Communication, teamwork, team-coordination – all buzzwords of patient safety and improved healthcare system performance. But does everyone truly know the meaning of these terms? We were presented a case study today in which an experienced and revered surgeon encouraged his surgical team to break protocol by closing a patient when the sponge count was off by one sponge. The surgeon cited, with amiability, the length of time under anesthesia as the urgency for ending the procedure before the missing sponge was accounted for – and rightly so, as longer times under anesthesia are associated with decreased patient outcomes. However, so are surgical materials left in patients. The concerned team deferred to the surgeon’s congenial and persistent request for the sutures to close the patient.
At first glance, this team could be considered to have some of the above qualities: they communicated about the missing sponge, they coordinated a course… Continue reading
When I began medical school, my academic mentor advised me to be cognizant of when the more experienced would drop pearls of wisdom. Well during these past 4 days it’s been raining pearls. After trying to absorb so much knowledge, my brain feels like an overfilled suitcase with a weak zipper; it’s about to burst. And therein may actually lie a problem. To those with less clinical and formal patient safety experience, Telluride covers too much information in too little time. Many of the activities and discussions felt rushed. Here I present an open, honest critique of the Telluride program and make suggestions for improvement.
I will focus on 3 observations: 1) The negotiations, listening and human factors lectures were some of the best received, 2) Group exercises/games are highly beneficial and are worth the time expense, 3) People felt that there was not enough time for discussion.… Continue reading