What if we lived in a blame free world where everyone could openly admit to their mistakes? How would the world of health care be different if we took the time to learn from one anothers mistakes before we are doomed to inevidably repeat them?
Walking down a narrow dirt path along the water, I couldn’t help but feel dwarfed by the snow capped giants above me. Among these natural pillars of the earth, our time on this planet can feel smaller then a speck of dust. Thinking about the stories Lewis Blackman and Michael Skolnik, I began to think that in an average lifespan of 42,048,000 minutes (approximately 80 years), if we spent just a fraction of those minutes pausing to have open and honest crucial conversations with our patients, we can singlehandedly save dozens of lives over our careers before ever prescribing a medication or… Continue reading
One of the phrases from Telluride that stuck with me the most was the idea of creating a “culture of safety.” To me, this epitomizes the teamwork that every care team should have to optimize patient care. One of the most difficult aspects of medicine is the rigid hierarchy – as a medical student, I generally feel uncomfortable correcting residents or attending physicians if I notice something that strikes me as odd, such as not adhering to proper protocols. In a culture of safety, the hierarchy disappears – everyone on the team is responsible for the well-being of the patient, and everyone should be encouraged to speak up.
After I returned from Telluride and was working on a project where I was observing hand hygiene in the ICUs, I kept the “culture of safety” in the forefront of my mind. I noticed when students and nurses were encouraged to speak… Continue reading
Telluride – a retreat that gives us the gift of taking us out of time and space to examine the state of health care and to connect to a deeper place where ideas and visions are planted that will blossom into reality one day….hopefully soon.
This is my fifth summer as faculty with The Academy for Emerging Leaders in Patient Safety. Not being a healthcare professional, I feel honored to be able to contribute my skills to supporting the next generation as they grow into the healthcare leaders of tomorrow.
Today I was struck by the intelligence of the medical students, nurses, residents and others as they collectively delved more deeply into identifying what needs to change and how they can partake in transforming healthcare…to make it safer, more humane and more efficient. They explored how they can harness their personal best to make the systemic changes that must… Continue reading
Patient engagement is crucial for helping patients to make informed decisions about their own healthcare. Transparency in communication through full disclosure of risks and adverse events will help improve patient outcomes and deliver patient centered care.
The second day at the Maryland/DC session was engaging and focused on some patient safety issues for providers to consider. The first half was on the importance of informed consent and shared decision making. The Michael Skolnik story and Lewis Blackman story shed light on the failures of medical staff to focus on the patients’ needs, values, preferences and goals. The main takeaway from the film discussion was that shared decision making is not an event, but a process. One single medication error may or may not result in patient harm, but almost all medication errors are considered as preventable with proper information sharing. It is also important for the medical staff to to… Continue reading
After two full days of Telluride East 2016 I am left with numerous thoughts and emotions that I am still processing. One of the most prevalent is one of support – being around like-minded people who speak my thoughts and share my concerns about where healthcare is and where it needs to be. As a non-clinician (healthcare administration) I sometimes feel like an outsider, yet here I am accepted with open arms and my ideas are highly valued. The ideas of partnership in this safe space give me hope for the possibilities outside these walls. I find myself nodding to nearly every comment that is made as I realize truly how similar we view the world around us and see the room for improvement still to be made.
Yet I am nervous…we are here because we share a passion for quality… Continue reading
It was a good day today. It was refreshing to be around so many other people who are passionate, open, and honest about quality improvement and patient safety. There are definitely times at my home institution where I feel like I am the shirtless man trying to make my silly dance a movement. A movement for others to be so excited about improving safety they come running down the hill to join the dance with enthusiasm. Hearing the stories of patient harm that have occurred make me want to pass on the importance of quality improvement and patient safety. That whether we mean to or not we are in positions to potentially kill patients everyday and without safeguards in place it isn’t a matter of if it will happen, but when…and will you be the one to do it? I have enjoyed all the… Continue reading
In today’s session, we discussed a number of topics ranging from dealing with communication problems to establishing the importance of placing patient safety as a core value, and not simply a priority as John Nance stated. What struck me most is that although we emphasize the strength in the power of one, there lies the opportunity to synergize our collective powers of one to become a new power of a united front. When examining the aviation industry and the reasons why it successfully turned its practices around to establish validated checklists and ensure customer safety for thousands of flights every day across the globe, one can find at its core the agreement between the leadership down through the staff that safety is at the forefront of all future decisions. Changes had to be made and over time, the leadership agreed, united and came together to tackle a monstrous task. Unfortunately… Continue reading
So often we are confronted with the question of whether to over or under communicate. Medical professionals are scrutinized for rushed care and poor lapses in judgment in deciding how to prioritize one patient’s matters over the others. In Day 1 of the 2016 Telluride Experience, there was clearly the spirit of a willingness to ask more questions and clarify when instructions or statements were unclear. Unfortunately, this is not necessarily as easily translatable into the clinical setting of our current medical reality. It is a shame that throughout our education before college, teachers, mentors, coaches, and parents would teach us to ask questions and to use our imaginations in the most explorative ways possible. But as we age, we let the experience, medical hierarchies and societal pressures prevent us from doing something so natural to us, asking a question and simply speaking up. From when do we let the… 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 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