Email I sent to my program leaders.

All,

I want to begin by saying THANK YOU for sending me to Telluride to learn from some of the nation’s pioneer leaders in patient safety and quality improvement. I have been so moved that I want this to be my “niche” in medicine as I continue on to become a pediatric hospitalist. I am hoping at some point to sit down with all of you to discuss the processes CMH has in place to reduce error and at the same time acknowledge human factors. I have not yet made it to error prevention training due to scheduling conflicts, but I am excited CMH is taking this step towards becoming a high reliability organization. Nick Clark has done a great job of incorporating patient safety moments into many of the meetings he has led, and I hope to carry this forward in some way.

We watched a variety of videos and heard multiple stories of near-misses and unfortunately, preventable patient morbidity and death. Carol, one of the representatives from the patient perspective, shared the powerful story of the loss of her daughter who had been diagnosed with leukemia 9 days before she died from a hospital acquired (and too late recognized) C. diff. infection. A C. diff. infection! This year has been particularly hard for Carol and her family as her daughter would have gone to senior prom this previous April and then graduated from high school in May.

In order not to make this email too long, I want to just make 2 more points and then, hopefully, I can discuss my thoughts with all of you in person at some point.

1) John Nance, writer of “Why Hospitals Should Fly,” said during his talk: “You have been trained to be the center of your own universe.” I do feel as if I was trained in medical school to practice “independently.” On rounds as students and many times as residents, we are expected to diagnose a patient (even if we are completely wrong), come up with a firm plan…and then present it confidently. Our goal is for everyone around us to nod their heads in agreement with the plan we have made. We hope no additional input is needed. However, this erases the team-based approach to medicine we MUST have in place in order to create the most safe environment for our patients. Our plans may be acceptable plans, but others’ ideas should be elicited EVERY time and considered EVERY time, so that we can ensure we have considered all options.

2) I want to begin my own QI project, but I’ll need a mentor. I just don’t know yet what I want to focus on. Sometimes it’s better when I write or talk about my interests or concerns, and then a person outside of my head points out the obvious to me. I appreciate all thoughts any of you have to offer.

Thanks,

Joy Solano, MD PGY-1

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