Award winning film “The Story of Michael Skolnik” closes Day #2 at Telluride Patient Safety Roundtable

Dr. Lucian Leape opened day #2 at the Seventh Annual Telluride Patient Safety Educational Roundtable with a call for the return of “Joy and Meaning in Healthcare Work”. After Dr. Leape’s motivating address, Roundtable attendees spent considerable time in small group breakouts building consensus on ways to address dispruptive caregivers, humiliation, bullying and harassment in healthcare – all critical issues that significantly contirbute to increased patient risk and medical errors. Patient safety experts attending the Roundtable all agreed that efforts to solve the patient safery crisis will not occur until unprofessional behaviors by some caregivers is rectified.

The second day closed with all Roundtable attendees and medical students watching the award-winning film The Faces of Medical Error…From Tears to Transparency: The Story of Michael Skolnik”. The educational film discusses the importance of shared decision-making – an important aspect of open nd honest communication in healthcare that is still lacking in many health systems. Patty Skolnik, Michael’s mother,  led the interactive discussions that followed. The film asks the question – Can a conversation save a life?”

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6 Responses to Award winning film “The Story of Michael Skolnik” closes Day #2 at Telluride Patient Safety Roundtable

  1. Jill Prafke says:

    Day number two was interesting and motivational. I found Dr Leape’s practical, focused approach very helpful. I like the idea of picking a focus, an area like respect and communication where improvements would go a long way to improve patient safety. I like the idea of then coming up with practical ideas of how to make meaningful change in that area. That is the great thing about this Telluride conference. It brings a diverse group together for discussion and formulation of practical ways for each of us to work towards the group vision.
    We also talked a lot about teamwork, communication and the changes in healthcare. I would recommend the recent publication in the New Yorker, of Dr. Atul Gawande commencement address to the graduating class of Harvard Medical School, Cowboys and Pit Crews. http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html

  2. Anonymous says:

    As a component of the overall challenge posed by Dr. Leape, a task for each small group was to discuss how CEOs should be motivated in order to make the culture of respect the priority in healthcare delivery. Having been inspired and educated by the concise, precise, and seemingly simple lecture that Dr. Leape had delivered, a connection that may be deemed fairly obvious to most was cemented in my mind – although the root causes for medical error are multifactorial, quite simply, the grand majority are nested in disrespectful behavior. In testing the hypothesis, I began to rethink through medical errors I’m familiar with and, sure enough, I was able to very easily dissect and pin down a component of disrespectful behavior in these cases. Although I think it is imperative that CEOs and leaders are motivated in order to make the culture of respect a priority, I truly feel that the first step that needs more attention is increasing awareness and subsequent embracement of the link between disrespectful behavior and medical errors. Once we are all on the same page, motivation will assume a more natural process.

  3. A says:

    The video today affected me in completely profound way that I am struggling to deal with afterward. Thinking back in the context of our discussions about Dr. Leape’s idea about the pivotal importance of respect, it seems clear that yes, this medical error too can be largely attributed to the lack of respect – for the patient, for the family, for the informed consent process, for the PCP’s medical opinion, and the list goes on. If something as simple as “The Golden Rule” that we learn as young children could have led to a conversation that would have saved a life, it is absolutely incomprehensible that somewhere the medical world has lost sight of the importance of this. Why can 7-year-old children learn and demonstrate respect for all others, whereas physicians and the health care world feel above this? Where and why do we lose this and how do we address this problem? We should never underestimate the importance of communication and respect regardless of who we are and it should not take tragedies to recognize that medical professionals and the medical system are no exception.

  4. Alejandra Navarro says:

    I would like to thank Patty Skolnik for sharing her experiences at the roundtable. She helped me understand how important it is to listen to and communicate with patients and their families. If all medical schools show her video, it would make a huge impact in how we as caregivers should share decision making and how a “conversation can save a life”. Thank you Patty Skolnik for making a difference in all of us today.

  5. A McCabe says:

    As discussed in the above comments, disrespectful behavior is a major causal factor in medical error. This is a failure in leadership. It’s easy to talk about how disrespectful behavior is wrong, causes errors, should not be tolerated, but when does talking become action and where does that action come from? Strong leaders act. It is one thing to empower medical students, to try to teach them assertiveness, but unless action to stop disrespectful behavior is taken, all that assertiveness training will be buried with their pride, idealism, love of career and most important priority–patient-centered care. It’s not enough to say, students you are the future leaders, you are the ones to make changes……..when?…….students are not in a position to implement change anytime soon, and as so clearly discovered the time for change is now.

    Another point is disrespectful behavior is not merely Attending to Student/Intern/Resident/Nurse. Disrespectful behavior is seen amongst Nurses, Nurses to medical student/intern/resident or the opposite direction. It can be toward or amongst any members of the staff. Patient safety is not one person, it is the entire hospital–the food service personnel, the housekeeping personnel, the billing department, the records department, the techs, CNAs, Pharmacists, nurses, students, interns, residents, Attendings, board of directors and ultimately is the responsibility of the CEO. If the CEO is in charge of the hospital, ultimately all errors lie on his/her shoulders. If there is disrespectful behavior amongst the nursing staff from 7am-7pm, it is a leadership failure of the charge nurse, the Nursing Supervisor, the CNO and the buck ultimately stops at the CEO.

    All organizations need to formulate clear expectations from leaders and staff. Leaders must then not only expect staff to abide by these expectations, but to model these expectations themselves. Leaders must lead from the front. If disrespectful behavior is not tolerated in an organization, all members of the staff need to be aware of this expectation and the negative consequences that will result. As an example, if a resident physician berates a nurse in front of a patient, the attending physician is responsible to correct the resident’s behavior. If the attending does not correct this behavior, the program director is then responsible to not only correct the disrespectful behavior of the resident, but also the leadership failure on the part of the attending. This must continue up the chain of command ladder until the disrespectful behavior and all leadership failures are corrected.

    On leadership, leaders are not born, leaders are made. How are leaders made? By having strong, influential leaders to emulate and learn from as they are developing.

    How do we get there from here? The senior leadership of an organization needs to ensure their expectations are clear to all levels. Leaders must be trained on the expectations, and trained in leadership skills to ensure organizational compliance. It must also be recognized that any member of the staff can be thrust into a leadership position at any time, so the entire organization must be equipped with tools to execute accordingly and the confidence that their actions, if in accordance with organizational values, will be supported and applauded.

    The time for change is now and it begins with leadership today. If today’s students are expected to be tomorrow’s leaders they need to have strong leaders at every turn. Leaders perpetuate leaders–good or bad. If today’s current students are given strong role models to emulate, they will develop into strong leaders themselves.

  6. Kate Sanserino says:

    I would also like to thank Patty Skolnik for sharing her experiences. Her strength of character and work to improve patient safety to prevent future tragedies like the one involving her son are truly inspirational. Further, the (excellent) video did an excellent job reinforcing the importance of a clear, open dialogue between patient, family (if applicable), and physician in order for effective informed consent to take place.

    As Patty and her husband pointed out in the video, they are both highly educated individuals. The fact that the consent project served them so poorly makes me especially mindful of the many patients who, either because of personality, cultural differences, or poor health litearcy would be even less likely to demand information from physicians. I had many experiences when volunteering as a Spanish interpreter in a free clinic that patients would tell physicians that they understood, agreed, and had no questions. When the physician left the room and I was left alone with the patients, a litany of questions and concerns would come forth. I was glad that I was there to receive these questions and to faciltiate further communication with physicians, but I frequently worry about the many, many cases where the questions are never asked.

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