Telluride Patient Safety Summer Camp

Reflections from Telluride East

First and foremost, I’d like to thank all the leadership, instructors, and patient families for having me and taking the time out of thier busy schedules to share with us their valuable information and experiences.  I will echo what Rick said yesterday in that this conference definitely re-ignited that fire in me to change our culture in Medicine and put the focus back on patients and their safety and well-being.  When I go back to my slightly younger self to think of how I expected to be as a physician, I never thought of the negative effects I could have on patients, I only thought of myself as a healer.  Then I said to myself, “OK, I can change my ways and improve myself so that I am better aware of errors around me or because of me, and correct them before they do real harm to… Continue reading

An apology

On Thursday our team accepted the faculty’s challenge and successfully piled even more people on and off of the teeter totter, in even less time, without breaking the eggs. Afterwards Dave congratulated us on an epic world record-setting accomplishment. I was so happy and proud of our teamwork! But last night, as I reflected on my contributions during the activity, I remembered doing something I wasn’t proud of.

On Tuesday, my teammate Collin had observed that wearing flip flops while inching backwards on the teeter totter was a potential source of error. So yesterday at the beginning of our record-setting performance, when I noticed Laura was wearing flip flops, I turned to her and told her she should take them off. I sensed her hesitation, which I quickly shot down by saying, “we noticed on Tuesday that someone in flip flops almost tripped.” Feeling the pressure from our team to… Continue reading

Telluride East Reflections

I really enjoyed the negotiation exercises we had today. It was interesting to see the concept of negotiation broken down into such small pieces. The results of the Hamilton Estate case were intriguing. I managed to settle on buying the property for $45M, which I thought is a pretty good price. It was $15M less than my best alternative. Yes, it was slightly above the maximum value of the property today, but not too much. I thought I negotiated well and that I got a great deal; I am happy with it. It turns out though that that price is actually at just about the average at which the property was sold across the entire group. I was really surprised to hear that one person bought the property at $31.5M – that’s well below the best alternative option of the seller! I am not… Continue reading

Gang warfare

In 1961, French historian and philosopher Rene Girard described a concept of mimetic desire, through which all human conflict is mediated. Based on his principle, the desire for possession of a singular item by two or more parties is likely to be settled through violence of action in order to take control of the object of desire. To imagine this in real life, picture that two children were given uninhibited access to a toy store. One child was allowed in first and began playing with a toy. A second child following shortly enters the store. Though both the children are allowed any toy in the store, which toy would the second child want to play with? What further degrades the situation is that the first child laid initial claim to the toy and is certainly not going to give up. Therefore, in a room full of toys two children fight… Continue reading

Intraprofessional Collaboration

Listening to Patti and David Skolnik speak about their late son Michael really brought to light how failures in communication can have devastating consequences. Though there were many missteps in the handling of Michael’s case, one area of concern that really stood out was the failure in communication between Michael’s family doctor and his neurosurgeon. Despite the family doctor’s unease that the surgery was being performed unnecessarily, the surgeon quickly diminished those concerns on the basis that the family doctor was “just a GP.” We often discuss how interprofessional collaboration and shared decision making with patients are lacking, but too often we forget that even within our own professions, there are many problems that can create tension and conflict and ultimately result in poor patient care. How can we work with patients and other professions, if we can’t work together within our own groups. I’ve witnessed this all too often… Continue reading

Including Patients in Safety Culture

This post will be relatively short. I spent time writing a rather lengthy post about the healthcare story of someone close to me with her blessing. However, when I read what I had written back to her, after telling me to make a couple changes, she decided that she did not want me to post the story anymore. I respected her wish, but asked her why she changed her mind. After all, I had not included names. She said that she felt bad that some of the healthcare providers in her story looked bad and could maybe somehow figure out the story was about them. I think there was something to be learned about the premature closure, lack of informed consent and shared-decision making, and lack of respect for the patient’s perspective on her illness that led to harsh complications, but I realize that we have already had this opportunity… Continue reading

The Art of Negotiating

Today I failed miserably in the art of negotiating. The Hamilton exercise validated how terrible I am and how much I lack the skills to be selfish and defend my qualities when it comes to negotiating a salary. I have had many opportunities in my short life to negotiate a salary and to be bluntly honest, I failed miserably at all of them. As Paul was explaining that most people avoid this type of exchange I started thinking about why do I have such a negative opinion of negotiations. I considered if it is because I enter this ritual with the predisposition that I have to do the numbers dance…. 35…30…34….32.5… , or that I expect some sleazy tactics to trick me, or is it that I view negotiating as a type of confrontation which I want to avoid at any cost. There was no process of elimination in my… Continue reading

Onward and Upward

I am so so grateful to have been given the opportunity to attend Patient Safety Camp. As the week progressed I started to wish that everyone could attend something like this; I will be highly recommending it when I get back to school. Since I know that everyone cannot attend Patient Safety Camp, I started thinking about how I could carry this information back to Indy and take with me wherever I go after that. My school has a Patient Safety elective (of which I am on the waitlist for), but beyond that we are given no formal training in the Patient Safety Culture. I’m going to sit down with my Integrative Medicine group e-board and see if we can get Patient Safety education to be one of our platforms. I’m likely jumping ahead of myself (as I often do) but we could do a series over the course of… Continue reading

Closing Thoughts from Lisa Freeman

By Lisa Freeman

The student session at Telluride East is wrapping up and I feel very hopeful.  I came here as a patient advocate and as a family member of someone who was harmed during surgery and subsequently died.  I have had the privilege to share my family’s story with many who are here and I have been told that you have taken something positive away from it. I have watched many of the participants have “Ah ha!” moments during the various exercises and games.  Listening to the commitments that have been made, and the ideas for change that everyone is bringing back home with them, I feel hopeful that what Patty, David, Helen and I, as well as all the other victims of medical harm have experienced will occur less and less often!

One last thought that I want to share as you return back to… Continue reading

Chick Fil A and Healthcare Quality

By Christine Galligan

My friend is allergic to gluten and can only eat the grilled chicken nuggets. One time on the way home from our internship, we stopped at Chick-fil-A and she ordered grilled chicken nuggets. However, when we pulled out of the drive-thru, she realized that she had been given fried chicken nuggets. This was a near miss as she could have had an extremely allergic reaction. We pulled around and parked, and she ran inside to report the mistake. We could have driven away and she could have gone hungry, but we decided to let the management know. At the very least, the cashier or the person wearing a headset at the drive-thru should be made aware. Human error exists. It is not a crime and it is typically not intentional. Chick-Fil-A is quite efficient at standardization. However, no one is perfect. Work one day in the food… Continue reading

Telluride Experience 2020 Dates

BRECKENRIDGE, CO:
CMF Session One*: 6/8 – 6/11
Bennathan Session Two: 6/15 – 6/18
Session Three: 6/22 – 6/25

WASHINGTON, DC/MD:
Session Four: 7/22 – 7/25

*Session exclusive to the COPIC Medical Foundation Residents.