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
Throughout today’s discussion various moments truly hit home to me, especially in regards to communicating with patients and families. People come to hospitals often in their most dire time of need, not to simply chat and sip coffee. Stress, fear, anger, and uncertainty mar the face of these individuals, leaving them to appear disfigured in comparison to their standard facade…leaving them at their most vulnerable. As healthcare workers it is our duty to identify that these people are hurting and understand that communication can assist in stopping the hemorrhage of “what if’s” and begin to help with the healing process.
Bringing to light that it is normal for individuals to have questions, I feel, is so important. As it was examined today, asking patients and families “what concerns you?” or “what bothers you about this?” truly provides an opportunity for individuals to stand up for themselves without feeling the pressures… Continue reading
I needed a few days after being at Telluride Summer Camp to let the experience settle in. It was a whirlwind of heart-wrenching stories, connections, and thought-provoking discussions. As a second-year resident, I came to Telluride with the baggage of a traditionally difficult intern year, with the baggage of having lost my grandfather due to a multitude of systematic medical errors, and the viewpoint of having been a nurse prior to medical school. I needed to see a room full of people that don’t accept the phrase, “that’s just the system we’re in.” I had grown tired and had half-way accepted that answer, so it’s amazing to see the influence that a group full of inspired professionals can do. Every time I spoke to someone new I was blown away by their dedication and drive. Every person in that room, from all types of training… Continue reading
Today we discussed Michael Skolnik’s story and really touched on the process of informed consent. As a nurse I am a witness of informed consent and I have been identified by some as to “who not to ask to be a witness to an informed consent” form by some physicians in my practice. Often times, as many of the residents in the program identified, informed consent is one of the many tasks that physicians have to check off their list throughout the day. First off, I will not sign an informed consent if I was not in the room during the process of obtaining an informed consent. I also want to make sure the patient’s, or their families/POA, are able to state the procedure in their own terms, and every risk or benefit that accompany each procedure. If they cannot, I will have the physician restate or rephrase whatever part… Continue reading
Telluride – a retreat that gives us the gift of taking us out of time and space to examine the state of health care and to connect to a deeper place where ideas and visions are planted that will blossom into reality one day….hopefully soon.
This is my fifth summer as faculty with The Academy for Emerging Leaders in Patient Safety. Not being a healthcare professional, I feel honored to be able to contribute my skills to supporting the next generation as they grow into the healthcare leaders of tomorrow.
Today I was struck by the intelligence of the medical students, nurses, residents and others as they collectively delved more deeply into identifying what needs to change and how they can partake in transforming healthcare…to make it safer, more humane and more efficient. They explored how they can harness their personal best to make the systemic changes that must… Continue reading
After two full days of Telluride East 2016 I am left with numerous thoughts and emotions that I am still processing. One of the most prevalent is one of support – being around like-minded people who speak my thoughts and share my concerns about where healthcare is and where it needs to be. As a non-clinician (healthcare administration) I sometimes feel like an outsider, yet here I am accepted with open arms and my ideas are highly valued. The ideas of partnership in this safe space give me hope for the possibilities outside these walls. I find myself nodding to nearly every comment that is made as I realize truly how similar we view the world around us and see the room for improvement still to be made.
Yet I am nervous…we are here because we share a passion for quality… Continue reading
It was a good day today. It was refreshing to be around so many other people who are passionate, open, and honest about quality improvement and patient safety. There are definitely times at my home institution where I feel like I am the shirtless man trying to make my silly dance a movement. A movement for others to be so excited about improving safety they come running down the hill to join the dance with enthusiasm. Hearing the stories of patient harm that have occurred make me want to pass on the importance of quality improvement and patient safety. That whether we mean to or not we are in positions to potentially kill patients everyday and without safeguards in place it isn’t a matter of if it will happen, but when…and will you be the one to do it? I have enjoyed all the… Continue reading
When I first thought of the title for my post, “More than what I bargained for”, I was specifically reflecting on the activities and learnings of the course yesterday, but as I am cuddled up in a robe from the world class whirlpool I enjoyed in the Spa this morning after my run I couldn’t help but thinking this resort is so much more than I bargained for also. As well as the town–last night we enjoyed an outdoor showing of Jurassic Park under the stars. There will be a lot of unforgettable memories added to what we learn here.
Reflecting on the conference portion of yesterday, I clearly came here expecting to learn about patient safety, which of course I am through the Telluride curriculum. However, thanks to the experience of all my fellow classmates I am also learning so much about how hospitals work, orders are made,… Continue reading
Great experience..Exceptionally well rounded training for building the future leaders like us..through the out the day one I was overwhelmed with tragedy faced by Lewis Blackman’s family. One of our attending once told us..” Hospitals are dangerous places over weekends”.. This incidence just gave the glimpse of it..enthusiastic and brain storming discussions filled the entire day..This is really preparing us to think through the process and find solutions for this growing prproblem of medical errors. Second day took us further in depth of this patient safety issues and need for culture change. I had been doing a lot of introspection about my experience in US healthcare system all these days..see,s like “healthcare reprogramming” is the best solution here. This work shop is preparing us for upcoming challenges.
The exciting part of this workshop is making new friends from different places and different specialities who are in various different levels… Continue reading