Telluride Experience – Day 1

Lack of communication/false assumption leads to errors:
In learning about the Lewis Blackman case, an event that directed a conversation toward communication’s ability to either prevent or impose a drastic medical error in a clinical setting, one of the events that stood out the most was the idea that nobody asked, “What is the worst thing this could be?” I work for a home health care team that aims to improve the quality of care and the patient experience by communicating patient alerts. Effective communication in my organization is essential to the effectiveness of our team. Thus, the lack of coordination and communication that was exhibited in the Blackman case struck me because, as these nurses assumed that Lewis was fine, it was these false assumptions and the lack of communicating alerts that predisposed the patient to a detrimental error resulting in the patient’s death. When you assume that the patient’s experience is explained simply because the procedure “usually” goes well, you can fail.  I think it is essential to conclude that the patient is okay while using evidence-based reasoning throughout the process.

Reporting Errors:

When discussing reporting errors in a clinical setting, I found it interesting when one of my fellow students discussed the concept of reporting with the terminology “on behalf of the patient”, considering the best interests of the patient, regardless of hierarchal roles within the clinical setting. This reminded me of a comment I heard at a past conference. A nurse discussed a model that negated the clinical hierarchy and promoted psychological safety by using the term “speaking in” rather than “speaking up”. This terminology promotes a safer setting of equal ground rather than making one professional’s opinion worth more than another.


EMR Utilization:

When discussing the utilization of electronic medical records, I am disturbed by the fact that there is zero liability for the producers of the respective products. Based on the discussion, the most effective tools seem to be the ones that are constructed by the users to fit the user’s specific needs, but faulty and complicated EMR systems leave room for error. It is incredible that there is no accountability for the producers of products that are potentially faulty and difficult to use. These EMR products predispose doctors to create mistakes. On a separate level, it is also surprising that these flawed systems are allowed to then enter and compete in a market where the stakes are high. Lives are at risk! It seems that based on the discussion, we need to find a way to test these systems properly, using a sample from the source of people who will be using them the most. This just proves difficult because doctors may be too busy to constantly be trained to test and fine tune EMR products. On a side note, like any other piece of dangerous equipment, if we implement periodic system-wide safety checks, similar to a yearly vehicle inspection, we can make sure that the product adjusts and evolves according to the needs of the systems utilizing it.

Discussion on blood product ethics:
It is so interesting to learn about the evidence that suggest a direct correlation between blood transfusions and an increase in cancer rates. I have been donating blood most of my life, and I plan on continuing to do so because people still rely on blood transfusions for various medical procedures. However, this conversation brought to mind a potential ethical dilemma in which I am unsure of an answer. If we have evidence to suggest that blood transfusions are likely to cause eventual harm, is it ethical to donate blood ourselves, thus predisposing patients to eventual harm? Do we then enable this eventual harm? When I donate blood, I cannot check off a box and say, “my blood can only go to someone who needs it according to ‘X’ specifications”. People might not approve of using their blood for immediate needed relief if it means that there will be eventual harm. I believe this falls to the doctors to use their discretion according to essential need while avoiding potential over-diagnosis. Any transfusion procedure that is deemed unnecessary, or could be avoided, perhaps falls in to that category over-diagnosis. Michael Hofmann noted that this leads to billions of dollars in wasted resources due to medical harm. It was mentioned that an estimated $40 billion dollars are spend in procedures due to the adverse effects from these blood transfusions. Not only are the patients being harmed, but this leads to an extreme overuse

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