Being transparent…time for confessions

I found myself feeling upset today, especially as we were discussing the case study. I felt so frustrated as a nurse when we were trying to figure out the accountable person for the patient fall. I felt like I had a weight on my shoulders. As nurses, we do shoulder a large portion of the responsibility related to patient falls. We talked this afternoon about how it is EVERYONE’s responsibility to help WATCH the patients in an effort to prevent falls.

I also confessed to my group that a lot of times I do not feel comfortable going to lunch when I am staffing. Why, you might ask? I know part of it is that it is hard for me to hand over control of my patients to another nurse, even if only for 30 minutes. So, I am working on that. The other part is that I work with a young group of nurses (young in experience), and so sometimes I am nervous about leaving my unit. I know that I need to build better trust. It will be one of my goals.

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Why are we afraid to admit we are human?

By Betsy Mramor, M2 MUSC

It seems like common sense for us to realize that we will all make mistakes at some point in our careers. So why are we so afraid of admitting this when it happens? Are our own egos so big that we can’t admit we are human? Why is it that this same humanity that our patients and society expect of us disappears in a mistake. By not talking about these mistakes we continue to allow society to form these unrealistic perceptions that the healthcare field is perfect. I believe that in order for the culture to change; this perception needs to be broken.  There is no other way for this perception to change unless mistakes are brought to the table, discussed, and proactive measures are taken to correct them. Sweeping them under the carpet will only end up reinforcing this perception of the perfect healthcare system. Not only will this perception be reinforced, but also the unacceptable behavior of hiding or covering up mistakes.

I was so happy to hear confirmation of my thoughts from Cliff. Earlier in the week, Cliff had told us a story about how he lost his first heart transplant patient. He told us how shaken he was afterward. So shaken that he came home and told his wife that he had a 100% mortality rate. The next day he was asked what he told his next heart transplant patient. He told us how he was completely honest. He told the patient it was his second time doing the surgery and he lost the first patient. I keep trying to place myself in this patient’s shoes. Would I let this physician do my own heart transplant? Even with odds not in his favor;  I would have let him. For myself, there is a feeling of comfort and safety that comes from someone willing to admit that he is just as human (imperfect) as me.

Trust and Safety in Medicine: Part 2 by Matthew Waitner M2 Georgetown

Perhaps, as Terry Fairbanks said yesterday, we should look not to our individual pursuits but the healthcare system that is in place.  Individually, we are each committed to the reason we put on the white coat – to cure, heal, and do our best to care for each of our patients.  And yet collectively as a system we are failing to provide that very goal.  How is it possible that such dedicated individuals are systemically failing – it would appear to be impossible, and the numbers certainly show that its more than just a few bad apples.  Perhaps our system needs to be overhauled.

I was struck at the insight that Dr. Fairbanks shared.  As a human factor engineer he explained that every other system in the world accounts for the natural errors in humanity.  There are fail-safes embedded in most systems to catch the errors before they cause undue harm.  Such fail-safes are not present in the culture of healthcare.  While every hospital is claiming to be patient-centered, we often fail to see the humanity within ourselves.  I am firmly convinced at this point that a systemic culture change is the only solution to our never-ending problem of patient safety.  Dr. Fairbanks made it clear that skill-based errors (or better put, automated errors) are the key to controlling our out of control safety issues.  In fact, as a first year medical student we learned in our neuroscience course about types of memory: short-term, declarative (semantic and episodic), procedural, priming, associative, and non-associative.  The last of these (non-associative learning) is when someone is habitually exposed to the same event over and over again that the event is done by rote.  This should sound familiar, as it’s the same as skill-based tasks that require automation or limited cognitive input in order to be achieved.

