::SIGH:: As a graduate student who does online blogging daily it is rare that I don’t know how to start a discussion, today is the exception. There are so may factors that I want to touch on;
After hearing Lewis’ story, the shock of Carol’s daughter, Alyssa, and then the movie ‘To Err is Human’ I am left very frustrated and almost helpless. It’s overwhelming… Continue reading
Firstly, I would first like to thank the Doctors Company Foundation & the MedStar Health Institute for Quality & Safety for the opportunity to participate in this year’s Academy for Emerging Leaders in Patient Safety. As I await the beginning of the Telluride experience, I cannot help but feel a tremendous amount of excitement about the immersive learning that will be happening in the coming days. There is no mistaking the importance of patient safety. As a 3rd year medical student on the inpatient wards, I quickly became very cognizant of how challenging issues surrounding patient safety and preventable harm can be in an environment as chaotic as an academic medical center. Because of this, I always made a conscious effort to advocate for my patients, especially those who I felt were not as knowledgeable on the inner workings of our deeply complex healthcare system. Those interactions with patients were… Continue reading
Ever since I was little, hospitals have always made me feel inherently safe; I always just felt instantaneously better being inside of one. Aside from the (I always joked) heaven-sent sign that this meant I was supposed to do something in healthcare, I attributed this feeling to it being something about how a hospital houses an institution of human beings whose collective purpose is to heal and make people better. I still feel this way (which I find to be a good sign), but I now see hospitals in a new light. Hearing stories like Josie’s at Johns Hopkins and stories of my classmates who have had loved ones harmed or killed by medical errors were heartbreaking, disturbing, and definitely jarring, but they all seemed removed from me. “Yes these things happen to others, but it’s never happened to me.” However, in these few days before the conference, I’ve been… Continue reading
I have to admit, I was skeptical when I was first asked to attend this conference. As a psychiatry resident in my last year of training I have been confronted on a daily basis by patients placing themselves and others in unsafe environments and situations. Between seeing patients who heavily abuse substances and then get into arguments with loved ones or god forbid get into a car, to patients who shun the comforts of home because of profound paranoia about their home environment, I have always thought of the hospital as a safe place for psychiatric patients.
However, on a daily basis we are faced with a patient population who all to often cannot advocate for themselves or when they attempt to do so are written off or unfortunately flat out ignored. In a bigger way, patient safety is integral to good patient care because by allowing our patients to… Continue reading
An Interdisciplinary Viewing
As a surgery resident, I had a different reaction to the the film “The Faces of Medical Errors…From Tears to Transparency: The Story of Lewis Blackman” than some of my fellow scholars. This is absolutely the value of viewing and discussing it in such a forum, as every perspective highlights specific opportunities for improvement.
As our interdisciplinary discussion highlighted, Lewis’ death was the unfortunate result of a broken system. Lewis was a 15 year old undergoing a new repair for pectus excavatum. The first systems issue brought up by his mother, who remains a strong patient advocate, was the informed consent process surrounding a new “low risk” surgery. The pectus repair was technically successful, but issues started intraoperatively. He was making minimal urine during the case and after. He received multiple doses of toradol, up to post-operative day #5, with minimal oral… Continue reading
While technically already in Breckenridge, I’d like to share the thoughts and key moments that led me here:
I first heard about the Telluride experience from a classmate of mine from the BU School of Public Health several years ago. The stars never aligned as far as scheduling, but I feel that I have now reached the point in my training where I want to focus my energy on the patient-centered care I entered medicine to improve. I have been exposed to patient safety events since long before I entered medical school and became part of this tribe. A great uncle was the victim of an OR fire many years ago. A close family friend and mentor went with undiagnosed and ultimately rapidly progressive head and neck cancer until persistence and a patient advocate got him to the NIH. I was taken to a urologist/chiropractor/acupuncturist… Continue reading
Having been a patient multiple times, going through surgeries and what not, I’m always anxious about what could go wrong. This anxiety sometimes translates into fear, what would happen medically, human or system errors and the outcome for me. These feelings have impacted the way I care for my patients leading to a desire to improve the patient experience by positively impacting treatment outcomes, promoting the kind of quality care I like to receive and mitigating errors that could arise from the process of care. I wanted to attend the Telluride camp to learn more about doing this. I once worked as a quality improvement consultant in a pediatric facility but the view/experience is a bit different when you are providing direct patient care vs non-direct patient care. I’m here to use my past experience and the knowledge from this camp to change my practice and drive change in my… Continue reading
What to say….what a powerful day, full of emotions. Today and yesterday were difficult for me. They brought back memories that I didn’t want to revisit, painful memories. Losing a child is so painful. Losing a child because of preventable mistakes is unacceptable.
The faculty are so amazing, so strong, I don’t know how they do it. I have not been able to move past losing Sebastian. His death broke me and my wife. We were crushed, walking through life without really living, just existing. For me, it was like being underwater. I felt like I was always drowning, over and over again. Then I just stopped feeling, stopped caring about anything. I didn’t want to feel anymore, I didn’t want the tears anymore. It took me a long time to get back to living life again.
I remember family and friends trying to make us feel better. They would… Continue reading
It is already a very emotional first day at Telluride as I re-watched Lewis Blackman’s story as a senior resident. Two years ago, prior to any patient encounters, I first watched it as an intern, incredulous at the turn of events. At that time it baffled me how health care professionals could diminish patient and parental concerns so callously, and how so many errors could pile up to lead to a tragic outcome. As an intern I vowed to never allow such reckless practice to occur under my watch. As a senior I reflect on how many vital sign abnormalities I let go, errors I let happen, and lives I let slip through my fingers.
As an ER resident, the acuity of illness is higher than other specialties and inherently the potential for medical errors. Two years ago, my naive intern-self entered residency with the goal of committing no preventable… Continue reading
As I reflect back on today, what struck me the most was the video we watched covering the tragic case of Lewis Blackman. This will likely always stay with me because I met Helen, Lewis’s mother. As she shared his life and legacy with our group, I could feel the raw emotion and pain that she had endured. No one should have to experience what she did. The tragedy is that I could see this happening again. Too often healthcare providers dismiss our patients – I was shocked and upset to learn that a nurse had rolled her eyes at Helen when she explained her concerns. Are patients ever wrong? NO! This is so obvious to me, but a lot of healthcare providers clearly don’t agree. Even if patients may not be correct in the medical sense, this is due to a lack of clear, concise patient education on the… Continue reading