Patient Safety

Premature Closure and the Medical Hierarchy

While premature closure may be related to process factors, like inexperienced providers and lack of oversight, it may also be built into the hierarchical structure of medicine. As a patient is evaluated by ascending providers, the amount and nature of information that travels up the hierarchy diminishes. For example, the comprehensive history and physical performed by the intern or medical student is filtered based on the experience of the senior resident, which may be further distilled when presented to the attending physician.

Day 2 Reflections by Steven Paretlatko

Day 2 was eye opening! The Skolnik’s story introduced the concept of informed consent- an essential part of shared decision making. This stressed the importance of clear communication and patient involvement in medical decision making. It was fun to apply what we learned in group breakout sessions. The day shifted in focus and the talk by David Claussen peaked my interest. The talk dissected EMR systems and I learned that the rush to implementation and false advertising by vendors has led to many of the frustrations that surround use- particularly the lack of human factors engineering considerations which ultimately have led to significant patient safety issues. To close off the day it was insightful to hear John Nance speak of his experiences in patient safety and inspire future healthcare professionals to make a commitment to change the system!

Out of Time and Space

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

The Magic In Transparency

This phrase struck me as the perfect way to describe an experience I had my intern year. My first continuity ob patient had a fetal demise at 34 weeks.  She was the first patient I had followed from the beginning of her pregnancy.  I performed her dating ultrasound at 9 weeks.  Unlike many of my patients, she and her husband faithfully came to every prenatal visit.  She did not smoke, use drugs and followed the dietary guidelines.  Her husband was the chatter one of the duo, while she would calmly take everything in at our visits.  They both teared up when I told them they were having a girl at the 20 week ultrasound.  They told me her name was Emma.

Then, I received a phone call from my colleague who had seen them for a prenatal check.  She could not… Continue reading

Uncovering A Deeper Truth

Diving deep into the depths of patient safety at #AELPS16 has uncovered deep truths, deeper desires and an epiphany…or as David likes to call it, an “a-ha” moment (and there were many for all of us at #AELPS16). Let me explain.

I work in emergency medicine. A buffer for the undifferentiated, where time-poor workers battle a “controlled” chaos. It’s also where patients come. Patients who have a stubbed toe, sprained ankle, a cough or a heart attack. By practicing the virtues of patient-centred care we can appreciate that these aren’t patients who have presented to be an inconvenience, but have come because there was nowhere else to go. Ask why. Why did they present. There are many reasons why they present including health literacy and healthcare infrastructure. The truth distills down to the fact that, in their mind, we are their only hope.

As staff within this chaos, because… Continue reading

Aviation Expert John Nance on Healthcare Culture Change and Educating the Young

Today’s post is by Guest Author, John Nance, Telluride Experience Faculty, Author and ABC Aviation Consultant

Why_Hospitals_Should_FlyHaving 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

I Am a Doctor

I am a doctor. I save lives. Sometimes, by accident, I take them. I fight off bad infections. I spread worse. I do no harm. I do no good. I order the right tests and the wrong ones. I do only what is necessary, then do more. Maybe I do less. I care for the individual. I care for their lab values. My care is evidence based and defensive.

I am a physician. I am the new guard and the old. I am bright eyed, optimistic, jaded and bitter. I have integrity and prescribe the drug rep’s newest candies. My patient’s autonomy knows no bounds, nor has my paternalism found its limit. I admire. I condescend. My patients are wise fools. I welcome their questions and scorn inquisitiveness. I listen to them. I don’t. I have the utmost respect for nurses when I dismiss their assessments. My patience is exemplary,… Continue reading

The Task: Write a reflection. The goal: Mindfulness.

Academy for Emerging Leaders in Patient Safety – Day 1, June 8, 2015

Sentences that stuck:

  • “People don’t remember powerpoints, they remember stories.”
  • “I need a little clarity.”
  • “Telluride has more dogs per person (1.8/person) than any other town in the U.S.”
  • “The most important question: ‘What’s the worst it could be?'”
  • “Why do we have a Monday-through-Friday culture when illness happens every day of the week?”
  • “The best way to starve a dog is to tell two people to feed it.”
  • “Make a plan to persuade; People are motivated by data, structure, and emotions.”
  • “Why are you here? What do you want to take with you? What are you willing to invest?”

After only one day of the “Telluride Experience”, I’ve got 6 pages of handwritten notes and an unending stream of questions and ideas buzzing around my head. Today Dr. Wendy Madigosky asked us to list situations… Continue reading

Reflections from Telluride East

First and foremost, I’d like to thank all the leadership, instructors, and patient families for having me and taking the time out of thier busy schedules to share with us their valuable information and experiences.  I will echo what Rick said yesterday in that this conference definitely re-ignited that fire in me to change our culture in Medicine and put the focus back on patients and their safety and well-being.  When I go back to my slightly younger self to think of how I expected to be as a physician, I never thought of the negative effects I could have on patients, I only thought of myself as a healer.  Then I said to myself, “OK, I can change my ways and improve myself so that I am better aware of errors around me or because of me, and correct them before they do real harm to… Continue reading

Impact through metaphors

An incredibly strong, sobering metaphor was made today at Arlington National Cemetery.  The notion that 400,000 lives lost over the course of several wars in the pursuit to protect the freedom of citizens to pursue meaningful goals matches the loss of those citizen life every year due to medical error is disheartening and baffling.  It hits home because just as each member in this cemetery belongs to a family…leaves behind loved ones… each patient who loses his or her life does too.  So it is sobering, but Arlington holds another impactful metaphor that offers hope to the medical discipline.  That is a metaphor that can be found in the ritual of the Changing of the Guard.

The Changing of the Guard has a long, rich history which each sentinel imbues and lives through his duty.  The process by which a… Continue reading

AELPS 2022 Dates

- CMF Scholars (Week 1)*: 6/5/22 - 6/9/22
*Session exclusive to COPIC Medical Foundation Residents.
- Sorrel McElroy Scholars (Week 2): 6/12/22 - 6/16/22
- Bennathan Scholars (Week 3): 7/19/22 - 7/23/22
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