Patient Safety

Can Patient Safety save a President?

As part of TSPER2014, we were able to read some fantastic books/articles/stories. They opened my eyes to the consequences of failing to make patient safety a priority.  I’d like to add another to the list (and give a recommendation for anyone looking for a good read).

Destiny of the Republic, by Candice Millard is the story of James Garfield, our 20th President of the US. Garfield is often forgotten as a president, perhaps because his legacy was cut short by his assassination in the middle of his Presidency. This book goes into the details of that story and what could have happened if he hadn’t been shot.

But what does that have to do with patient safety? The truly interesting part of Garfield’s story is the medical care he received after being shot. At the hands of his doctors, a very survivable trauma became 11 weeks of torture and… Continue reading

Proud, Humbled, and Somewhere in-between!

To say today was educational, informative, and life-changing would be an understatement.

Before the conference we were instructed that we would be introducing a fellow conference attendee at an icebreaking event. We were encouraged to email and get to know one another in order to provide a concise yet effective introduction. My partner and I had many interests and motivations in common- we are both from Oklahoma, we both are interested in mastering the skills necessary to become patient safety advocates, and, perhaps most importantly (or most movingly), both of us have lost a grandfather to an avoidable medical error. In our introduction we both shared this information with the group which I felt made the group more tight-knit because of the personal connections that echoed throughout the room- it seems everyone in some way has been directly affected by an adverse medical outcome. The camaraderie I felt after sharing… Continue reading

To be obnoxious.

“I’m a little obnoxious sometimes,” claimed Dan Ford this afternoon discussing his fervent advocacy of root cause analyses in response to sentinel events. Earlier that morning, Mandy too had confessed to being “that annoying nurse” who unabashedly telephones on-call residents when a concern arises. These champions of patient safety proudly own these deprecatory adjectives like “obnoxious” and “annoying” because they know that their actions are challenging the status quo for the betterment of patient care.

It is my hope that all of us, students and professionals alike, emerge from this week in Telluride a bit more enthusiastic about being obnoxious. To be “obnoxious” in this context is to put our patients’ needs first in spite of a bruised ego. We “annoy” despite the fear of openly defying the medical culture’s norms, and we “irritate” others because we have the courage to understand that it will take assertive individuals to lead… Continue reading

Where is our support…

On Wednesday 6/11 we discussed the case of “Sally,” a 9 year old girl who died because of medical errors. Regardless of how you look at it, this is a tragedy. In our discussion, the presenter described why this resident was “set up to fail.” The resident had undergone numerous emotional battles in the prior months on the wards and in the ICU, had struggles outside of the hospital, and unlimately quit the residency program as a result of Sally’s death, but there was not one discussion on Wednesday about how we should care for our residents. Unfortunately, this resident’s story is all too common. Many of our Telluride attendees sympethized with the resident outlining how similar their experiences have been to Sally’s resident. I too can look back and see myself in that position.

It is well documented in the literature that residents, regardless of profession, develop higher rates… Continue reading

Fresh air for fresh perspectives

JSuh_BlogPhoto_061014Sometimes we need to step out of the confines of our hospitals, clinics, and institutional cultures of inertia and status quo to get fresh perspectives on health care improvement. Lucky for us, we are breathing in spectacularly fresh Telluride air to engage in critical conversations around patient safety with world-renowned leaders and a room full of amazing residents from across the country from CIR, COPIC, MedStar and others. I’m looking forward to tackling difficult topics of transparency, communication, and leadership. I know what I learn this week will make me a better family doctor, patient advocate, and physician leader. I have a sneaking suspicion I will also be a more conscientious spouse, daughter, sister and friend!

 

 

 

Going the distance….

At the close of our first day in Telluride, I find myself hopeful.  Today we were presented with the story of Lewis Blackman.  The tragedy of medical errors involving his case were not in vain. I believe we have become a culture that would protect Lewis Blackman if he were in our hospital today.   I found myself surprised by how far we have come in patient safety in the last decade.  And I feel confident many of the failures of his case would not occur today.  Am I foolish to be this hopeful?  I believe we as a medical community have learned from our past and strive to not repeat it.  Safety mechanisms are now in place that would have prevented Lewis Blackman’s tragic end.  At Medstar GUH, we have a list of mandatory events that demand contact with the on call… Continue reading

Gemba

Today- the first day at Telluride 2014 – was filled with stories. I expected lessons on safety and quality, but the teaching was much more organic. We heard incredible, emotional stories that left many us of us jarred, uncomfortable, and often in tears– especially Helen Haskell’s story. As a new parent myself, the idea of the loss of a child is incomprehensible. Today’s teaching came out of our own reactions to the difficult stories we heard as a group. My takeaway today goes back to Paul Levy’s book and the concept of going to Gemba — the “actual place.” As I finish up my PGY-1 year and think about all of the very sick patients I cared for, I realize the importance of physically being in the place of importance– the bedside. So much of my work this year has been away from the bedside, reviewing charts and entering orders,… Continue reading

Being transparent…time for confessions

I found myself feeling upset today, especially as we were discussing the case study. I felt so frustrated as a nurse when we were trying to figure out the accountable person for the patient fall. I felt like I had a weight on my shoulders. As nurses, we do shoulder a large portion of the responsibility related to patient falls. We talked this afternoon about how it is EVERYONE’s responsibility to help WATCH the patients in an effort to prevent falls.

I also confessed to my group that a lot of times I do not feel comfortable going to lunch when I am staffing. Why, you might ask? I know part of it is that it is hard for me to hand over control of my patients to another nurse, even if only for 30 minutes. So, I am working on that. The other part is that I work with… Continue reading

#TPSER9 Reflections: Day Three

By Mary Blackwell, Nursing Student, UPenn

By the end of day three my mind is saturated and I feel so lucky to have the opportunity to be here at the Telluride East Conference. Aside from the twins in utero, as a rising senior in UPenn’s undergraduate nursing program I am certainly the youngest conference attendee. As a student, and a nursing student at that, in the hospital I often feel like the lowest on the food chain. But in this environment of open communication the medical hierarchy collapses and it amazes me to see various healthcare professionals come together for the betterment of patient outcomes. Never before have I had personal connections or meaningful conversations with interdisciplinary healthcare students surrounding issues in healthcare. Because it is so clearly valuable to have these types of conversations, I wonder why academic programs don’t put a larger effort into connecting various healthcare students… Continue reading

Trust and Safety in Medicine: Part 2 by Matthew Waitner M2 Georgetown

Perhaps, as Terry Fairbanks said yesterday, we should look not to our individual pursuits but the healthcare system that is in place.  Individually, we are each committed to the reason we put on the white coat – to cure, heal, and do our best to care for each of our patients.  And yet collectively as a system we are failing to provide that very goal.  How is it possible that such dedicated individuals are systemically failing – it would appear to be impossible, and the numbers certainly show that its more than just a few bad apples.  Perhaps our system needs to be overhauled.

I was struck at the insight that Dr. Fairbanks shared.  As a human factor engineer he explained that every other system in the world accounts for the natural errors in humanity.  There are fail-safes embedded in most systems to catch… Continue reading

AELPS 2022 Dates

BRECKENRIDGE, COLORADO:
- 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
 
ELLICOTT CITY, MARYLAND:
- Bennathan Scholars (Week 3): 7/19/22 - 7/23/22
 
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