Transparency – How much do you weigh?

It was a great first day at Patient Safety Camp!  It is a privilege to learn from leaders in quality and safety from around the country and internationally (thanks for coming back, Kim!!).  The bigger privilege, and the one I didn’t anticipate prior to arriving, was the privilege of meeting fellow residents from around the country.  At first it was a little intimidating to be surrounded by residents who had accomplished so much as leaders in the IHI, leaders in CIR, radio talk show hosts, and pharmacists… the list went on and on.  But as the day progressed I realized that I was lucky to be surrounded by such great people that I can hopefully learn from for years to come.  We have already learned so much from each other by discussing ways to improve transparency and communication with patients, how to increase physician reporting… Continue reading

Reflection day one

After hearing about the LB story, it brought back numerous experiences with similar breaches in communication. One potential remedy which was not discussed today was the importance of a read back. Applying it to today’s discussions…what if a formal read back from an attending was expected by the culture of that hospital community?….
Attending: So you’re telling me this 15 year old patient is tachycardic, has a rigid abdomen, and has new onset severe abdominal pain, and you attributed some of his abnormal vital signs to blood pressure cuff size??

I’m sure that after repeating those words out loud, the story would’ve had a different ending.

1st Day Thoughts

Telluride is beautiful – leaving me breathless. First day of programming was packed with goodies. Lots of great discussion – respect for everyone who shared their thoughts – fellow residents, teachers, and patient families. For me, it was my intro to twitter – which I’d signed up for but never used. Check out @edcountydoc which I took to throughout the day with thoughts. Some are shared here.

One tweet that received no love was my tweet on handoffs. We are always so focused on the number of handoffs that we point fingers at the number and poor quality of handoffs as a major reason that errors and patient safety have not improved since work hour restrictions. However, I think this is a correlation and not causation. The thing that never comes up is that handoffs are not usually 1:1. During the day, there are multiple teams on duty. For… Continue reading

Day 1 completed

The day started with an introduction and objectives for the week. We were introduced to the story of Lewis Blackman. Although i had heard the story before, it is always great to hear different view points. It is hard to imagine how many things went wrong in such a short period of time. Even though 10 years has gone by, I’m not sure how much has changed. I can imagine a similar scenario taking place today. It is frustratring how difficult it is to change the cuture. I do believe exposing future physicians to these stories will create a paradigm shift. The question is, how long before we see the results? The afternoon held a great team building and communication exercise. This was a unique iteration of the exercises I have participated in in the past. The day wrapped up with people sharing personal stories. Today seemed as though it… Continue reading

First day reflections

Great first day of safety conference today, which really helped set the stage for a great week.

I am excited because my role in patient care is very different from others as a “non clinical” physician, but hearing stories about other people’s experiences and systems failures which impact patient care has really helped me see how we all fit together in healing and in making/preventing error.

I am looking forward to discussing the role of technology, EMR and specifically how radiology contributes to errors. Id like to see how we can form safer systems that still take advantage of the benefits technological advancement offers, while keeping patient safety the primary goal of improvement.

Ah Haa moments

It’s hard to pick just one “Ah Haa” moment from today, especially being surrounded by so many amazing residents, faculty and patient advocates in the gorgeous setting of Telluride. I think throughout the day in small groups, teeter totter activity, and dinner with fantastic colleagues I am developing a collection of small “Ah Haa” moments. These moments, and the ones I have yet to collect this week, are nuggets of valuable information and suggestions that I am looking forward to taking back to my residency and community hospital.

Going the distance….

At the close of our first day in Telluride, I find myself hopeful.  Today we were presented with the story of Lewis Blackman.  The tragedy of medical errors involving his case were not in vain. I believe we have become a culture that would protect Lewis Blackman if he were in our hospital today.   I found myself surprised by how far we have come in patient safety in the last decade.  And I feel confident many of the failures of his case would not occur today.  Am I foolish to be this hopeful?  I believe we as a medical community have learned from our past and strive to not repeat it.  Safety mechanisms are now in place that would have prevented Lewis Blackman’s tragic end.  At Medstar GUH, we have a list of mandatory events that demand contact with the on call… Continue reading

It’s in the air.

Being from Canada, I am spoiled by gorgeous mountains, picturesque town and even snow in June. But being short of breath and having fast heart rate while relaxing in town is a first for me. The thin air is eliciting a physiological reaction that I usually feel when I see sick patients, or after I feel I might have made a mistake. Unlike in the hospital, the sensation doesn’t go away here, even after I close my eyes, it persists with every breath I take,

These few days of immersion will probably transform a lot of us. Being health care providers, we’ve gotta start breathing patient safety.

Gemba

Today- the first day at Telluride 2014 – was filled with stories. I expected lessons on safety and quality, but the teaching was much more organic. We heard incredible, emotional stories that left many us of us jarred, uncomfortable, and often in tears– especially Helen Haskell’s story. As a new parent myself, the idea of the loss of a child is incomprehensible. Today’s teaching came out of our own reactions to the difficult stories we heard as a group. My takeaway today goes back to Paul Levy’s book and the concept of going to Gemba — the “actual place.” As I finish up my PGY-1 year and think about all of the very sick patients I cared for, I realize the importance of physically being in the place of importance– the bedside. So much of my work this year has been away from the bedside, reviewing charts and entering orders,… Continue reading

Reflections on Lewis Blackman

Unfortunately, there were countless errors from before the start of Lewis’ surgery all the way through the handling of his death. The one systematic error I will comment on is physician-patient communication.  Every patient undergoing a procedure needs to sign an INFORMED consent, which includes understanding the risks, benefits and alternatives to the treatment being offered. The situation continued to tailspin into a downward spiral as family was unaware of the expectations post op.  There were multiple efforts made by the patient’s mother and nursing staff to notify the physicians that something was wrong.  The physicians ignored the most valuable resource available to them, Lewis’ mother, who knows him better than anybody else.  Her concerns were repeatedly disregarded or ignored because the doctor did not want to believe something was wrong.

Dr Levy eloquently stated, ” if you can’t see your mother/sister/daughter/son in your patient,… Continue reading