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

Telluride 10th Anniversary Patient Safety Summer Camps Kick Off Monday, June 9th

Mountains in the background on Bear Creek hike

On Monday, June 9th the Telluride Patient Safety Summer Camps will begin their 10th year, thanks in part to the generous and continued support of The Doctors Company Foundation (@doctorscompany), COPIC, CIR (@CIRSEIU) and MedStar Health (@MedStarHealth, @MedStarSafety). As the yearly preparations come to a close for faculty, including Summer Camp creator, Dave Mayer MD (@dmayer33), the trek and education are set to begin once again. This year, anticipated attendance will include 130 resident physicians, medical and nursing students and faculty from as far off as Australia.

It’s true that change in healthcare can sometimes feel like dog years passing, but it only takes a week at the patient safety summer camps in Telluride to remind us that educating the young is also ripe with rejuvenation for the older generation if open to the wisdom, passion and idealism of youth. As the social… Continue reading

Telluride East Final Reflections: Never Stop Improving

By KenRicklam

When I began medical school, my academic mentor advised me to be cognizant of when the more experienced would drop pearls of wisdom. Well during these past 4 days it’s been raining pearls. After trying to absorb so much knowledge, my brain feels like an overfilled suitcase with a weak zipper; it’s about to burst. And therein may actually lie a problem. To those with less clinical and formal patient safety experience, Telluride covers too much information in too little time. Many of the activities and discussions felt rushed. Here I present an open, honest critique of the Telluride program and make suggestions for improvement.

I will focus on 3 observations: 1) The negotiations, listening and human factors lectures were some of the best received, 2) Group exercises/games are highly beneficial and are worth the time expense, 3) People felt that there was not enough time for discussion.… Continue reading

Why is Pushing the Wrong Button So Easy?

By Sarveshwari Singh

On the first day of the Telluride East Summer Camp, Kathy Pischke-Winn and Dr. Joe Halbach organized a game using dominoes.   It really showed how miscommunication in health care can happen so easily and how simple steps can prevent it.

We assembled in groups of three — one person role-played a doctor, another a nurse, and the other an administrator.  The physician sat with his/her back to the nurse and instructed the nurse how to arrange the dominos according to a prescribed pattern.  The nurse couldn’t ask any questions.  Not surprisingly, the nurse didn’t arrange them correctly.

This scenario brought home how communication disconnects among clinicians happens so often in health care, and it underscores why a leading cause of errors is failure in communication.  Also, informal rules can deter students and residents from asking questions, which can lead to a… Continue reading