“I don’t trust the nurses”

We heard this sentiment several times yesterday, and though I understand the visceral reaction to label that statement as “the problem” there’s more to unpack in that statement than we were able to do. I guarantee that many of the residents in that room and certainly back in our hospitals and clinics have felt the exact same way. And we need to be able to talk about it honestly, even if it’s politically incorrect to do so.

There are multiple issues of communication, accountability, fragmentation behind that statement, and all need to be addressed. I’m interested in concrete examples of how we build relationships with nurses and other healthcare workers in a meaningful and accountable way.

A few examples I’ve heard over the week:

– Nick at Children’s Mercy is part of a Nurse-Resident Council. He is also at a historically nurse-run hospital, and likely in a place where the… Continue reading

Where is our support…

On Wednesday 6/11 we discussed the case of “Sally,” a 9 year old girl who died because of medical errors. Regardless of how you look at it, this is a tragedy. In our discussion, the presenter described why this resident was “set up to fail.” The resident had undergone numerous emotional battles in the prior months on the wards and in the ICU, had struggles outside of the hospital, and unlimately quit the residency program as a result of Sally’s death, but there was not one discussion on Wednesday about how we should care for our residents. Unfortunately, this resident’s story is all too common. Many of our Telluride attendees sympethized with the resident outlining how similar their experiences have been to Sally’s resident. I too can look back and see myself in that position.

It is well documented in the literature that residents, regardless of profession, develop higher rates… Continue reading

Reaching new heights both literally and figuratively

The day started with a fantastic hike. Although the weather didn’t cooperate, things cleared up on the way down. After a great lunch afternoon lectures commenced. I was Fascinated to learn about the topic of human factor engineering. This may be an area of interest I may explore in the future. l would be very interested in developing ways to reduce harm by utilizing properly designed tools. The last topic of the day was an emotionally charged story which evoked not only some personal stories but also controversial dialogue. The important point I took away from the discussion is that these events can happen anywhere and to anyone. During my training as a pilot, l learned an important lesson which I try to recall with every flight: complacency kills.

Workout

Today was a workout, both physically and emotionally! We went on an awesome hike this morning and then after exercising my quads and hamstrings, we had some riveting discussions at conference this afternoon that was like putting my neurons through P90X. I’m looking forward to our final day tomorrow, but cheers for a good “hump day” at patient safety camp.

Day 2 Reflections

Shared Decision Making – perhaps better known as Informed Decision Making
— It would be interesting to have stock videos to educate patients about procedures, but this has to be used in conjunction with explained. (apparently this occurs with a single company out there)
— It would be cool to have specific consent forms for specific conditions that look like this (see attached pic):
Shared
— We have to be careful with numbers (risk) and make sure it’s meaningful and the data is being applied correctly and that the numbers cited are actually applicable to the case at hand.
— We can’t rely overly on numbers as there are certain things we can’t really quantify: for example, I can tell you that the rate of infection for LP is 5%, but I can’t quantify the risk of not doing the procedure – it’s hard for me to say you have… Continue reading

Making decisions for vs. with the patient

As a 3rd year internal medicine resident, I have so many times made decision for my patients without asking them for their opinion about it. Most of the time, it has been as routine as starting a new blood pressure medication while not talking to the them about the possible side effects that I have found to be one of the important factors resulting in non-adherence by my patient to that medication and then having them labeled as “uncontrolled HTN in the setting of non-adherence to medication”.  What I have learned in only 3 years is that when it is a shared decision the results are much better, patients are less likely to be non-adherent and they  trust in me and team more.  Yesterday we had a session on the consent form and the value and importance of shared decision-making. We talked about catastrophic … Continue reading

Considering informed consent

After watching the Michael Skolnik story here at Telluride, the residents and faculty broke into small groups to consider the issues involved in getting proper informed consent from patients who are about to undergo procedures.  Faculty member Kim Oates later reminded the residents, “The consent form doesn’t replace the conversation. And the conversation
is not a conversation unless it is a two-way conversation.”Although the focus was on the humanitarian reasons for engaging in proper consent procedures, faculty leader Dave Mayer also pointed out that informed consent breakdowns are a top
reason for losing malpractice cases. He also reminded the residents of the value of encouraging people to seek second opinions, not only for the patients themselves, but also for the doctors: “We’re all biased towards doing the procedures
we’re trained to do. If you think you’re
not, you’re fooling yourself.”

Here’s a composite of pictures of the members of… Continue reading

QI Project Idea – Comments Encouraged!!!

Hi All,

As you are all interested in patient safety/QI, I wanted to run an idea by this very talented group and see if you had any thoughts/improvements/additional ideas.

Background: At the Washington DC VAMC there is minimal communication between the house staff and nursing staff, often the two groups don’t interact all day.  One of the biggest hurdles that residents feel they must overcome is being able identify which nurse is caring for their patients and how to get a hold of them.  The current work environment yields fractionated and adversarial relationships with the patient’s medical team, hindering a patient centered approach to treatment.

Aim: To improve communication between nursing staff and house staff with regards to patient care

Intervention: On day one of the rotation, all house staff will be taken to each medicine ward floor and introduced to the nursing staff.  Each team room… Continue reading

Shared Decision Making #SDM

Today’s discussions revolved around the importance of involving patients and families in care planning. We touched on a number of important topics within this theme — informed consent, outpatient medication choices, code status/goals of care, and much more. I appreciated that today’s SDM discussion was paired with a fantastic workshop on negotiation led by Paul Levy, which broadened the concept of negotiation for me. Some of the stories regarding SDM were striking. Parents having procedures performed on their children without their knowledge or consent. Patients consenting while heavily sedated. Many terrifying stories today. I think the toughest barriers to involving patients and families in care planning are the incredible asymmetry of knowledge and the difference in perception of severity between provider and patient. What I consider a routine procedure or a common medication may be the biggest risk/benefit decision the patient has ever had to make. We need educational systems… Continue reading