Healthcare Quality

His Name was Bill

Today I had the humbling opportunity to hear stories from individuals whose lives were turned upside down as a result of medical error. They spoke with grace, conviction, and courage. They also spoke with frustration and sadness. Their stories are important and what they shared today is heart-breaking. Their stories need to be heard, not only in the medical community but also throughout the general public.

As I reflect on the many stories I have read and heard surrounding medical error and the horrifying impact these errors have had on patients and their families, I am ashamed and heart broken. We, physicians, nurse practitioners, physician assistants, nurses, assistants, enter the health care field to heal, to bring hope, and to be there to provide comfort and expertise in, perhaps, one of the darkest hours of an individual’s life. However, as medical error seeps into our interactions and creates a culture… Continue reading

Pre-Telluride Thoughts (Napa Valley, CA 2019)

Firstly, I would first like to thank the Doctors Company Foundation & the MedStar Health Institute for Quality & Safety for the opportunity to participate in this year’s Academy for Emerging Leaders in Patient Safety. As I await the beginning of the Telluride experience, I cannot help but feel a tremendous amount of excitement about the immersive learning that will be happening in the coming days. There is no mistaking the importance of patient safety. As a 3rd year medical student on the inpatient wards, I quickly became very cognizant of how challenging issues surrounding patient safety and preventable harm can be in an environment as chaotic as an academic medical center. Because of this, I always made a conscious effort to advocate for my patients, especially those who I felt were not as knowledgeable on the inner workings of our deeply complex healthcare system. Those interactions with patients were… Continue reading

Pre-Telluride Reflections

Ever since I was little, hospitals have always made me feel inherently safe; I always just felt instantaneously better being inside of one. Aside from the (I always joked) heaven-sent sign that this meant I was supposed to do something in healthcare, I attributed this feeling to it being something about how a hospital houses an institution of human beings whose collective purpose is to heal and make people better. I still feel this way (which I find to be a good sign), but I now see hospitals in a new light. Hearing stories like Josie’s at Johns Hopkins and stories of my classmates who have had loved ones harmed or killed by medical errors were heartbreaking, disturbing, and definitely jarring, but they all seemed removed from me. “Yes these things happen to others, but it’s never happened to me.” However, in these few days before the conference, I’ve been… Continue reading

Failure to Rescue: The Story of Lewis Blackman

An Interdisciplinary Viewing

As a surgery resident, I had a different reaction to the the film “The Faces of Medical Errors…From Tears to Transparency: The Story of Lewis Blackman” than some of my fellow scholars. This is absolutely the value of viewing and discussing it in such a forum, as every perspective highlights specific opportunities for improvement.

As our interdisciplinary discussion highlighted, Lewis’ death was the unfortunate result of a broken system.  Lewis was a 15 year old undergoing a new repair for pectus excavatum.  The first systems issue brought up by his mother, who remains a strong patient advocate, was the informed consent process surrounding a new “low risk” surgery.  The pectus repair was technically successful, but issues started intraoperatively.  He was making minimal urine during the case and after.  He received multiple doses of toradol, up to post-operative day #5, with minimal oral… Continue reading

En Route to Colorado: A Belated Post

While technically already in Breckenridge, I’d like to share the thoughts and key moments that led me here:

I first heard about the Telluride experience from a classmate of mine from the BU School of Public Health several years ago. The stars never aligned as far as scheduling, but I feel that I have now reached the point in my training where I want to focus my energy on the patient-centered care I entered medicine to improve. I have been exposed to patient safety events since long before I entered medical school and became part of this tribe. A great uncle was the victim of an OR fire many years ago. A close family friend and mentor went with undiagnosed and ultimately rapidly progressive head and neck cancer until persistence and a patient advocate got him to the NIH. I was taken to a urologist/chiropractor/acupuncturist… Continue reading

Safety and quality first

Having been a patient multiple times, going through surgeries and what not, I’m always anxious about what could go wrong. This anxiety sometimes translates into fear, what would happen medically, human or system errors and the outcome for me. These feelings have impacted the way I care for my patients leading to a desire to improve the patient experience by positively impacting treatment outcomes, promoting the kind of quality care I like to receive and mitigating errors that could arise from the process of care. I wanted to attend the Telluride camp to learn more about doing this. I once worked as a quality improvement consultant in a pediatric facility but the view/experience is a bit different when you are providing direct patient care vs non-direct patient care. I’m here to use my past experience and the knowledge from this camp to change my practice and drive change in my… Continue reading

Learning from the Telluride Experience.

Getting to know the histories of Lewis Blackman and Michael Skolnik, showed me how an error can affect the life of many and the wound that despite all treatments and solutions is there for the rest of their days.  Transparency, since day 1, is an important stone to set a good relation with patients and their families.

Nobody deserves a wall of silence when there is a father, mother, son, sibling, any human been involved in a medical error as Mrs. Gibson stated in our visit to Arlington Cemetery. Every soldier that rest in this place had a history well known by their bothers in arms and their families, every patient and their families deserve to know without delays all the details regarding adverse events.

The experience of Mr. Gentry, as a former negotiator, was very illustrative when comparing his former job with the effective communication tools that we… Continue reading

Telluride Experience – Day 1

Lack of communication/false assumption leads to errors:
In learning about the Lewis Blackman case, an event that directed a conversation toward communication’s ability to either prevent or impose a drastic medical error in a clinical setting, one of the events that stood out the most was the idea that nobody asked, “What is the worst thing this could be?” I work for a home health care team that aims to improve the quality of care and the patient experience by communicating patient alerts. Effective communication in my organization is essential to the effectiveness of our team. Thus, the lack of coordination and communication that was exhibited in the Blackman case struck me because, as these nurses assumed that Lewis was fine, it was these false assumptions and the lack of communicating alerts that predisposed the patient to a detrimental error resulting in the patient’s death. When you assume that the… Continue reading

On tribal hierarchy

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

Reflections Day 1: Intern vs Senior Resident

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

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Telluride Experience 2020 Dates

BRECKENRIDGE, CO:
CMF Session One*: 6/8 – 6/11
Bennathan Session Two: 6/15 – 6/18
Session Three: 6/22 – 6/25

WASHINGTON, DC/MD:
Session Four: 7/22 – 7/25

*Session exclusive to the COPIC Medical Foundation Residents.