#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.

Telluride Day 2 Reflection by Yimei Huang Pharm.D Candidate 2015

The day started with Dr. Cliff’s “railmen story”–Listen to the Rhythm. I was deeply impressed by Dr. Cliff’s kindness to, and caring for others, whom he does not know and may never know. Not only did he give extra notice to the things easily overlooked as a passerby, but he also carried out his caring despite the inconvenience to himself. I was thinking to myself what in the world could stop this devoted man from becoming extraordinary? He is so caring to the world outside of his expertise, then what level of caring does he pay to his field? I was also reflecting on myself on how far I am behind him as for the caring heart—-how often I overlook what’s going on outside because I am already quite full with my own business?

A fun thing for today was Teeter Totter Game. This was my first time playing the game personally, and I really enjoyed the moments when our team worked so closely for a common end. At those moments, I felt so supported, accompanied and comfortable to come up with and share ideas with my teammates to work out a better plan. We were successful, but it was not the outcome itself that is dearest to me. It was the process before, during and after that 10 minutes. I would say every team has achieved this process and experienced the similar feeling as ours.

The most emotional and thought-provoking activity of the day was discussing the film “The Story of Michael Skolnik”. As I said in the meeting, I am curious to know what measures have been taken in the past ten years to improve. What has been done to cut off the unnecessary incentives that make surgeons desire to do procedures and even induce patients to agree? What has been done to guarantee a second-point checker for the clinical decision even when patients themselves do not have the second resource accessible? What has been done to ensure that risks are thoroughly informed rather than partially? How well is the fact of surgeon’s expertise and experience honestly communicated to patients? How often does it still exist that assuring patient of one senior surgeon to win their signature but actually carrying out the procedure by his/her student? Maybe taping or video taping the informed consent conversation would help? Maybe a consultant meeting with everyone involved in the case would help? Maybe a written form of patient’s teach-back document files to the supervision level would help? Where are we getting right now?

The day ended with a recap on Dr. Cliff’s Listen to the Rhythm. What an inspiring day!

Day One: Telluride East Reflections

By Linda Hunter, RN, PhD Student

I continue to learn from and be impressed with my health professional peers and feel like we are starting to get closer to the top of the patient safety mountain and picking up speed as we move “up and over”. I am thrilled to see the interaction and reflection amongst the multi-disciplinary group we have.
When Rose mentioned that Lewis was with us and watching – it reminded me of when my sister passed away due to a medical error involving morphine. She was 24 yo and legally blind due to juvenile diabetes but was vibrant, intelligent and fun! She died while I was working in Saudi Arabia and when I was coming home on the plane (crying the whole way) I looked out and saw her walking on the clouds and smiling at me. We can never forget the loved ones we have lost due to error – every “error” has a face and all have a story that continues. Let’s continue to work together and realize how vital it is that we all have and use this knowledge and then share and spread the patient safety knowledge with our peers back home.

By Lynne Karanfil RN

What makes a train? Not just the engine or cars but the coupling device that hooks it together….Professor Cliff Hughes indicated….we need to be a team to make change happen…brilliant!

And then Garrett, 2nd year medical student asked me why don’t all medical school curricula have a course on patient safety like Telluride East? Spot on Garrett! All healthcare providers should have this basic training! Day one at Telluride East was phenomenal! I always learn something new from listening to Lewis’s story and how to engage the healthcare community to become better change agents. Day two..bring it on!

By Rose Ngishu

From tears to transparency is a very powerful story that captures many of the barriers to patient safety in our hospitals. It is more than an irony of ironies. As Helen Haskell pointed out, it is sad that “if Louis had been anywhere other than the hospital, he would still be alive.” Until every patient is safe all the time in the hospital, we are challenged to keep speaking up. And when that goal is achieved, we have yet to keep speaking up on matters of safety.

Telluride Reflections for Days 2 and 3

This continues to be such an amazing week here at the Patient Safety Summer School for Residents. I am currently sitting with a group of residents at the beautiful backyard patio of the Ah Haa School for the Arts, listening attentively and raptly to Paul Levy’s voluntary advice about negotiations. I just can’t believe I am surrounded by such an amazing and inspiring group of people. I cannot even begin to reflect on all the incredible moments of which I have been a part so far this week (and it’s only Wednesday!) but this is definitely going down as one of them. From the team building and communication we learned from the Teeter Totter game yesterday to the powerful and emotionally stirring video on the tragic story of Michael Skolnik to the unbelievable scenery and serenity of the Bear Creek Trail hike this morning, this is an experience that can never be recreated but that I will hold in my heart and my mind forever. It is so easy to become jaded in medicine, especially as a resident, and this is exactly what I needed at this point in my life to reinforce why I went into medicine in the first place: for the patient.  I’m making a personal commitment to myself and to everyone here at TSRC that I am taking this home and will implement more patient safety measures and quality improvement at my home program at MedStar Georgetown University Hospital. I am going to start with resident education because I feel like this is the greatest need at present. We can each make a difference as long as we keep our eye on the common goal which is the health and safety of the patient, and thanks to this amazing week, I truly  believe this and am ready to do my part.

Students Jump for Safety and Social Media #TPSER #hcsm

This has been the most successful social media start to the Student Summer Camps yet!

Thanks to everyone’s participation on the blog, facebook and Twitter, the Transparent Health blog hit an all-time high number of page views today with 241 hits to the blog. Thanks so much for sharing your wonderfully creative insights and thoughts on how healthcare can become safer for all of us.

Let’s keep the conversation going–and not let up. As you all learned today, a conversation can change an outcome. The more noise out in the Twitterverse, the blogosphere and whatever “they” call Facebook-land–the more likely the Telluride Summer Camp messages of: transparency, open/honest communication, patient-centered care, creation of a just culture in medicine, respect and joy in the workplace and building of high reliability organizations that drive preventable medical error to zero will catch fire–in a good way. Keep the momentum going even after heading home and we will nurture this community that continues to build strength. The Tipping Point is well within reach.

“The Faces of Medical Error from Tears to Transparency” film kicks off Telluride Patient Safety Roundtable

The patient safety film “The Faces of Medical Error from Tears to Transparency…The Story of Lewis Blackman” was shown this morning to international patient safety leaders, patient advocates, medical educators and 20 medical student leaders from across the US. The award winning film kicked off the Seventh Annual Telluride Patient Safety Educaitonal Roundtable. This years Roundtable continues the discussions and consensus building from the previous two years on the need for Open, Honest and Professional Communication between caregivers and patients/families related to unanticipated patient care outcomes. Helen Haskell, the mother of Lewis Blackman, along with Tim McDonald and Dave Mayer led interactive discussions with attendees after the film on (1) why honest communication in healthcare has been lacking and (2) the positive changes that have been observed by health sytems who have adopted a culture of open, honest and professional communication after unanticipated outcomes occur.  Rick Boothman from the University of Michigan will join Tim McDonald in facilitating the afternoon’s open and honest communication educational session on “Where we are and how we got here”.

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