Today- the first day at Telluride 2014 – was filled with stories. I expected lessons on safety and quality, but the teaching was much more organic. We heard incredible, emotional stories that left many us of us jarred, uncomfortable, and often in tears– especially Helen Haskell’s story. As a new parent myself, the idea of the loss of a child is incomprehensible. Today’s teaching came out of our own reactions to the difficult stories we heard as a group. My takeaway today goes back to Paul Levy’s book and the concept of going to Gemba — the “actual place.” As I finish up my PGY-1 year and think about all of the very sick patients I cared for, I realize the importance of physically being in the place of importance– the bedside. So much of my work this year has been away from the bedside, reviewing charts and entering orders,… Continue reading
Unfortunately, there were countless errors from before the start of Lewis’ surgery all the way through the handling of his death. The one systematic error I will comment on is physician-patient communication. Every patient undergoing a procedure needs to sign an INFORMED consent, which includes understanding the risks, benefits and alternatives to the treatment being offered. The situation continued to tailspin into a downward spiral as family was unaware of the expectations post op. There were multiple efforts made by the patient’s mother and nursing staff to notify the physicians that something was wrong. The physicians ignored the most valuable resource available to them, Lewis’ mother, who knows him better than anybody else. Her concerns were repeatedly disregarded or ignored because the doctor did not want to believe something was wrong.
Dr Levy eloquently stated, ” if you can’t see your mother/sister/daughter/son in your patient,… Continue reading
One of the most important lessons I have learned from the past three days is the urgency in which we need to act to bring ethics back to the forefront of healthcare systems. Too often the best interests of the patients and their families are put behind financial, legal, and personal factors. It may never be possible to prevent every error, but we have a professional duty to take responsibility and put patients’ and their families’ needs first in the aftermath of a medical error. I wish to express a sincere thank-you to Carole for your courage in sharing your personal story so that future healthcare professionals can learn from it. I hope that each of us will continue this conversation of patient safety to make a difference in patient care when we return to our institutions.
Today I also learned about the concept of anchoring. Anchoring is a… 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 John Joseph, MS2 Wayne State School of Medicine
We completed the first day of the Telluride Patient Safety Summer Camp and I can say already that I am so glad I took the time to make the trip out. Telluride is a beautiful place and the enthusiasm and passion of the participants and leaders has reignited my interest. The lesson that stood out the most to me today was the video put together by Drs. Mayer and McDonald on the heartbreaking case of Lewis Blackman. His mother, Helen Haskell, fought tremendously for Lewis while he was in the hospital (and she continues to fight the system that killed him to this day) after a routine surgery. She trusted her instincts that something was wrong and repeatedly pushed for more senior physicians to examine Lewis, over and over and over. I was shocked that despite her insistence, that her requests… Continue reading