On tribal hierarchy
On day one of the “Academy of Emerging Leaders in Patient Safety” conference, we started by watching a video featuring a patient’s mother who brought up the tribes of healthcare (doctor tribe, nursing tribe, etc) and the role that the element of hierarchy played in her son’s unfortunate outcome. In healthcare, we often witness two of mankind’s most primitive motivators – the desire to care for others and the drive to survive. The “doctor tribe” is predominated by competitive, type A, detail-oriented individuals, and deference to the hierarchy is one of our tribe’s oldest traditions. In the patient safety community, the need to address this specific tribal tradition is frequently discussed. Knowing that old habits die-hard brings up a number of questions: Is hierarchy still alive and well? How can it be addressed? How receptive will the tribe be to solutions proposed by external parties?
Take a… Continue reading
It is already a very emotional first day at Telluride as I re-watched Lewis Blackman’s story as a senior resident. Two years ago, prior to any patient encounters, I first watched it as an intern, incredulous at the turn of events. At that time it baffled me how health care professionals could diminish patient and parental concerns so callously, and how so many errors could pile up to lead to a tragic outcome. As an intern I vowed to never allow such reckless practice to occur under my watch. As a senior I reflect on how many vital sign abnormalities I let go, errors I let happen, and lives I let slip through my fingers.
As an ER resident, the acuity of illness is higher than other specialties and inherently the potential for medical errors. Two years ago, my naive intern-self entered residency with the goal of committing no preventable… Continue reading
As I reflect back on today, what struck me the most was the video we watched covering the tragic case of Lewis Blackman. This will likely always stay with me because I met Helen, Lewis’s mother. As she shared his life and legacy with our group, I could feel the raw emotion and pain that she had endured. No one should have to experience what she did. The tragedy is that I could see this happening again. Too often healthcare providers dismiss our patients – I was shocked and upset to learn that a nurse had rolled her eyes at Helen when she explained her concerns. Are patients ever wrong? NO! This is so obvious to me, but a lot of healthcare providers clearly don’t agree. Even if patients may not be correct in the medical sense, this is due to a lack of clear, concise patient education on the… Continue reading
Early this morning I was awakened by sun illuminated mountains outside my window and I couldn’t help but feel the energy that Breckenridge emanates. Coming out to the Telluride Summer Camp I was a bit anxious and unsure of what to expect as I have never been invited to attend such a unique program; However, after meeting everyone and spending some time in this picturesque town, my fears have dissolved.
Starting off the day with the Lewis Blackman film was emotional and so powerful for me. I’m so thankful that Helen has come out to share her tragic story with us because it really brings home the importance of patient safety and highlights so many dangerous aspects of healthcare within the hospital. As a night shift nurse, I was effected most when I learned Lewis’ nurse caring for him that weekend night knew something wasn’t right but she dismissed her… Continue reading
Today was difficult. Listening to how communication can go so wrong so quickly is intimidating. As a nurse, I thought healthcare allowed people to choose their desires. Michael and his family were never given that option. The neurosurgeon never gave them an alternative… he said this is what Michael needs to survive and that his family trusted that the neurosurgeon had Michael’s best interests at heart. I can keep going on about all the terrible things that happened, but I’m not.
We need to make a practice change. As a nurse, I’m going to start giving my patients the options to make more decisions about their care… and I’m going to start educating my patients on the healthcare system and what they can do to be informed. When I do an admission, I’m going to start asking them the tough questions- do you have a medical power of attorney?… Continue reading
What a way to start a week! I had an idea of what this week would be like, but not to the extent of the material in which it would encompass. First thing this morning, we touched on a subject that hit so close to home: the difference between the thought processes and communication processes between nurses and physicians. The first activity of the day included a video of the Lewis Blackman story. There are so many events/problems that occurred between all interdisciplinary members of the team. One of the issues being that Lewis was not admitted post op to a medical-surgical floor for post-op management/observation; rather he was transferred to an oncology unit. No matter how we are trained, if we don’t regularly treat and manage a certain population, we need refreshers on what we should be looking for, and how to manage their care.
In the video we… Continue reading
We started our week of patient safety discussions with the story of Lewis Blackman. As we watched the tragedy unfold, I felt sick watching well-meaning medical professionals ignore numerous red flags as well as the concerns of Lewis’s mother during the four days following his surgery. One quote from Lewis’s mother, Helen Haskell, stayed with me long after we finished the film and it is something I will never forget. She said if Lewis had been anywhere else but a hospital, she would have called 911 and Lewis would still be alive today. To me, this speaks to the horrifying extent to which the healthcare system has failed patients and the poisonous Wall of Silence that continues to be perpetuated. How can the place where you are supposed to be the safest be the one place where you are most isolated from the care that you need? For a person… Continue reading
What if we lived in a blame free world where everyone could openly admit to their mistakes? How would the world of health care be different if we took the time to learn from one anothers mistakes before we are doomed to inevidably repeat them?
Walking down a narrow dirt path along the water, I couldn’t help but feel dwarfed by the snow capped giants above me. Among these natural pillars of the earth, our time on this planet can feel smaller then a speck of dust. Thinking about the stories Lewis Blackman and Michael Skolnik, I began to think that in an average lifespan of 42,048,000 minutes (approximately 80 years), if we spent just a fraction of those minutes pausing to have open and honest crucial conversations with our patients, we can singlehandedly save dozens of lives over our careers before ever prescribing a medication or… Continue reading
My hope in joining the Telluride Summer Camp was to hear more patient safety issues from clinicians. How do they respond when something goes wrong? What functionalities do they expect if health information technology may help? What technology do they not like? – As poorly designed technologies may become a burden instead of being helpful. How do they learn from lessons? All of these questions mean a lot to me because I am on my way to becoming a medical informatician and a researcher who commits to improve patient safety and quality of health care through data science and information engineering.
A lesson I learned from the past three days is empathy. I told Dan the second day that ‘I am now learning to stand in a nurse and a physician’s shoes to think.’ How did I make that? I sit with fellow students and faculty watching films where… Continue reading
The films telling the stories of Lewis Blackman and Michael Skolnik served their purpose of putting faces on medical errors very well. More than once I found myself struggling, and failing, to keep my tears from running as the stories were told. It is one thing to know that hundreds of thousands of people die due to preventable medical errors each year; it is a whole other thing to observe one or two of those deaths closely as a human tragedy. One may want to reverse the order of the sentences in Stalin’s famous quotation into “a million deaths is a statistic; a single death is a tragedy”, just so as to remind oneself of how devastating each single one of those “numbers” are.
As tragic as they were, the deaths of Lewis and Michael were [arguably] not totally in vain, thanks to their dedicated families and shrewd professionals… Continue reading