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
By Betsy Mramor, M2 MUSC
It seems like common sense for us to realize that we will all make mistakes at some point in our careers. So why are we so afraid of admitting this when it happens? Are our own egos so big that we can’t admit we are human? Why is it that this same humanity that our patients and society expect of us disappears in a mistake. By not talking about these mistakes we continue to allow society to form these unrealistic perceptions that the healthcare field is perfect. I believe that in order for the culture to change; this perception needs to be broken. There is no other way for this perception to change unless mistakes are brought to the table, discussed, and proactive measures are taken to correct them. Sweeping them under the carpet will only end up reinforcing this perception of the perfect… Continue reading
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
Loved the discussion on communication and the different styles. When we were in groups for the case study, it struck me as interesting that the behavior of the surgeon in one version was not “bad”, but it still changed behaviors, and not in a positive way. Also, I was thinking about how I would feel if I were Naomi or Tess? I was thinking it would be hard to “rock the boat”, especially in a time-sensitive situation like an operating room, and especially at the end of a long shift / procedure.
I really like what Cliff had to say about why do we keep trying to hide information, when he was referring to his operation record. It is so true. We are all so egotistical, proud, scared, and a host of other emotions.
I like the thought of looking at the hazards, and not just the extreme cases. I… Continue reading
This week we transport the Telluride Patient Safety Educational Roundtable and Resident/Student Summer Camps to the heart of the nation’s capitol — Washington DC. Dave Mayer MD and Tim McDonald MD/JD along with faculty Paul Levy, Rosemary Gibson, Helen Haskell, Cliff Hughes, Kathy Pischke-Winn, Joe Halbach, Gwen Sherwood and more will educate the young of healthcare, sharing communication skills, patient stories and negotiation training in the spirit of keeping patients safe. The Telluride alumni numbers continue to grow, building that critical mass of voices who can share the wisdom of open, honest communication and transparency throughout medicine.
Student reflections on this year’s camps, as well as last year, are found throughout the Transparent Health blog, on Educate the Young and on faculty member Paul Levy’s blog, Not Running A Hospital. Look for additional reflections from this week’s class soon to come, and follow us on Twitter via #TPSER9. The… Continue reading
One of the highlights of the Telluride Patient Safety Summer Camp was the in-depth discussion of the meaning of informed consent. It is not as straightforward as “here, sign this”. In fact the paper consent itself is in a sense the last and least component of informed consent. I was a bit surprised and secretly glad to hear some places have rid themselves of the informed consent form, which reinforces the notion that informed consent is some kind of administrative scut to be dished out to residents. Informed consent isn’t extra, it isn’t something for special procedures, it really should be an integrated part of every doctor-patient relationship. The heart of it is shared decision making and coming to the best course of action based on the patient’s preferences, values, needs, and goals. (“Preferences, values, needs, and goals” was in fact one of my takeaways – a mental checklist… Continue reading
By Garrett Coyan, University of Kansas Medical School
The last week I spent at Telluride was very eye-opening for me. I was glad to be surrounded by so many other healthcare professionals that had the same desire to provide the safe and high-quality patient care experiences as I do. Reinvigorated with ideas for improving communication and decreasing risk to my patients, I couldn’t wait to get back to my institution and start implementing change. However, as I returned to the hospital today, I was quickly reminded of the main reason why this goal will be so difficult. Not only does cultural change need to occur in the hospital, but I would argue that even more importantly, cultural change needs to occur in the education of health professions students. This was made evidently clear by a conversation I had with one of my recently graduated colleagues who is staring his internship… Continue reading
By Nicole T. Jiam, Johns Hopkins University School of Medicine
About a month ago, I was sitting in on a clinical correlation led by an aneurysm neurosurgeon and his patient at the Johns Hopkins Hospital. These clinical correlations are incredible opportunities for medical school students to learn directly from the patients themselves by hearing their story and then asking them questions.
During this particular clinical correlation, the neurosurgeon discussed the importance of informed consent and the decision making process that stretches over several weeks. The decision to undergo a surgery and which neurosurgeon requires deliberation and time.
At one of the meetings prior to the operation, the Johns Hopkins neurosurgeon candidly told his patient: “One of the most important ways of evaluating physician competency is case volume. You want to pick a surgeon that has a huge wealth of experience doing this procedure.”
To which the patient… Continue reading
Wow. I’m not even sure how to reflect on the amazing day we had today. From the horrors of the Michael Skolnik case video, to the excitement of being the first group ever to save Stewie (our egg ‘patient’), to the heartbreaking story that Carole courageously shared with the class, today has been emotional and eye-opening.
So many moments today, as we listened to and became engrossed in the narratives being shared, I found my face scrunched up or my mouth falling open wondering how we could possibly treat our patients and families in some of the ways that we do. I like to believe that people are good and generally do the best they can. And yet, hearing about health care providers who ignore and belittle a mother worried about her child, or administrators who threaten a mother who just lost her child to… Continue reading
By Jenna Reece MS2 Columbia College of Physicians and Surgeons
Many fantastic take-home thoughts from Day 2 of Telluride. Hearing the medical error stories, I couldn’t help but reflect on my main reason for being here, and for working towards improving the medical profession: I want to be a part of a profession that I can believe in.
A lot of the stories that we have heard reflect a willingness to see the world through one myopic lens, rather than stepping back, and considering why we all went into medicine in the first place.
For example, we have heard terrible stories about the way that hospitals have treated the victims of medical error. These actions, to me, reflect fear. We are so terrified of lawsuits, that we fail to step back and consider the ethics of their situation, and the humanity of our victims. The… Continue reading