It has been just about a week since I returned from Telluride to Boston. Although the altitude change is welcome, the excitement of the conference is still keeping me awake at night. One such topic is the power and impact of our medical language. We heard a powerful story about the impact of a casual word thrown into a patient’s chart and how that created an anchoring bias that ultimately cost a child’s life — unnecessarily. That story was profound, but I’ll focus on this one aspect of it now. What struck me is my own transformation over the past year. As I’ve really become immersed in the world of medicine — because intern year is nothing if not an “immersion” experience– the language I think in has fundamentally changed. Most of my day is spent either talking about patients to other providers in Medicalese or documenting in the same… Continue reading
As part of TSPER2014, we were able to read some fantastic books/articles/stories. They opened my eyes to the consequences of failing to make patient safety a priority. I’d like to add another to the list (and give a recommendation for anyone looking for a good read).
Destiny of the Republic, by Candice Millard is the story of James Garfield, our 20th President of the US. Garfield is often forgotten as a president, perhaps because his legacy was cut short by his assassination in the middle of his Presidency. This book goes into the details of that story and what could have happened if he hadn’t been shot.
But what does that have to do with patient safety? The truly interesting part of Garfield’s story is the medical care he received after being shot. At the hands of his doctors, a very survivable trauma became 11 weeks of torture and… Continue reading
Inspired by what I learned in Telluride, I joined the fledgling House Staff Quality Council. Founded in late 2013 as requirement from ACGME and CLER, the HSQC has become an organization that reports to the medical board and collects information from the patient care hotline. As a core leadership member, I decided to write a mission statement full of quality care gold nuggets. Anyone care to help me revise?
The HSQC aims to encourage a hospital culture of blameless error reporting and safety risk mitigation through resident-driven quality improvement and patient safety projects, and to allocate a $50,000 annual budget funded by NY Methodist Hospital through a collective bargaining agreement with CIR-SEIU. The council further serves as an interdepartmental collaborative effort among all house staff at NY Methodist Hospital.
The council will review error reports via the patient-safety hotline (x5988), identify threats to… Continue reading
I made the mistake of thinking that as a well-seasoned runner, the altitude wouldn’t dare touch me. I was wrong. It wasn’t a mile in that I started gasping for air and didn’t seem to be catching any. Apparently one is expected to ‘acclimate’ before these runs become enjoyable. This information was provided post-run, of course!
I knew Colorado was beautiful. I’ve been here before. But I have never been to Telluride. And let me just say- it brings a whole new meaning to the word Beauty with a capital B. Mountains stretch on for miles and miles and the view from just about any point is spectacular. I keep finding myself fiddling with my camera and my smartphone camera trying to capture just a glimpse of how incredible it is here, only to be disappointed. The lighting is off, the flash doesn’t capture it correctly, a gondola passes by… Continue reading
On Monday, June 9th the Telluride Patient Safety Summer Camps will begin their 10th year, thanks in part to the generous and continued support of The Doctors Company Foundation (@doctorscompany), COPIC, CIR (@CIRSEIU) and MedStar Health (@MedStarHealth, @MedStarSafety). As the yearly preparations come to a close for faculty, including Summer Camp creator, Dave Mayer MD (@dmayer33), the trek and education are set to begin once again. This year, anticipated attendance will include 130 resident physicians, medical and nursing students and faculty from as far off as Australia.
It’s true that change in healthcare can sometimes feel like dog years passing, but it only takes a week at the patient safety summer camps in Telluride to remind us that educating the young is also ripe with rejuvenation for the older generation if open to the wisdom, passion and idealism of youth. As the social… Continue reading
By Mary Blackwell, Nursing Student, UPenn
By the end of day three my mind is saturated and I feel so lucky to have the opportunity to be here at the Telluride East Conference. Aside from the twins in utero, as a rising senior in UPenn’s undergraduate nursing program I am certainly the youngest conference attendee. As a student, and a nursing student at that, in the hospital I often feel like the lowest on the food chain. But in this environment of open communication the medical hierarchy collapses and it amazes me to see various healthcare professionals come together for the betterment of patient outcomes. Never before have I had personal connections or meaningful conversations with interdisciplinary healthcare students surrounding issues in healthcare. Because it is so clearly valuable to have these types of conversations, I wonder why academic programs don’t put a larger effort into connecting various healthcare students… Continue reading
By Linda Hunter, RN, PhD Student
I continue to learn from and be impressed with my health professional peers and feel like we are starting to get closer to the top of the patient safety mountain and picking up speed as we move “up and over”. I am thrilled to see the interaction and reflection amongst the multi-disciplinary group we have.
When Rose mentioned that Lewis was with us and watching – it reminded me of when my sister passed away due to a medical error involving morphine. She was 24 yo and legally blind due to juvenile diabetes but was vibrant, intelligent and fun! She died while I was working in Saudi Arabia and when I was coming home on the plane (crying the whole way) I looked out and saw her walking on the clouds and smiling at me. We can never forget the loved ones we have… Continue reading
By Pat Bigaouette, Georgetown University School of Medicine
While riding in the plane from Dallas to Montrose I was reading the book “Collateral Damage”, which was suggested/required reading for Telluride. Immediately after the stewardess gave us our drinks, the man directly across the aisle from me leaned across and asked if I was going to Telluride. I looked and my book and then looked at him and replied “yes”. He introduced himself as Tim McDonald and I immediately recognized the name and remembered it being listed as of the four coordinators of the conference.
Knowing that the man I was speaking to would probably be giving several lectures, and that he was probably very important in the patient safety/quality community, I tried to keep a low profile while being polite as possible. I imagined 100s of people squished into a hotel conference room and I had a huge fear that… Continue reading
There’s an old adage in medical education “see one, do one, teach one.” I don’t particularly subscribe to it in a literal sense because I think training requires a more intensive learning process than that. But sometimes it does apply quite nicely. A perfect example of this was on Wednesday when I helped run a session about shared decision making and informed consent at our new house staff orientation. The session consisted of a viewing of the video of Michael Skolnik’s story followed by a moderated discussion with the house staff. The idea came out of a casual conversation with my hospital’s Associate Vice President for Academic Affairs. I thought it would be a helpful to new residents to think about these important issues before they really start on the wards and she let me run with it. Just two weeks out… Continue reading
The hike today was amazing. We set our today at the bottom of the mountain with reservations of conquering the challenge ahead of us. Some of us were unsure if we would make it to the top. We already had moments of being short of breath just from the altitude. The hike symbolized the challenges we will face as we move forward to implement change and increase patient safety. At times we walked together; similar to when we are all in agreement with a change. At times we also walked up hill alone, similar to when we do not have buy in for a change and we carry the burden to move it forward alone. The journey seamed long at times and it was hard to know how far we had left to go, and felt unsure of how far we had come.… Continue reading