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

Day One Reflection

::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;

  1. I appreciate hearing from the different professions on the many viewing and stories we heard today. I am not currently at a major teaching hospital and wasn’t aware of the mounting pressure and expectations that exist among medical students/residents.
  2. One of the quotes I took to heart today was “Develop mindful engagement to have situational awareness to help create a sustainable safety culture through a shared medical model.”
  3. Another quote that I feel will become almost my mantra is that “change comes through disruptive innovation”

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

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!

 

Pre-Telluride Thoughts (Napa Valley, CA 2019)

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

Pre-Telluride Reflections

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

Safety is more than preventing physical harm

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

Failure to Rescue: The Story of Lewis Blackman

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

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

Pre-Telluride Thoughts

As I look forward to the Telluride Experience next week, I reflect back to when I first really thought about patient safety in the context of my own career.  Thinking back to my White Coat Ceremony this past fall, I got chills as I pledged the Hippocratic Oath for the first time and made a commitment to “first, do no harm.” At that time, I was overcome by the excitement and seriousness of the journey that I was about to undertake. Since entering medical school, I have started to think more about how our humanness plays into our futures as healthcare providers. I have considered how our patients will need us to play a multitude of roles as their doctor—problem solver, caregiver, teacher, healer—but also, human—with a human’s compassion and empathy. I have also, however, experienced and reflected upon the fallible nature of our being in the context of… Continue reading

Flatten the Hierarchy, but Blame the Intern?

Wow what a great 3 days the Telluride Experience has been thus far. My eyes have been opened to the small, innocent miscommunications that can ultimately lead to patient and caregiver harm. Whether it is the missed after hours critical lab value or the anchoring bias causing us to miss diagnose Angina for GERD, no one is invincible to the patient safety events we have been discussing this week.

However, with all of the amazing lessons learned and the strategies to improve communication, I can’t help but feel defensive after each case and video we discuss. Maybe it’s because 90% of the patient safety events are surgical or procedural and I am one of the only surgeons in the room? Maybe it’s because not too long ago I was the intern having to work up abdominal pain in a post-op patient? I feel emotionally exhausted every day because of the… 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.