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
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
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
We are just back to our condo after a wonderful family dinner of resident scholars and faculty. Like family, at any one time along the big tables we were giving each other a hard time, laughing, problem solving, enjoying the moment and deciding how we want to act when we are “grown up” by the example of our elders. Today we came together as a group. It was also the first day I have thought that I wouldn’t be alone in my undertakings after Telluride. In conversation, I heard friends express the same sentiment: It’s going to be easier going forward knowing that everyone else is out there doing this work, too. It is easy to feel like you’re on an island when you’re in the thick of a project nobody else seems to prioritize. Keeping in touch after this week to both stay motivated and to not lose… Continue reading
The article Dave Mayer shared today, Check a Box. Save a Life: How Student Leadership Is Shaking Up Health Care and Driving a Revolution in Patient Safety, is a motivating reminder that we all can can make a difference in healthcare starting today. Don Berwick’s idea of a “Sprint” to Safe Care is exciting and even more so as Twitter, YouTube, blogs and Facebook extend networks into places we all have only dreamed about going. His combined effort with Atul Gawande and students across the country to improve surgical care is summarized in the following YouTube video.
What is it you want to change most in healthcare for the good of your patients? Can even a small part of that be accomplished in 90 days? In 180 days? In a year? Why not create our own Telluride Sprint to Safety? Let’s reach out to our social and professional networks… Continue reading
I really would like to say thanks to all those who made my week learning about patient safety possible. Certainly David Mayer and Tim McDonald need to be thanked for all of their work in setting up this past week, but all the faculty and facilitators need to be commended. Thanks again, Shelly, Ric, Allen, Barbie, Jill, Paul, Bruce, Carol, Harry, Tracy, Bill, Jeff, and anyone else I may have left out!
I’ve been think a bit more about the role of technology in patient safety. I am certainly of the mindset that technology ideally serves us to make the world we live in a bit more manageable, to make our lives easier, and to provide solutions to common problems. This blog is a useful example of how information can more easily be transferred to a larger audience who share common interests. I was struck… Continue reading
Today was the midpoint of our Telluride Roundtable on “Open and Honest Communication Skills in Healthcare”. After two full days of discussion, discovery and curriculum building, many participants shared a group hike up the mountain to Bear Creek waterfalls. The scenery was magnificent and the two-hour climb provided hikers a great opportunity to reflect on the first two days of work while continuing discussions on open and honest communication issues before reconvening in our classroom for the afternoon working session. Participants were still feeling the excitement and energy generated from Tuesday’s sessions on shared decision-making and open disclosure education.
Our afternoon session focused on newer information technology (IT) platforms that could support open and honest communication skills in healthcare. After discussing the impact of informatics on patient safety (both positive and negative), discussion turned to how IT can support (and not replace)… Continue reading