To say today was educational, informative, and life-changing would be an understatement.
Before the conference we were instructed that we would be introducing a fellow conference attendee at an icebreaking event. We were encouraged to email and get to know one another in order to provide a concise yet effective introduction. My partner and I had many interests and motivations in common- we are both from Oklahoma, we both are interested in mastering the skills necessary to become patient safety advocates, and, perhaps most importantly (or most movingly), both of us have lost a grandfather to an avoidable medical error. In our introduction we both shared this information with the group which I felt made the group more tight-knit because of the personal connections that echoed throughout the room- it seems everyone in some way has been directly affected by an adverse medical outcome. The camaraderie I felt after sharing… Continue reading
As I was born and raised in Nepal, I felt like I will not have problem being in this altitude. But I soon realized I was so wrong, I was out of breath after few steps uphill. I also began to appreciate how well maintained Telluride the town is. If places in my country were managed or organized this way, we could probably do so much better with tourism industry and move our country in right direction. But what I wish, what general people wish and expect are not fulfilled because we do not have good leaders at the top, we do not have resources, and the influence of surrounding countries do not make it easier either. When I look at health care industry here in the States, I feel like it is the same way: patients want everything to go perfect, and healthcare providers wants the same end results… Continue reading
“I’m a little obnoxious sometimes,” claimed Dan Ford this afternoon discussing his fervent advocacy of root cause analyses in response to sentinel events. Earlier that morning, Mandy too had confessed to being “that annoying nurse” who unabashedly telephones on-call residents when a concern arises. These champions of patient safety proudly own these deprecatory adjectives like “obnoxious” and “annoying” because they know that their actions are challenging the status quo for the betterment of patient care.
It is my hope that all of us, students and professionals alike, emerge from this week in Telluride a bit more enthusiastic about being obnoxious. To be “obnoxious” in this context is to put our patients’ needs first in spite of a bruised ego. We “annoy” despite the fear of openly defying the medical culture’s norms, and we “irritate” others because we have the courage to understand that it will take assertive individuals to lead… Continue reading
This week we repeatedly discussed how hospital safety culture must learn from high reliability organizations (HRO’s) such as the airline industry, nuclear power plants, and aircraft carriers. Just before my 90 minute shuttle from Telluride arrived at Montrose airport, I received an email communication from United Airlines notifying me that my flight had been cancelled due to “aircraft maintenance.” Unfortunately, the next flight out of Montrose would not be until ~6am the following morning. In the past, I would have been rather disgruntled with the airline and likely would have projected my anger and frustration onto the check-in staff over the cancellation much like the two gentlemen at the counter next to me. However, after our discussions of HRO’s and reading John Nance’s Why Hospitals Should Fly, I was disheartened at first knowing it would be one more day until I got to see my fiance and dog… Continue reading
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
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):
— 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
Telluride is beautiful – leaving me breathless. First day of programming was packed with goodies. Lots of great discussion – respect for everyone who shared their thoughts – fellow residents, teachers, and patient families. For me, it was my intro to twitter – which I’d signed up for but never used. Check out @edcountydoc which I took to throughout the day with thoughts. Some are shared here.
One tweet that received no love was my tweet on handoffs. We are always so focused on the number of handoffs that we point fingers at the number and poor quality of handoffs as a major reason that errors and patient safety have not improved since work hour restrictions. However, I think this is a correlation and not causation. The thing that never comes up is that handoffs are not usually 1:1. During the day, there are multiple teams on duty. For… Continue reading