Communication, teamwork, team-coordination – all buzzwords of patient safety and improved healthcare system performance. But does everyone truly know the meaning of these terms? We were presented a case study today in which an experienced and revered surgeon encouraged his surgical team to break protocol by closing a patient when the sponge count was off by one sponge. The surgeon cited, with amiability, the length of time under anesthesia as the urgency for ending the procedure before the missing sponge was accounted for – and rightly so, as longer times under anesthesia are associated with decreased patient outcomes. However, so are surgical materials left in patients. The concerned team deferred to the surgeon’s congenial and persistent request for the sutures to close the patient.
At first glance, this team could be considered to have some of the above qualities: they communicated about the missing sponge, they coordinated a course… Continue reading
Today- the first day at Telluride 2014 – was filled with stories. I expected lessons on safety and quality, but the teaching was much more organic. We heard incredible, emotional stories that left many us of us jarred, uncomfortable, and often in tears– especially Helen Haskell’s story. As a new parent myself, the idea of the loss of a child is incomprehensible. Today’s teaching came out of our own reactions to the difficult stories we heard as a group. My takeaway today goes back to Paul Levy’s book and the concept of going to Gemba — the “actual place.” As I finish up my PGY-1 year and think about all of the very sick patients I cared for, I realize the importance of physically being in the place of importance– the bedside. So much of my work this year has been away from the bedside, reviewing charts and entering orders,… Continue reading