Why is Pushing the Wrong Button So Easy?

By Sarveshwari Singh

On the first day of the Telluride East Summer Camp, Kathy Pischke-Winn and Dr. Joe Halbach organized a game using dominoes.   It really showed how miscommunication in health care can happen so easily and how simple steps can prevent it.

We assembled in groups of three — one person role-played a doctor, another a nurse, and the other an administrator.  The physician sat with his/her back to the nurse and instructed the nurse how to arrange the dominos according to a prescribed pattern.  The nurse couldn’t ask any questions.  Not surprisingly, the nurse didn’t arrange them correctly.

This scenario brought home how communication disconnects among clinicians happens so often in health care, and it underscores why a leading cause of errors is failure in communication.  Also, informal rules can deter students and residents from asking questions, which can lead to a really bad outcome. That’s what happened to Lewis Blackman, as we saw in Tears to Transparency.

Next, the group got a different domino pattern and could have a briefing before the start of the game.  Also, I noticed that in our group, the person playing the physician gave more precise instructions and repeated them for more clarity.  So there was learning and improvement between the first and second rounds. This time, the person role-playing the nurse arranged the dominoes correctly.

I took away from this experience lessons on how I need to be precise in communicating, whether in the classroom, at work or at home.

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“Some is not a number and soon is not a time”

By Fiona Campbell (Medical Student at the University of Calgary)

It was refreshing to hear all of the insightful closing comments from all of the Telluride East participants today, and exciting to hear what we all plan to work towards as we return to our schools. It’s easy to see why we would all come away with such momentum and inspiration. This week was full of eye-opening discussions and thought-provoking workshops. It’s easy to feel empowered by everyone with a shared passion, and to think that we really can make healthcare better around the world.

But it’s also easy to succumb to real life and let that momentum fizzle away. It’s easy to forget how important patient safety is when you’re once again surrounded by leaders who don’t value it. It’s easy to get caught up in all of the knowledge we are expected to learn at school and forget about pursuing initiatives that will improve the system.

I’m still in the newlywed zone and every day I am reminded of the vows that I spoke one short week ago. They weren’t ground breaking, but by speaking them out loud in front of so many loved ones, it helps me hold myself accountable to following them. Today, we all vowed to each other to take what we’ve learned here, bring it back to our institutions and create something from it. Let’s not let life get in the way of accomplishing what we promised to do, and let’s hold each other accountable for making change. But as Dr. Mayer pointed out, some is not a number and soon is not a time – we need to think in realistic milestones in order to hope to accomplish anything. So let’s create more specific goals for ourselves and share our successes and shortcomings along the way.

My first step will be to do a patient safety project with the Human Factors group at the University of Calgary. I will start by defining the scope of the project this month and come up with a manageable deliverable to be completed before I start Clerkship in March. I’ll come back to this blog at least twice along the way to share my progress and get inspiration. Thank you to all of the Telluride East participants and faculty for the knowledge, motivation, and support to work on making healthcare safer one project at a time.

Hope everyone has a safe drive home from the airport!

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