Before coming to this camp, I was trying to explain the purpose of this camp to some of my family and friends, and I struggled to find ways to explain why we shouldn’t just blame health care workers when medical errors occur. Placing blame is such a pervasive method in our society for “solving” problems that I struggled to find ways to frame the issue of medical errors in a new way to help them understand. Over the past two days, we’ve said over and over again that medical errors are not caused by mean people, and I think that is one of the key phrases I will use in the future in trying to explain this experience. Medical errors are not caused by mean people. In fact, the vast majority of the time, the people involved in medical errors were actively trying to avoid… Continue reading
What a way to start a week! I had an idea of what this week would be like, but not to the extent of the material in which it would encompass. First thing this morning, we touched on a subject that hit so close to home: the difference between the thought processes and communication processes between nurses and physicians. The first activity of the day included a video of the Lewis Blackman story. There are so many events/problems that occurred between all interdisciplinary members of the team. One of the issues being that Lewis was not admitted post op to a medical-surgical floor for post-op management/observation; rather he was transferred to an oncology unit. No matter how we are trained, if we don’t regularly treat and manage a certain population, we need refreshers on what we should be looking for, and how to manage their care.
In the video we… Continue reading
We started our week of patient safety discussions with the story of Lewis Blackman. As we watched the tragedy unfold, I felt sick watching well-meaning medical professionals ignore numerous red flags as well as the concerns of Lewis’s mother during the four days following his surgery. One quote from Lewis’s mother, Helen Haskell, stayed with me long after we finished the film and it is something I will never forget. She said if Lewis had been anywhere else but a hospital, she would have called 911 and Lewis would still be alive today. To me, this speaks to the horrifying extent to which the healthcare system has failed patients and the poisonous Wall of Silence that continues to be perpetuated. How can the place where you are supposed to be the safest be the one place where you are most isolated from the care that you need? For a person… 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
My time spent at the Telluride Patient Safety Summer Camp was enlightening and life-changing. It was life-changing for me and my future patients. In my application essay I spoke about how “I want to be part of the solution and enhance patient safety by figuring out how to prevent nosocomial infections, lower remittance rates, and develop better communication strategies between health professionals”. I learned this and much more.
The statistics presented to us were powerful. I cannot believe I was never informed about the infamous IOM report in my first year of medical school. The Hippocratic Oath says we must do no harm; it would be wise if we learned how to actively not do this in medical school. However, this patient safety conference has educated me and I plan to spread awareness to my class. Medical errors account for the third leading cause of death in the U.S.; 100,000… 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
The films telling the stories of Lewis Blackman and Michael Skolnik served their purpose of putting faces on medical errors very well. More than once I found myself struggling, and failing, to keep my tears from running as the stories were told. It is one thing to know that hundreds of thousands of people die due to preventable medical errors each year; it is a whole other thing to observe one or two of those deaths closely as a human tragedy. One may want to reverse the order of the sentences in Stalin’s famous quotation into “a million deaths is a statistic; a single death is a tragedy”, just so as to remind oneself of how devastating each single one of those “numbers” are.
As tragic as they were, the deaths of Lewis and Michael were [arguably] not totally in vain, thanks to their dedicated families and shrewd professionals… Continue reading
As medical students we are often made to feel like an annoyance to everyone: the attending who can’t be bothered to teach yet another new batch of newbies, the nurse who wishes we would get out of their way so he/she can do their job, the resident who is post call and just wants a bed, and yes, even sometimes the patient who at times view us as yet another person who will do the same thing to them that 3 other people had already done that day. However, after having heard the stories and discussed with fellow colleagues at the camp today, I realize that I should not let anyone make me feel like a hassle. I should take ownership of my assigned patient and do my absolute best to help them. I need to not be kept in the sidelines, but to be in the trenches with 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