Telluride Day 1

My week at Telluride is off to a great start. I can’t imagine a more beautiful place to escape the distractions of our daily lives to focus our attention on patient safety and quality improvement. There are so many interesting and impressive individuals here, both students and faculty, from whom I’m excited to learn.

Today, we watched a film about the story of Lewis Blackman. Often times, when people hear about tragedies like his, they assume that these events are uncommon and would likely not happen in their own hospitals, when in reality the opposite is true. Lewis’s case reminded me of that as it brought me back to a patient I had been following on my pediatric surgery rotation. She was a 3-year old girl, who had had an appendectomy for perforated appendicitis. After the surgery, her father expressed concerns daily that she was not improving – her abdominal pain continued and she remained significantly distended. Everyday, the team dismissed his concerns saying that she had a post-op ileus and would improve with time. After all, this was the most likely diagnosis given the timeline of symptoms. However, the team was failing to ask, “what’s the worst it could be?”

Around POD#7, the father continued with his complaints, and the resident finally spoke up to the attending, beginning to get concerned himself, and asked that we get CT scan of the abdomen. It showed a closed loop bowel obstruction, and the patient was taken immediately to the OR. Fortunately, in this case, despite have a complicated hospital course to follow, our patient was eventually discharged home in good condition.

Thinking back to this incident, I can’t help but feel uneasy. Although our patient survived, it didn’t seem to be because we had a strong patient safety culture in place but rather luck. I remember during her hospital stay there were times that both nurses and residents were questioning the post-op ileus diagnosis, but the former may not have felt comfortable speaking up to the attending and the latter fell victim to the premature closure trap.

My take aways from these stories are: 1) always listen to your patient and their family – they have valuable insight that is vital to their care, 2) remember to ask, “what’s the worst it could be?” to avoid premature closure, and 3) barrier less communication between all members of the team, including (but not limited to)¬†attending¬†physicians, residents, nurses, students and patients is critical to keeping our patients safe. I look forward to what the rest of the week here at Telluride holds and how I can learn to put these concepts into action to ensure the safety of our patients.

 

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