With each day, I feel empowered, engaged, and energized about patient safety and quality improvement. I am reminded on why I chose nursing as a career and my desire to assist vulnerable populations and serve as a change agent in healthcare institutions.
I found the discussions involving the power of storytelling and cognitive interviewing especially interesting and thought provoking. In particular, I was struck by the story of the physician pulling out the central line and the complications that followed due to lack of protocol, training, and a general health system malfunction. I focused a lot of my reflective analysis day one on the sense of powerlessness and vulnerability patient and families can feel while navigating the healthcare system. However, an essential component that was highlighted today was how the healthcare system can isolate and set providers up for failure. Oftentimes, the culture in institutions does not allow for providers… Continue reading
I was grateful to hear from the exceptional faculty members and fellow emerging leaders during this first day in Napa, California.
There were several themes mentioned throughout the day that resonated with me as a nurse in the PICU and family nurse practitioner student. The discussions today focused upon the isolation family members can feel while navigating the complex healthcare system. My question that I continue to reflect upon is, how can healthcare professionals (residents, nurses, pharmacists, etc.) begin to address this sense of isolation and inaccessibility between provider and patient? The answer will take a collaborative and focused effort to change culture, systems, and attitudes. Reflecting upon my own practice as a pediatric nurse and future family nurse practitioner, I believe a crucial first step is listening to the patient or patient’s family. Helen Haskell’s and Carole Hemmelgarn’s tragic stories remind all providers that one must never discount a… Continue reading
The first day was emotional and thought-provoking. The video about the family whose young child died was particularly emotional. To a certain extent, I had always accepted that if a loved one were in the hospital I would need to be with them or arrange for someone else to be with them to keep them safe. I had also assumed that if I were with them or someone else was with them, they would be safe.
This family was taking the actions that I have always thought of as the security blanket or insurance- the things that would just make absolutely sure that a loved one was safe while receiving care. They were advocating for their child, asking for help, and had knowledge of the healthcare system and this still happened to them. This story made me think about how much more challenging and risky it is for patients who… Continue reading
Today we talked about just culture. We talked about the importance of leadership. The quote I will take with me from today’s presentation, “having the kind of leadership and leadership not being about punishing and blaming but about using every single instance of anything gone wrong as a process of learning from the event.” I want to take this quote with me, and remember about the leaders I admire as they lead by example. Often it is easiest to blame the person or the problem, but often discovering the problem is easy. But what are we doing to fix the problem? How can we, as individuals, go about a resolution to a problem alone? Instead of doing it alone, don’t look at one part of the process to blame, but instead the systems that were established, that don’t prepare us with the tools to succeed. We must come together; analyze… Continue reading
Today we discussed Michael Skolnik’s story and really touched on the process of informed consent. As a nurse I am a witness of informed consent and I have been identified by some as to “who not to ask to be a witness to an informed consent” form by some physicians in my practice. Often times, as many of the residents in the program identified, informed consent is one of the many tasks that physicians have to check off their list throughout the day. First off, I will not sign an informed consent if I was not in the room during the process of obtaining an informed consent. I also want to make sure the patient’s, or their families/POA, are able to state the procedure in their own terms, and every risk or benefit that accompany each procedure. If they cannot, I will have the physician restate or rephrase whatever part… Continue reading
As many of us begin our regular summer pilgrimage to Telluride, Colorado, it is hard to believe that thirteen years have passed since a small group of passionate healthcare leaders came together in Telluride to design a comprehensive patient safety curriculum for future healthcare leaders. As a result of that work, many wonderful and highly committed patient advocates and safety leaders will once again convene in Telluride the next two weeks to continue our mission of Educating the Young. For those not from Colorado, summertime in Telluride may be one of the best kept secrets in the United States. Be it the old west feel of the town, or the hypoxic “magic” that happens at an elevation of 9,500 feet, Telluride has always been an educational mecca for everyone that joins us during these memorable weeks of high altitude learning led by the MedStar Institute for Quality and Safety and… Continue reading
Today’s post is by Guest Author, John Nance, Telluride Experience Faculty, Author and ABC Aviation Consultant
Having had the delightful experience of attending and working with all of the sessions of the Telluride Experience this summer, I’ve spent some time since returning from Napa thinking through the scope and the effectiveness of what we all came together to advance: The goal of never again losing a patient to a medical mistake or nosocomial infection.
It may well sound hackneyed, but in fact I think all of us as faculty mean it to the depth of our beings when we say that the medical students and residents and nurses – all of those who joined us – are truly the best hope of changing the course of a noble but tattered non-system that slaughters people at the rate of 50 per hour. That does not mean that existing healthcare professionals cannot… Continue reading
Health care fascinates me. As a field dedicated to alleviating suffering through service to fellow people, you would assume that providers would be compassionate towards all and work towards helping all. Through conversations with fellow medical students and partner nursing students, I received a much deeper understanding of the realities of the inequities faced and perpetuated by health care providers from different professions. The historically paternalistic roots run deep and persist to contribute to the damage inflicted on those who receive care as well as those who provide it. Are we, as health care professionals, able to serve those who need us most when we can’t even take care of each other?
Contradiction 1: Doctors put nurses down and nurses resent doctors. Doctors put newer doctors (in-training) down and those trainees suffer – personally and professionally. Nurses cause trouble for newer (in-training) nurses and those nurses suffer. The cycle… Continue reading
I really enjoyed all of my experiences today. I took tons of notes. A grouping of notes was for my nursing students. There is so much I want to share with them. I think I do a pretty good job about reminding them that the patients are human beings and they should call them by name, not by room number. I let them know right away there is no dumb question or concern. I now realize that this is their first lesson in feeling empowered to ask questions and speak up. I am going to be sure to use that word specifically now. I also like to have my students look at vital signs and lab results overtime for comparisons and trends. This will definitely be something I reiterate.
Some new concepts that I would like to talk to them about is remembering to ask themselves: does this make sense?… Continue reading
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