Commuting and discomfort

After attending a conference in Snowbird, UT I knew there was going to be discomfort to push through upon arrival at Telluride due to the atitude. However, this trip had the added insult of that flight between Denver and Montrose! Talk about a one, two punch. I wanted to die last night. The shortness of breath is one thing but the intense headache is yet another. Oh, of course the time difference too. You might think 2 hours is nothing but by the end of the day, it hurts. I can only imagine what my face was showing yesterday and most of today. Talking hurt and talking is what we are here to do. So, accept my apologies.

Commuting to work via Gondola pooling is awesome!! This by far is going to be one of my highlights. Every ride is different, with different occupants, good conversation, and of course the… Continue reading

Reflection

First I just want to say thank you to everyone that has put this whole experience together for us. I feel so lucky to be a part of this group and to learn from everyone here. Todays experience was so enlightening. It is hard to pick a few things to talk about because there were so many good points that were made throughout the day. I guess the one statement that stayed with me all day and makes me say ok this is why I am here was the statement about the Lewis Blackman story. I don’t remember if it was in the movie or if it was the faculty that said it but they said that the hospital was the one place that he could not get the medical care that he needed. That just really struck me hard. It really brings home just how important our jobs are… Continue reading

To be obnoxious.

“I’m a little obnoxious sometimes,” claimed Dan Ford this afternoon discussing his fervent advocacy of root cause analyses in response to sentinel events. Earlier that morning, Mandy too had confessed to being “that annoying nurse” who unabashedly telephones on-call residents when a concern arises. These champions of patient safety proudly own these deprecatory adjectives like “obnoxious” and “annoying” because they know that their actions are challenging the status quo for the betterment of patient care.

It is my hope that all of us, students and professionals alike, emerge from this week in Telluride a bit more enthusiastic about being obnoxious. To be “obnoxious” in this context is to put our patients’ needs first in spite of a bruised ego. We “annoy” despite the fear of openly defying the medical culture’s norms, and we “irritate” others because we have the courage to understand that it will take assertive individuals to lead… Continue reading

Mountains, new friends, and negotiations

Today was our first full day of the Patient Safety Roundtable.  I feel so fortunate to be a part of this group.  Everyone has so much to share and discuss, and it’s a safe and comfortable environment for discussing patient safety.

I really enjoyed the session on Negotiations.  Most people don’t get much exposure to or training in negotiating, so it was a really valuable experience, and one that I will continue to think about and reflect upon this week and after I go home.  We negotiate in every aspect of our lives–with our spouses, parents, siblings, children, friends, co-workers and patients.  Just understanding the basics of the dynamics involved is practical and useful.

I am enjoying the group of students and faculty.  Everyone is warm and welcoming, and I appreciate the opportunity to make new friends and connections.  I appreciate the face-to-face… Continue reading

Learning patient safety at Telluride

It’s such a privilege to return as a faculty member to the Telluride Patient Safety Student and Resident Physician Summer Camps, organized by Dr. David Mayer, vice president of quality and safety at MedStar Health. This is a lovely opportunity to meet a few dozen residents and medical students who compete to attend an intensive seminar or quality, safety, transparency, disclosure, and other topics that are unrepresented in medical school and residency training.  Here’s a note, for example, from Julia Meade, who attended last week’s residents’ program, and is about to start her fellowship:

I received 1 hour of training on patient safety as a medical student and 2 hours as a resident physician. During my time in Telluride, I learned more on how to keep you and your loved ones safe than I have in 7 years of medical training.

The newly arrived medical students have… Continue reading

Gondolas, S’mores, and Overwhelming Beauty

I made the mistake of thinking that as a well-seasoned runner, the altitude wouldn’t dare touch me. I was wrong. It wasn’t a mile in that I started gasping for air and didn’t seem to be catching any. Apparently one is expected to ‘acclimate’ before these runs become enjoyable. This information was provided post-run, of course!

I knew Colorado was beautiful. I’ve been here before. But I have never been to Telluride. And let me just say- it brings a whole new meaning to the word Beauty with a capital B. Mountains stretch on for miles and miles and the view from just about any point is spectacular. I keep finding myself fiddling with my camera and my smartphone camera trying to capture just a glimpse of how incredible it is here, only to be disappointed. The lighting is off, the flash doesn’t capture it correctly, a gondola passes by… Continue reading

Telluride Reflections by Patient Advocate Melissa Clarkson: Part Two

I am now back in Seattle, home from the Telluride Patient Safety Roundtable & Summer Camp. I am very thankful I had the opportunity to participate. It was emotionally exhausting (I cried the first three of the four days), but I have a sense of hope. I met leaders in patient safety—some of whom I had seen in online videos, others I had not heard of. But the message from all of them was clear: There is no compromise in patient safety. No compromise in disclosure. No compromise in informed consent. Safety and transparency must underlie all of healthcare.And that is a very different perspective than my family has encountered in Kansas, at both the local hospital we are dealing with and at the state level. So today I feel hope knowing that my family is not alone, but I also feel overwhelmed knowing that those… Continue reading

HRO’s- A Fitting End

This week we repeatedly discussed how hospital safety culture must learn from high reliability organizations (HRO’s) such as the airline industry, nuclear power plants, and aircraft carriers. Just before my 90 minute shuttle from Telluride arrived at Montrose airport, I received an email communication from United Airlines notifying me that my flight had been cancelled due to “aircraft maintenance.” Unfortunately, the next flight out of Montrose would not be until ~6am the following morning. In the past, I would have been rather disgruntled with the airline and likely would have projected my anger and frustration onto the check-in staff over the cancellation much like the two gentlemen at the counter next to me. However, after our discussions of HRO’s and reading John Nance’s Why Hospitals Should Fly, I was disheartened at first knowing it would be one more day until I got to see my fiance and dog… Continue reading

TSC#4

Concerning the discussion on listening awareness. I realized some of my barriers such as competing, defending and protecting. Interesting only recently have I realized defending and protecting as a barrier to listening. I had always thought it best to defend the side not present in conversation for a balance and productive discussion , however this can sometimes also impede active listening.

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The discussion about Human factor engineering and just culture underscored the importance of a blameless investigation in sentinel events which can uncover system or processes error and thus prevent errors in future. The story of the nurse who misinterpreted the blood sugar reading several times and was suspend. However after an investigation, triggered by a second event by a different nurse, it became apparent that there was an underlying factor which resulted to these errors. I also thought the point reached by Paul was one of significant importance—namely how leadership will own the initial poor response of suspending the nurse, acknowledge her work and support her moving forward.