hospital stay and how many people were involved.  How did no one say anything day after day of the patient not getting any better and then actually getting worse?  As a nurse, I was especially upset with the lack of advocacy by Lewis Blackman’s nurses.  Nurses are with their patients at the bedside all day.  They should be able to recognize small changes in the patient’s condition.  When one of the nurses noticed that something didn’t seem right, nothing happened.  Was anyone notified of her findings?  Although it can sometimes be intimidating to go up the chain of doctors, nurses and residents should do it if they are worried about their patient and they feel their concerns are being ignored.  One of the… Continue reading

Day 1: initiating safer patient care

Telluride Academy initiated its journey today. The video of 15yo boy Lewis, the personal story from Mr. Gentry, the domino game activity, and lectures were utilized to emphasize importance of effective communication in health care. I had a chance to intensely probe and exam my previous interactions with patients, their families, nursing staffs, and other members in treatment teams. Throughout the day, I had numerous moments when I recalled my memories from when I volunteered at multiple different health care settings as a college student.
We take an oath during white coat ceremony to DO NO HARM to our future patients. We have seen from reports that there are hundred thousands of lives are lost due to medical errors. According to the BMJ 2016, medical errors were third leading cause of deaths in the US after heart disease and cancer. Not making any mistakes treating our patients would be ideal… Continue reading

Day 1 Reflection

The story of Lewis Blackman was very effective in showing how important communication is. As a peds resident, I watched the whole video looking at all the errors made from the resident perspective, but when listening to others comments, I heard nurses looking at it just from the nursing view and you realize in any medical error, each profession looks at what they could have done better and it seems that we are always hardest on ourselves in the situation. That ties into Jack Gentry’s story, that admitting your fault helps deal with our own turmoil we experience after the situation. So many times the hospital wants to protect their financial responsibility but in the end, things can go a lot smoother when you are upfront with the patient and their family. Listening to Jack Gentry’s story, I thought if that was my family member I would have been so… Continue reading