I am so so grateful to have been given the opportunity to attend Patient Safety Camp. As the week progressed I started to wish that everyone could attend something like this; I will be highly recommending it when I get back to school. Since I know that everyone cannot attend Patient Safety Camp, I started thinking about how I could carry this information back to Indy and take with me wherever I go after that. My school has a Patient Safety elective (of which I am on the waitlist for), but beyond that we are given no formal training in the Patient Safety Culture. I’m going to sit down with my Integrative Medicine group e-board and see if we can get Patient Safety education to be one of our platforms. I’m likely jumping ahead of myself (as I often do) but we could do a series over the course of… Continue reading
Most of the week as well as today has focused on methods to improve some aspect of communication. The breakdown of communication reaches beyond just the interdisciplinary team, hospital staff to administration, and physician to patient though. It applies to the messages healthcare as an industry communicates to the general public too. As any good PSA will tell you, knowledge is power, and if we continue to strive for a patient-centered/empowered industry, we should seek to educate. Those responsible for the education – hint, hint: us – tend to fall short on delivering a palatable message. Instead, the frontlines of patient education are social networks and blogs. More concerning, the majority of those sources obtain their information from other media outlets.
Now, in theory that doesn’t sound like an alarming statement. The media reports on most issues, health being no exception. It… Continue reading
We discussed several topics today, however, two of the most powerful were transparency and shared decision making. After reviewing the story of Michael Skolnik, my heart ached for families that have suffered similar loss. For the Skolnik family, the loss was intensified by the lack of transparency and shared decision making. As an advanced practice nursing student, I witnessed a situation in which transparency and shared decision making was present in an otherwise unfortunate event. A patient arrived to the hospital in the midst of his second heart attack. After stabilization, options were presented with one being coronary artery bypass surgery. The patient chose bypass surgery, however, his surgery was on hold for coagulation issues. When it was time for the patient to have surgery, an emergent patient arrived necessitating a potential delay in the first patient’s bypass. Transparent communication occurred between the patient and provider detailing the situation and… Continue reading
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
A flurry of faces, information, challenges and thoughts have accompanied the start of Telluride East 2014. Several issues were discussed, all equally valid and important, but one occurred early and stands above the rest. It set the tone for the rest of the day as its message remains the proverbial yoke weighing on our shoulders – the impact of ignoring the human element in the face of error. We can’t just press the reset button once an error is made, but we can reset our perspectives on the best way to mitigate, manage and cope with the error, or even the potential for error.
So why reset the perspective? Well, it’s due to an unanticipated emotional response that led me to wonder (in text-speak) WTF? Lewis Blackman’s story, although tragic and emotionally charged, led to a slew of… Continue reading
“Speak little, do much.” by Benjamin Franklin has always been one of my favorite quotes. However, it struck me in the past three days that while action is important, speaking, or communicating is just as equally important, especially in healthcare. The story of Michael Skolnik clearly illustrate that it does not matter if you are doing/offering the best you could, patients and family and sometimes the providers can be harmed physically and psychologically when there is a communication breakdown.
We as care providers like to believe that we are “not that bad” in communicating with the patients, nevertheless now when I think back on my experience as a patient or a family member of a patient, I can easily think of places where there is a breakdown in communication. What scares me is that I did not think it is abnormal until very recently. As patients, we expect not… Continue reading
Yesterday was Father’s Day, 2014. I woke up before everyone else in my room. Rolling out of bed, I padded down the stairs and brewed a cup of much-needed coffee. Pouring my face over the steaming cup, I looked out my window to the inspiring landscape of endless white-capped mountains. This year marks the ninth Father’s Day that I have spent without my dad, but the mountains and my purpose this week made me feel as though he were standing there with me, sharing our cup of morning coffee, just as we used to.
After taking the gondola ride into Telluride, the students and faculty plunged into our work of expanding our knowledge in the field of patient safety. We watched a documentary outlining the tragic case of Lewis Blackman, a 15-year-old boy who died due to medication error, miscommunication, and assumptions made by his medical team. The film explored… Continue reading
“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
I am now back in Seattle, home from the Telluride Patient Safety Roundtable & Summer Camp. I am very thankful I had the opportunity to participate. It was emotionally exhausting (I cried the first three of the four days), but I have a sense of hope. I met leaders in patient safety—some of whom I had seen in online videos, others I had not heard of. But the message from all of them was clear: There is no compromise in patient safety. No compromise in disclosure. No compromise in informed consent. Safety and transparency must underlie all of healthcare.And that is a very different perspective than my family has encountered in Kansas, at both the local hospital we are dealing with and at the state level. So today I feel hope knowing that my family is not alone, but I also feel overwhelmed knowing that those… Continue reading
It was a great first day at Patient Safety Camp! It is a privilege to learn from leaders in quality and safety from around the country and internationally (thanks for coming back, Kim!!). The bigger privilege, and the one I didn’t anticipate prior to arriving, was the privilege of meeting fellow residents from around the country. At first it was a little intimidating to be surrounded by residents who had accomplished so much as leaders in the IHI, leaders in CIR, radio talk show hosts, and pharmacists… the list went on and on. But as the day progressed I realized that I was lucky to be surrounded by such great people that I can hopefully learn from for years to come. We have already learned so much from each other by discussing ways to improve transparency and communication with patients, how to increase physician reporting… Continue reading