Medical Error

Questions > Answers

I told a colleague I would be out for a week to attend a patient safety conference, and her first comment was, “Oh, is that a particular interest for you? Patient safety?” As a student training to work with patients as a career, I couldn’t understand how any topic with the word ‘patient’ in it had the option of being an interest. Whether I liked it or not, I needed to know it and figure out how to make it an interest because it would be the main focus of my career.

From the opening remarks of the Telluride Experience, it was clear that whatever level of interest I had in patient safety prior to the conference would be exceeded as it has now consumed my thinking. It was the perfect riddle. Everything seemed to contribute to it and lack of something reduced it. Everyone needed to be aware of… Continue reading

Tomb of the Unknown Patient

By Roger Leonard, MD

I am grateful to Rosemary for eloquently guiding our visit to Arlington Cemetery – the visual images and mental reflection. I saw the changing of the guard at the Tomb of the Unknown and found another Tomb of the Unknowns for Civil War soldiers where 2111 remains were buried together. I thought of a Tomb of the Unknown Patients. How many patients did I harm during my 40 years of practicing internal medicine and cardiology for whom I am clueless?

Why am I clueless? Like many peers in my generation of physicians, I viewed complications as an acceptable risk in the care we provided. Indeed, by explaining those risks to patients & families, we may have felt absolved. I participated on many peer review committees and this was a common thread, rather than carefully analyzing the medical record and the details of our actions. Were there… Continue reading

The power of story

Storytelling is a great way to learn , connect, empathize and remember about an iincident for a lifetime. When we look at just statistics or plain charts and data, even though they draw your attention with regards to severity of a given situation they however fail to leave a lasting impression. This maybe because They present a very impersonal account. However, when someone tells you a story, they draw you a picture with words, they convey the strong emotions they have undergone and draw you into their lives by sharing something very personal and private. They not only connect to your heart and gut but also leave a mark on your mind.

We kicked off our event with two powerful stories told by the surviving mothers of two patients who were victims of sentinel events. These stories were excellent learning opportunities. They were scary, but yet inspiring to do a… Continue reading

Council of the Safety and Quality Jedi

Over a decade ago, our nation’s healthcare sector was in upheaval following the disclosure of the Institute of Medicines report on deaths due to medical errors (IOM, 2000).  In response, a Jedi warrior with a passion for patient safety education determined that someone needed to bring like-minded warriors together to discuss the plight of healthcare in America. Contemplating the vast need to join forces with other patient safety Jedi masters, the warrior identified and invited select masters to the table. In 2004, select Jedi made their way to a remote mountain in Telluride, Colorado. Over five long days and nights, each member of the Jedi council shared their knowledge and experience at the Telluride Roundtable. As the council members engaged in open conversation and consensus building, the initial plans for the rebellion against medical error became a reality.  As each member shook hands and agreed to meet again… Continue reading

The black box and improving informed consent

This was another educational and emotional day for me at the Telluride QI/PS summer camp. The first part of the day was focused on informed consent and shared decision making. I was moved to tears watching the story of Michael Skolnik and am so thankful to his parents for sharing their story with us.

It really got me thinking about the appropriate use of the informed consent document and how poorly we often counsel and consent our patients for complex and dangerous procedures.

In Michael’s case we will never know what transpired between him and the surgeon on the day he was consented for that second procedure. But Michael is not the first nor will he be the last patient who cannot tell us whether he received and understood all the necessary information to make an appropriate decision about such an invasive procedure.

Should we as physicians be relying on… Continue reading

Failure to Escalate by Jillian Fickenscher

Failure to escalate. That is one of the many concepts in Patient Safety that stood out to me today during the first day of our conference. I find this concept especially challenging in the environment of academic medicine. Unfortunately, a hierarchy as well as “tribes” or “silos” still do exist, as this has been so long-engrained in the culture of academic medicine. And this culture may often create a barrier to escalation.

I found myself thinking back to my first night of cross-covering the Family Medicine inpatient service at one of the community hospitals where our residents work. This hospital is a bit different than the University Hospital where there is always both an intern and a supervising resident in-house, and access to multiple specialists at all times. Because this is a smaller, community hospital, there is one resident (that night –me!) covering all the patients on our service, including… Continue reading

We are clinicians, and we are human

To err is human, and to fail to recognize our humanity is disastrous. It think this recognition is at the core of what we’re talking about this week. One of the reasons that I’ve seen people being resistant to QI is because they are afraid that QI and patient safety interventions are making clinicians more “robotic” by introducing standardization and guidelines. Really though, I cannot think of a field that is trying harder than Patient Safety to get clinicians to recognize and accept themselves as human beings capable of error, empathy, creativity, mistakes, and brilliance.

We are all capable

Of humility. We began our second day in Telluride discussing disclosure of medical errors to patients and families. Recognizing our humanity in this situation is being able to admit failure, learn from it, and be humble enough to accept its consequences. That humility will allow us to tell patients and their… Continue reading

Search and Rescue

Today was the first official day of 11th Telluride Patient Safety Camp and it far exceeded any expectations I might have had. From the moment I sat around the fire outside of our beautiful lodge nestled in the jaw dropping landscape that makes up Telluride, I was sold. The enthusiasm of everyone around me, the great conversations and the energy radiating off of this group of people all excited to be here learning from some of the best in patient safety as well as from each other tipped me off that this is going an unforgettable experience in my medical career.

After hopping on the gondola and experiencing one of the best morning commutes I could imagine, we settled in for a day filled with thoughtful discussion, heart wrenching stories and collaborative learning. Unlike many of my colleagues here, I have a very limited background in quality improvement and… Continue reading

What’s the Worst Thing It Could Be?

To kick off our Telluride experience, today we watched Helen Haskell recount the tragic story of her son’s death at the hands of the healthcare system in From Tears to Transparency: the Story of Lewis Blackman. While watching the film, Dr. Tim McDonald offered a great pearl of wisdom about arriving at a diagnosis. He said to always ask “what’s the worst thing it could be?” when piecing together a clinical puzzle in order to avoid premature closure and confirmation bias. As a rising second-year medical student, this advice resonates with me and I will carry this story and this advice with me as an example of how things can go awry when we lose sight of the importance of keeping an open mind and looking at all of the clinical clues.

I think Dr. McDonald’s advice rings just as true is in the realm of team… Continue reading

I Am a Doctor

I am a doctor. I save lives. Sometimes, by accident, I take them. I fight off bad infections. I spread worse. I do no harm. I do no good. I order the right tests and the wrong ones. I do only what is necessary, then do more. Maybe I do less. I care for the individual. I care for their lab values. My care is evidence based and defensive.

I am a physician. I am the new guard and the old. I am bright eyed, optimistic, jaded and bitter. I have integrity and prescribe the drug rep’s newest candies. My patient’s autonomy knows no bounds, nor has my paternalism found its limit. I admire. I condescend. My patients are wise fools. I welcome their questions and scorn inquisitiveness. I listen to them. I don’t. I have the utmost respect for nurses when I dismiss their assessments. My patience is exemplary,… Continue reading

Telluride Experience 2021 Dates

BRECKENRIDGE, CO:
CMF Session 1*: 8/23 - 8/26
TDCF Scholars Session 2: 8/30 – 9/2

*Session exclusive to the COPIC Medical Foundation Residents.
 
ELLICOTT CITY, MD:
Bennathan Scholars Session 3: 9/9 - 9/12
 
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