Patient Safety

His Name was Bill

Today I had the humbling opportunity to hear stories from individuals whose lives were turned upside down as a result of medical error. They spoke with grace, conviction, and courage. They also spoke with frustration and sadness. Their stories are important and what they shared today is heart-breaking. Their stories need to be heard, not only in the medical community but also throughout the general public.

As I reflect on the many stories I have read and heard surrounding medical error and the horrifying impact these errors have had on patients and their families, I am ashamed and heart broken. We, physicians, nurse practitioners, physician assistants, nurses, assistants, enter the health care field to heal, to bring hope, and to be there to provide comfort and expertise in, perhaps, one of the darkest hours of an individual’s life. However, as medical error seeps into our interactions and creates a culture… Continue reading

Hospital employee well being

After today’s sessions I realised how intricately all the causes of patient harm are interrelated.

I feel that you work harder and are less efficient when you are sleep deprived. And I feel sleep deprivation, apathy, compassion fatigue are all interrelated. Working as an internal medicine resident at a busy hospital I realize how overworked residents are more prone to making medical errors. I feel a huge investment towards patient safety would be resident/physician/health care provider well being.

I personally feel the difference in my attitude and care I provide on a Monday vs a Friday, at 7 am vs at 7 pm! There are personal events in everyone’s lives that we cannot avoid, but creating a better work environment should be a higher priority for hospitals. The physical wellbeing of Alcoa employees was discussed today, and maybe  graduate medical education programs should learn from them too!

 

The Quest for Zero: Climbing the Mountain of Patient Safety

For my telluride post, I decided to reflect on the activity that impacted me the most, and I realized that a great lesson lies in the hike we all went on. On Wednesday we all went on a hike up a mountain range, which was a fun activity to do. While climbing, all my focus was to just keep going up, hoping not to fall amid the decreasing levels of Oxygen and the increasing snow. However, after we were done with the climb yesterday and went into one of the afternoon sessions. It just dawned on me that there was a clear parallel with what transpired during the climb, and what we have been talking about this week on patient safety.

While climbing we all encountered some slippery slopes and those ahead would always call back to warn those of us behind them about the slippery areas, making us aware… Continue reading

What are you most afraid of after you leave here…

The second day of Telluride was possibly even more thoughtful and vulnerable than the first day. We started things off with a bang through the story of Bob Malizzo and the tragedy that faced his daughter Michelle. We had the unique and humbling experience of hearing from Dr. Tim McDonald who was directly involved in her care and in disclosing the events to her family.

The session then closed with a very challenging question posed to the group: What are you most afraid of after you leave here? My knee jerk reaction was probably one that most trainees would answer (beyond being worried broadly about patient harm which is, of course, also a major concern): I’m worried about the day when I kill someone’s child. Not if, but when… because inevitably a bad outcome will occur… because in medicine we are lifelong learners and therefore cannot know everything, cannot predict… Continue reading

Telluride Day 1 Reflection

The first full day at Telluride was full of complex and honest discussions, as well as personal stories to help provide context and reminders that patients with adverse outcomes aren’t merely a statistic. In particular, we were honored to have Helen share a tragedy involving her son Lewis, and she was able to provide her perspective as a mother, as a patient, and as a patient safety advocate. Something that really struck me was when Helen mentioned that if Lewis had been anywhere else but the hospital (such as at home) then he may have had a different outcome due to a new set of eyes and an open mind about his deteriorating clinical status and acute abdomen. While our culture is changing and hopefully becoming more multidisciplinary and team focused there are still so many more steps we need to take to get to a place where all members… Continue reading

Pre-Telluride Post

As many of us have experienced we oftentimes serve as a translator for all things medical when it comes to our families, but sometimes decisions are made and adverse events happen but there is no clear way to explain why or how you got to where you are. I have seen a loved one undergo unnecessary and invasive medical procedures simply due to a language barrier, or prolonged hospitalization due to insurance issues and facility placement. I have also seen patient safety concerns from the perspective of a resident physician, when new autonomy in ordering medications, studies, and procedures could be potentially dangerous if a trainee isn’t aware of the boundary between what they know and what they don’t. In particular, as a pediatrician, the decisions we make when caring for children and the outcomes or adverse events that they face completely change the course of both their life… Continue reading

Telluride Experience – Day 1

Lack of communication/false assumption leads to errors:
In learning about the Lewis Blackman case, an event that directed a conversation toward communication’s ability to either prevent or impose a drastic medical error in a clinical setting, one of the events that stood out the most was the idea that nobody asked, “What is the worst thing this could be?” I work for a home health care team that aims to improve the quality of care and the patient experience by communicating patient alerts. Effective communication in my organization is essential to the effectiveness of our team. Thus, the lack of coordination and communication that was exhibited in the Blackman case struck me because, as these nurses assumed that Lewis was fine, it was these false assumptions and the lack of communicating alerts that predisposed the patient to a detrimental error resulting in the patient’s death. When you assume that the… Continue reading

On tribal hierarchy

On tribal hierarchy

On day one of the “Academy of Emerging Leaders in Patient Safety” conference, we started by watching a video featuring a patient’s mother who brought up the tribes of healthcare (doctor tribe, nursing tribe, etc) and the role that the element of hierarchy played in her son’s unfortunate outcome. In healthcare, we often witness two of mankind’s most primitive motivators – the desire to care for others and the drive to survive. The “doctor tribe” is predominated by competitive, type A, detail-oriented individuals, and deference to the hierarchy is one of our tribe’s oldest traditions. In the patient safety community, the need to address this specific tribal tradition is frequently discussed. Knowing that old habits die-hard brings up a number of questions: Is hierarchy still alive and well? How can it be addressed? How receptive will the tribe be to solutions proposed by external parties?

Take a… Continue reading

Telluride Day One

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

Breckenridge Day 1

Early this morning I was awakened by sun illuminated mountains outside my window and I couldn’t help but feel the energy that Breckenridge emanates. Coming out to the Telluride Summer Camp I was a bit anxious and unsure of what to expect as I have never been invited to attend such a unique program; However, after meeting everyone and spending some time in this picturesque town, my fears have dissolved.

Starting off the day with the Lewis Blackman film was emotional and so powerful for me. I’m so thankful that Helen has come out to share her tragic story with us because it really brings home the importance of patient safety and highlights so many dangerous aspects of healthcare within the hospital. As a night shift nurse, I was effected most when I learned Lewis’ nurse caring for him that weekend night knew something wasn’t right but she dismissed her… Continue reading

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Telluride Experience 2020 Dates

BRECKENRIDGE, CO:
CMF Session One*: 6/8 – 6/11
Bennathan Session Two: 6/15 – 6/18
Session Three: 6/22 – 6/25

WASHINGTON, DC/MD:
Session Four: 7/22 – 7/25

*Session exclusive to the COPIC Medical Foundation Residents.