#TPSER9 Reflections: Day Three

By Mary Blackwell, Nursing Student, UPenn

By the end of day three my mind is saturated and I feel so lucky to have the opportunity to be here at the Telluride East Conference. Aside from the twins in utero, as a rising senior in UPenn’s undergraduate nursing program I am certainly the youngest conference attendee. As a student, and a nursing student at that, in the hospital I often feel like the lowest on the food chain. But in this environment of open communication the medical hierarchy collapses and it amazes me to see various healthcare professionals come together for the betterment of patient outcomes. Never before have I had personal connections or meaningful conversations with interdisciplinary healthcare students surrounding issues in healthcare. Because it is so clearly valuable to have these types of conversations, I wonder why academic programs don’t put a larger effort into connecting various healthcare students during their training. Having positive experiences with one another while we’re all still humbled by the title of student could change the culture of staff dynamics in our future clinical settings.

Over the course of the past two days we have heard several stories of near miss or sentinel events in hospitals across the country. As individuals focused on honing our clinical knowledge and skill, it is inevitable to put ourselves in the shoes of the providers in these cases. I shared the shame that several students expressed during these presentations. It was difficult to watch mistake after critical mistake during the tears to transparency videos. It made me cringe in frustration and anticipation as I watched medical professionals continue cause harm to trusting patients. It’s hard to imagine missing the telling vitals signs in the story of Lewis Blackman or passively allowing the sedated Michael Skolnik to sign a consent form. However the focus of our discussions have been that many of these errors arise from faulty systems, not faulty health professionals.

During Terry Fairbank’s discussion of human factors engineering I was able to understand how systems can keep professionals from practicing to their full potential. One of the great examples of systematic hazard was the nurse who accidentally hit the wrong button on the defibrillator in an emergency situation. Instead of delivering the necessary shock to the patient in cardiac arrest, the defibrillator turned off. This delay the life saving care for the patient decreased the patient’s chance of survival. I could imagine myself making this mistake as easily as I do when quickly pressing the wrong button on my cell phone or car. A normal error such as this could happen to anyone in a high stress environment. The instrument was poorly designed; the off button was green while the correct button in this situation was red and flashing. In our society, green means go and red flashing means stop so this design is counter-intuitive.

For the first time I appreciated my constant second-guessing as a student. It’s when patient care becomes routine, second nature that mistakes are easier to make without systematic support. It’s going to be great for us to all go back to our institutions hyper-aware of these systematic barriers.

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