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
It always saddens me when a medical mistake is reported in the media, and the immediate reaction of so many people is: “Someone that careless and incompetent should be fired. There is absolutely no excuse for hurting a patient by omitting such a basic step as calculating the right dose / making sure you have the right patient / checking for allergies / etc… ”
My immediate response to this is always: “Have you ever locked yourself out of your house?” Human beings make mistakes. Human beings sometimes omit basic, crucial steps from tasks they supposedly have mastered. We make small, stupid, high-consequence mistakes so predictably, so inevitably that an entire industry (locksmithing) is dedicated to undoing the small, stupid, high-consequence mistake of not ensuring we have our keys when and where we need them.
The keys analogy is actually a great way to think about… Continue reading
I found this article today and thought it was worth sharing for two reasons:
1. It talks about the most progressive hospitals being the ones that are also the most transparent concerning costs and medical records.
2. It highlights my ice breaker partner Luis’s hospital (Montefiore Medical Center in Bronx, NY) for their work in the community on social issues.
By Fiona Campbell (Medical Student at the University of Calgary)
It was refreshing to hear all of the insightful closing comments from all of the Telluride East participants today, and exciting to hear what we all plan to work towards as we return to our schools. It’s easy to see why we would all come away with such momentum and inspiration. This week was full of eye-opening discussions and thought-provoking workshops. It’s easy to feel empowered by everyone with a shared passion, and to think that we really can make healthcare better around the world.
But it’s also easy to succumb to real life and let that momentum fizzle away. It’s easy to forget how important patient safety is when you’re once again surrounded by leaders who don’t value it. It’s easy to get caught up in all of the knowledge we are expected to learn at school and forget… Continue reading
The morning was spent in the trip to Arlington Cemetery. Going on trip with colleagues is a very different feeling from going on trip with families or usual friends. The trip actually provided a chance for us to talk over things that we would not cover in the conference room, such as a bit more personal life about ourselves. I appreciate that the conference has brought together people with so much diverse background, which could be inspirational to the others.
The afternoon started in the discussion of SBAR style communication. I had no experience watching professionals in my university hospital exactly using this, neither was this mentioned frequently in our courses, at least not in our pharmacy courses. From people’s discussion I realized that this “technique” has been much more emphasized than what I thought. This can be a good point to note and observe when I get back… 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 discussions on high reliability. Healthcare can learn a lot of lessons from the US Navy as Dave Mayer pointed out. If you want to see our Navy in action, you only need to go to Facebook. Each vessel has a Facebook page that they post how they do some of their operations. Below is a link to the carrier USS John Stennis. They also share their thoughts on leadership as well. We don’t have to go to far on seeing how to do things safer! Sometimes the answers are in our own backyard.
The day started with Dr. Cliff’s “railmen story”–Listen to the Rhythm. I was deeply impressed by Dr. Cliff’s kindness to, and caring for others, whom he does not know and may never know. Not only did he give extra notice to the things easily overlooked as a passerby, but he also carried out his caring despite the inconvenience to himself. I was thinking to myself what in the world could stop this devoted man from becoming extraordinary? He is so caring to the world outside of his expertise, then what level of caring does he pay to his field? I was also reflecting on myself on how far I am behind him as for the caring heart—-how often I overlook what’s going on outside because I am already quite full with my own business?
A fun thing for today was Teeter Totter Game. This was my first time playing the… 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
On my way back home from Telluride, I happened to pick up a copy of USA Today from 20 June. I was pleasantly surprised to see that the front page featured a special report, “When Health Care Makes You Sick: Under the knife for nothing.”
Although the article highlights medical errors, interviews Lucian Leape and Rosemary Gibson, and even mentions the story of Michael Skolnik, its tone perpetuates acceptance of medical errors and withholding of valuable information: there is a way to know the total number of cases in which people got surgery that wasn’t needed if honest disclosure is practiced; hospitals are required to report infection and surgical errors to a governing body, but reporting to the patient and family (those who are most affected) may not be required. The article… Continue reading