I’ve been reflecting on the amazing experience we had at the Telluride Patient Safety Conference. I can’t help but think of it often, as it truly has changed the way I view medicine. I pause throughout the day and think about the patient’s perspective. When something powerful happens, I check in with my team. While the changes I’ve been trying to make have been slow coming, I’m comforted in the reaction from my peers. I showed the ‘Bleed Out’ documentary during one of our conferences. My peers could not believe the e-ICU and the many other shameful ways the Burrow family was treated. I will continue to be one of Jack’s bumble bees any way that I can! Keep buzzing everyone!
What the most striking aspect of the day was, of course, watching Bleedout. The perspective I had was probably very different from what others might have had, however. I work at the same healthcare organization where Judy Burrow was hurt due to medical error. As I shared with everyone, I have had a strange relationship with my work. One of the Advocate hospitals was the hospital where my dad was mistreated and we had to write letters for months to get the bill forgiven. Because of the merger, I now work at the same healthcare organization.
Steven and Margo’s journey was heartbreaking. As I commented after the movie, I was glad that he was able to record every detail as much as he could. One thing we should advise patients as patient advocates (which I believe everyone in healthcare organization should stand at the same side of the patients)… Continue reading
I had a selfish reason to suggest Regina Holliday to the planning committee of the Telluride, I should confess. It has been 10 years since Fred, Regina’s husband, has passed away and she has had her own conference a week before Telluride. She invited all jacket owners. I could not get days off in a row but I wanted to meet her so bad; we knew each other for a while and we were messaging each other regularly but never met. Knowing how close she was to the Turf Valley Resort and how wonderful she would be as a speaker, I decided to suggest the idea to Stacy, the planning guru of this camp. Regina told me she was coming after it was finalized! I was so excited and she did a wonderful job in everything she did at the conference. I am so glad I have asked and so grateful to Dr Mayer who has taken the idea. It truly made my day and kicked off the camp with a great start.
Artist’s statement about the jacket she painted for me: In this painting your father’s necktie is the periwinkle blue of the ribbon for esophageal cancer. The meaning of periwinkle is everlasting love and the beginning of friendship. Hibiscus syriacus is the flower of South Korea and it means eternity and inexhaustible abundance.
OMG! Today’s session (well technically yesterday as it is now after midnight) was very intense! We just ended our talk in the lobby with Steven and his wife about their documentary “Bleed Out”. I’d previously viewed it on HBO but seeing it again with my new (hopefully lifelong) colleagues was powerful and intense! I remember watching it at home & being so outraged and astounded by what happened to them & Judie Burrows. Her name will live on forever and has forever changed my life! I spoke with David after the viewing and I personally have a lot of soul-searching to do as I now question my own practice and values! Not my personal practice but being a part of a system that has been broken for a long time and continuing to condone such atrocities! Then yesterday hearing from Jack & Regina & about Lewis just drove home how… Continue reading
This experience has quickly emboldened by passion for patient safety. Our system is so broken and the thought of repairing it quickly becomes over whelming. It is hard to imagine that small changes can make a significant impact. I have to remind myself that it takes years and sometime decades to change a culture. Yet seeing the ideas and compassion in my colleagues gives me hope. By learning these important lessons at our stage in training, we can work to change the way healthcare functions. We can spread the word, even if slowly; it will get out. As it was beautifully put earlier today, “we must educate the young, and regulate the old.” As we emerge into the field of medicine, I am confident we will make a change. I hope that each of us will be advocates for that change and through our work inspire others. It is disheartening… Continue reading
It has already been a week since my time in Napa came to a close, but I find myself continuing to reflect on all that I have learned. I was speaking with Helen on our last day when I told her that the Telluride Experience was truly life-changing. Although that may sound dramatic or hyperbolic, I believe that I will practice medicine differently now that I’ve attended the Academy. I am so fortunate to work at MedStar Georgetown where patient safety is a priority, full disclosure is encouraged after a medical error, and safety initiatives are being implemented continuously. The biggest change I anticipate moving forward, therefore, is within myself. Having met Helen, Jack, Teresa, Carole, and Steve – hearing their stories and speaking with them afterwards – I can no longer be complacent about patient safety because I can now place a name and face to medical error. The… Continue reading
The Telluride Experience is a revolution in healthcare safety.
An evolution to a culture of safety can only occur when all health professionals, with no exception, receive the training, knowledge and skills that the Telluride Experience has to offer.
There were several highlights from Day 1, including Mr. Gentry’s story and Regina Holliday’s, who both exhibited and it appears for years have shown a great courage in telling their stories. I am floored by their candor, their willingness, and the composure with which they share what happened to them, and what they have been able to do about it since.
But yesterday, the idea that stuck with me the whole time was ‘Premature Closure.’ I struggled with the idea and what it truly encompasses throughout the afternoon since the Lewis Blackburn story. To me, my initial thoughts were that it was similar to Anchoring Bias, where clinician hunker down on the initial working diagnosis and don’t properly consider alternative diagnoses. That’s something that I have seen time and time again as a physician trainee – medical school, Internal Medicine, and now GI. I know I have certainly been guilty… Continue reading
In my personal nursing practice, and as an adjunct clinical instructor, patient safety is the foundation in providing quality patient care that leads to optimal outcomes. I was lucky enough to be involved last spring in the implementation of a fall bundle reporting form which allowed me to see how informatics can be incorporated into patient safety data gathering to make well educated process improvement. I was also involved in implementation of the Nurses Improving Care of Healthsystem Elders (NICHE) recommendations to help in the safety of elderly patient’s experiencing delirium in acute care. Patient safety is the basis of my clinical teaching with nursing students to ensure their abilities to identify, evaluate, assess and make implementations to keep their patients safe.
The opportunity to learn and interact with multiple disciplines would be stimulating and is imperative to the development of improved patient safety outcomes. I would look forward to… Continue reading
I recently completed my night senior rotation—it’s one of the few times in pediatric residency where residents can function fully autonomously, without a full team, attending, and all the resources that are present during the day. While adjusting to a fully nocturnal schedule for several weeks can be difficult, there is a lot of personal growth that happens during those few weeks. Being alone in the hospital overnight is an interesting experience—it is less insulated, and the “system” as a whole becomes more obvious. I wouldn’t say that errors tend to occur more overnight, but being the primary person responsible for my team made me question things more. I approached each problem that arose with a higher level of scrutiny—wondering how it happened, if I missed something, and if it could have been avoided. I dealt with many patient safety issues —from patients being escalated in support shortly after being… Continue reading