From my class example, this is when you live over a flight path (which I actually do), and you tune out the sound of the overhead planes because you hear them every few minutes.  Every once in a while a plane will fly lower causing a louder that normal event that triggers you to notice them again, and again with habituation it disappears from your thoughts.  So it is clear that our mind can become habituated by automated responses that require little cognition, and it is only when there is a difference that your routine is noted.  Hence is the case discussed today of the NICU heparin incident – habituation caused major medical errors.  I am fascinated by the idea that this system error could have been avoided if there had been a slight difference (a different shaped vial, a different drawer, any change from the expected norm).  Dr. Fairbanks would argue that this is how well-meaning, caring professionals make simple mistakes that cost lives – and it is not the individual practitioner, it is the system involved regardless of how mindful we may be.  That same error was noted in the book “Why hospitals should fly” when the flaps were not engaged yet 3 people confirmed a 15,15 green (indicating the flaps were extended) – it was the expected result and therefore it was what was seen.  These sorts of systemic errors are where the most margin for improvement can occur – because like any job, medicine becomes routine and we become habituated, and our brains are physiologically wired to become habituated.

To say this conference has been insightful would fall short of its true meaning in my eyes as a future medical professional.  These past two days have shown me that our profession is far from perfect (even though each of us strives for such), and requires some major safety overhaul before the public catches wind of our missteps.  In fact, I’m not sure how much longer we can pull the wool over their eyes before they catch us red-handed, and I’m not exactly sure how we have been fooling them for as long as we have.  The numbers are out there, the mistakes make headlines, and yet we are still more trustworthy than a stranger on the street, and we deserve no such pride.  As medical professionals, its time to put egos aside and start doing what we swore an oath to do: do no harm.

Collections of random thoughts for the day

Loved the discussion on communication and the different styles. When we were in groups for the case study, it struck me as interesting that the behavior of the surgeon in one version was not “bad”, but it still changed behaviors, and not in a positive way. Also, I was thinking about how I would feel if I were Naomi or Tess? I was thinking it would be hard to “rock the boat”, especially in a time-sensitive situation like an operating room, and especially at the end of a long shift / procedure.

I really like what Cliff had to say about why do we keep trying to hide information, when he was referring to his operation record. It is so true. We are all so egotistical, proud, scared, and a host of other emotions.

I like the thought of looking at the hazards, and not just the extreme cases. I think we do not talk about near misses, and these are huge learning opportunities for staff, as well as for thinking about system improvements. I appreciate the comments around “mindfulness”, and especially the dialogue between Gwen and Terry. I think I probably see things a little differently than Terry, but that is okay. I think of it this way. If a nurse is not mindful, goes on with some tasks, rather mindlessly, there is an increase for potential error. However, if a nurse is mindful during these tasks, I believe there is less chance of error.

Telluride “East” Kicks Off at Georgetown University in Washington DC

This week we transport the Telluride Patient Safety Educational Roundtable and Resident/Student Summer Camps to the heart of the nation’s capitol — Washington DC. Dave Mayer MD and Tim McDonald MD/JD along with faculty Paul Levy, Rosemary Gibson, Helen Haskell, Cliff Hughes, Kathy Pischke-Winn, Joe Halbach, Gwen Sherwood and more will educate the young of healthcare, sharing communication skills, patient stories and negotiation training in the spirit of keeping patients safe. The Telluride alumni numbers continue to grow, building that critical mass of voices who can share the wisdom of open, honest communication and transparency throughout medicine.

Student reflections on this year’s camps, as well as last year, are found throughout the Transparent Health blog, on Educate the Young and on faculty member Paul Levy’s blog, Not Running A Hospital. Look for additional reflections from this week’s class soon to come, and follow us on Twitter via #TPSER9. The goals of this week’s program follow.

TRANSFORMING MINDSETS III

“The Power of Change Agents: Teaching Caregivers Effective Communication Skills to Overcome the Multiple Barriers to Patient Safety and Transparency”

Patient Safety Student and Resident Summer Camp learning objectives:

By the end of the Patient Safety Summer Camp, students will be able to:

1.)   Describe in-depth at least three reasons why open, honest and effective communication between caregivers and patients is critical to the patient safety movement and reducing risk in healthcare.

2.)   Recognize and apply basic communication skills to improve effective communication among members of the healthcare team.

3.)   Utilize effective tools and strategies to lead change specific to reducing patient harm.

4.)   Implement, lead and successfully complete a Safety/QI project at their institution over the next twelve months.

