Transparency

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

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

a part of someone’s story

How many talks on patient quality and safety have I seen where numbers are quoted (18% of GDP, 3rd leading cause of death, 26th in mortality) but stories are left out? Numbers have their place, to help policymakers and advocates for health system redesign (like me) to make a rational argument for change. I’ve been compelled by these numbers for years now, and in fact, I’ve decided to make a whole career out of making those numbers move toward equity. But it’s been a long time since I reflected on the stories that originally brought my attention to the world of patient safety and quality. Reflecting on that this week, I think I’ve missed those stories.

A story has a particular power to compel, because it reaches out and reminds you that you’re human. I think we humans derive much of our meaning from life by seeing ourselves as part… 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

Reflections Day 1: Intern vs Senior Resident

It is already a very emotional first day at Telluride as I re-watched Lewis Blackman’s story as a senior resident. Two years ago, prior to any patient encounters, I first watched it as an intern, incredulous at the turn of events. At that time it baffled me how health care professionals could diminish patient and parental concerns so callously, and how so many errors could pile up to lead to a tragic outcome. As an intern I vowed to never allow such reckless practice to occur under my watch. As a senior I reflect on how many vital sign abnormalities I let go, errors I let happen, and lives I let slip through my fingers.
As an ER resident, the acuity of illness is higher than other specialties and inherently the potential for medical errors. Two years ago, my naive intern-self entered residency with the goal of committing no preventable… 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

Changing My Practice After Telluride

After my time at Telluride, I only had one day to process everything we learned, and then got right back on the horse and went back to work in the Emergency Department. I truly felt like I was seeing my clinical practice from a new angle. Rather than completing tasks and checking boxes, I found myself thinking through clinical situations and inviting patients and family into conversation about their care.

Of everything that we experienced at Telluride, I am most thankful for the opportunity to learn from the Blackman and Skolnick families. My heart is broke for these two young men and their families, who put their faith in healthcare members, who they should have been able to trust. I learned from their stories that open and honest communication with patients and families, from the very beginning (in my case, the ED waiting room) … Continue reading

That Creeping Feeling…

First of all, I want to say that Richard’s presentation was so phenomenal today. I distinctly remember hiking up the San Juan mountains in Colorado at last summer’s Telluride conference after a great session the day before thinking, “I’ve found my people.” It really is a special thing. I still see one of the other alums every now and then at hospital meetings and it literally warms my heart to hear his name and that he is doing great things at his home institution.

We talked a lot about informed consent and a patient’s understanding of their own experience in the healthcare system. As a primary care physician, I couldn’t help but wonder how Patty’s son’s primary care doctor felt about the horrific outcomes of his patient at the hands of a surgeon who probably didn’t need to operate in the first place, someone he tried to… Continue reading

Saying Sorry

I was particularly struck today by some of the discussions centered around how healthcare providers can begin to make amends for mistakes through open, honest communication with patients, their families, our colleagues, and ourselves. As a rising second year medical student, the past year was focused on learning everything “the right way.” We’ve been trained so far to accumulate a toolkit of basic science information, and to use that to pick the best multiple choice answer to a question. In some ways, I feel like this type of thinking is almost moving me further away from being a compassionate caregiver, capable of owning up to mistakes and admitting when I was wrong.

 

Until today, I haven’t really grappled with the idea that I could make a serious error that could affect (or take) a life. When reviewing exams, wrong answers on questions usually have a relatively simple explanation- 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.