Infection Rates: It’s not just transparency, it’s informed consent

One of the highlights of the Telluride Patient Safety Summer Camp was the in-depth discussion of the meaning of informed consent. It is not as straightforward as “here, sign this”. In fact the paper consent itself is in a sense the last and least component of informed consent. I was a bit surprised and secretly glad to hear some places have rid themselves of the informed consent form, which reinforces the notion that informed consent is some kind of administrative scut to be dished out to residents. Informed consent isn’t extra, it isn’t something for special procedures, it really should be an integrated part of every doctor-patient relationship. The heart of it is shared decision making and coming to the best course of action based on the patient’s preferences, values, needs, and goals. (“Preferences, values, needs, and goals” was in fact one of my takeaways – a mental checklist worth committing to memory.) Granted, we do have a long way to go in learning the best way to approach individual patients. The ideal of informed consent and shared decision making poses a number of difficult issues. For example, people don’t perceive risks and benefits in the most rational way, especially when presented as numerical probabilities.

Doctor: “The risk of death is 1 in 100,000.”

Patient: “I’m sorry, all I heard was death!”

(Lest we think we are special, it’s people who struggle with perception, not just patients.)

Further difficulties arise when patients are in some ways incapable of truly understanding certain risks because they do not live in the healthcare world. They haven’t seen what it’s like to be in the ICU for a prolonged stay with a “complicated post-op course”. And of course, there is the perception that risks are things that happen to other people, but not to me.

To add to the complexity, doctors may inject their own biases – either optimism or otherwise – into conversations about risks and benefits. “The risks include bleeding, infection, and death, but that’s like any procedure. We kind of have to say that with pretty much any procedure we do these days…”

Again – I think we have a good idea what the ideal of informed consent looks like, but the issues presented in getting there are a different story.

That said, the issue of publishing infection rates comes up in the context of transparency. In fact, infection rates have everything to do with informed consent, too. If I’m having a procedure that puts me at risk for infection, wouldn’t it be nice to know exactly how much risk I’m undertaking, particularly from hospital to hospital? Sure, I could find some bulk statistics for the infection risk of the procedure in a textbook (or government website) somewhere, and that information is likely to be outdated. If I’m having the procedure done at hospital X, then the most accurate estimate of my true risk of infection will most likely be the actual rate of infections at hospital X. If a hospital has enough volume of a certain procedure, they ought to track their own complication rates. It’s more than just transparency, it’s about being as honest and as forthright as you can, and providing patients with the best, most accurate and up-to-date information about what kind of outcomes they can expect when they come to your hospital.

Culture Change? Which One?

By Garrett Coyan, University of Kansas Medical School

The last week I spent at Telluride was very eye-opening for me. I was glad to be surrounded by so many other healthcare professionals that had the same desire to provide the safe and high-quality patient care experiences as I do. Reinvigorated with ideas for improving communication and decreasing risk to my patients, I couldn’t wait to get back to my institution and start implementing change. However, as I returned to the hospital today, I was quickly reminded of the main reason why this goal will be so difficult. Not only does cultural change need to occur in the hospital, but I would argue that even more importantly, cultural change needs to occur in the education of health professions students. This was made evidently clear by a conversation I had with one of my recently graduated colleagues who is staring his internship in a week. At our school, we take a one month class in our fourth year about public health, health policy, and healthcare practice. A few days of this class are slated to discuss patient safety and quality improvement. When I asked my friend about the content of this lesson, he told me frankly he couldn’t remember, because he and most of his classmates thought the information was either common sense or not really applicable. He related that most of this lesson was simply going over “bundles” of different types, and maybe 15 minutes was spent on communication between providers. The material was never really tested, and apparently didn’t stick with this particular colleague of mine. This, of course, was rather startling to me after the experience I had just had in Telluride!
In order to change the safety culture of the hospitals and health systems we work in, we need to create providers who are trained, knowledgeable, and willing to implement the changes needed to provide quality, compassionate, and safe care to our patients. It is for this reason that I will be speaking with my dean, director of quality improvement, all of my mentors, and as many of my classmates that will listen about making this information a mandatory and testable portion of our curriculum. It is only then that we can hope for young medical students, residents, and physicians to be competent and comfortable enough to speak up when medical errors are made, and confront them head on and honestly with our number one partner in healthcare: our patient.

I suppose the hardest part of the Telluride experience was not being involved in the intense and productive discussions that took place, but coming down from the mountain (literally and figuratively). It’s time to get to work. Culture change will not occur until we start demanding it!

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