Telluride Day 3 Reflection

The morning was spent in the trip to Arlington Cemetery. Going on trip with colleagues is a very different feeling from going on trip with families or usual friends. The trip actually provided a chance for us to talk over things that we would not cover in the conference room, such as a bit more personal life about ourselves. I appreciate that the conference has brought together people with so much diverse background, which could be inspirational to the others.

The afternoon started in the discussion of SBAR style communication. I had no experience watching professionals in my university hospital exactly using this, neither was this mentioned frequently in our courses, at least not in our pharmacy courses. From people’s discussion I realized that this “technique” has been much more emphasized than what I thought. This can be a good point to note and observe when I get back to school.

The highlight of today was root cause analysis workshop. I was designated by our facilitator Dr. Roger to play the role of risk manager to lead the discussion. Oh my god… I totally lacked the experience to play the role. I even had not comb my thinking flow well within such short time after reading the case, let alone to lead the conversation for others… There were teammates demonstrating much more experience than me, from which I learned that there is a long way to go before I can really play a good leadership role in this area. This is critical to know. Before the Telluride meeting, I thought everyone would be at the similar level, at least I would not imagine myself that far behind since I was on our school’s Enhanced Medical Training Track on Patient Safety and Clinical Quality. The first time I realized the reality is not like this was in the first day’s ice-breaker—-some people has already got years of practice experience to back up their knowledge in safety and quality issue while I am still kind of green…… now the impression strikes me the second time, reminding and stimulating myself to keep moving forward.

The most thought-provoking part of the day was Dr. Mayer’s lecture on transparency. What the elements of transparency are, what the barriers and benefits are, what actual outcomes of those stories are. I am particularly interested in and admired their story on this issue at early stage, when transparency was quite not yet advocated as a trend, when culture change was more difficult. It takes vision, belief and courage to be a pioneer, it also takes strategy, patience, and supports from friends. How “rich” the person should be before he/she deserves the reputation of “pioneer”! Facing these pioneers these days, one more thing I have learned is humility.


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.

Informed Consent and Transparency

So much has been covered in the last three days at The Telluride Research Experience #TPSER9 that I hardly know where to begin…I have thoughts on communication, patient safety, interdisciplinary interactions, and transparency with my patients and coworkers…I think as I process through all of these I will create multiple posts. For now I would like to focus on transparency in care.

In thinking about informed consent and transparency in medical and nursing care, I wonder what that looks like on a daily level, particularly on the floor. Obviously there needs to be informed consent for major surgical procedures and tests. I feel most people understand that. But what about the daily things? Starting a new antibiotic, initiating an indwelling foley catheter, starting an IV…each of these have risks associated with them. The antibiotic could cause some GI upset or increase risk of C. diff., the catheter will increase chances of a UTI and could cause some trauma if not inserted properly. How often are these risks discussed and is active bilateral dialogue had between the patient and the healthcare provider (versus saying “we are doing this”)? Furthermore, how do we verbalize this as students?

Should we be telling a patient we have never inserted a foley catheter, an IV, had a successful venipuncture on the first try, or inserted an NG before? Shouldn’t the patient know the person doing this procedure has only done this on dummies or a model? Or is this a “part of being in an academic hospital” and “they should know that”? (Comments I have overheard many times.)

I for one remember learning in school to never say to a patient this was my first (or second) time doing something, and if they asked to not directly answer (I have, after all, started an IV on a mannequin arm multiple times.) Is this building trust though?

After some of the discussion over the last few days I now feel it is not. Isn’t withholding information synonymous to lying? What do you all think? Do you think this would affect patient care and build trust? And on the flip side, do you think this would affect the learning experience for nursing students and medical residents as we attempt to gain clinical experience?

Curious to hear what you all think.

First Day at Telluride Reflections

Such an incredible day! I’m amazed by the stories I’ve heard so far and the people I’ve met. It’s so comforting and inspiring to meet residents from all different programs from various parts of the country and realize that we all have the same issues and in some cases the same ideas for solutions. If we can all take back to our home programs even one or two of the things we learn from each other here, we’re already going to be so much closer to reaching our common goal of improved patient safety and transparency in medicine. I’m so grateful for this experience and am really looking forward to the rest of the week!

Resident Reflections–#TPSER8

If I had spent the last four days locked in a library researching the patient safety literature non-stop, I would not have walked away with as much knowledge, enthusiasm, and support as I acquired participating in the Transforming Mindsets: Patient Safety Summer School for Resident Physicians in Telluride, Colorado.  The collective efforts, shared experience, and mutual support of everyone involved made for a special atmosphere (in the already special atmosphere of nine thousand feet) that allowed each of us to rise above our prior potentials.  Within an hour of resuming clinical duties today, I was already championing our collective cause, walking a fourth year medical student through an incident report about a delayed dose of nevirapine in a newborn; her initial grimace at the optional “name of reporter” question eventually morphing into an enthusiastic smile as she entered her name following our discussion about the benefits of reporting and transparency. I couldn’t be more excited right now to motivate these types of small shifts towards a safety mindset while also pursuing large-scale systems shifts that ensure safety as well.  Thank you to all the faculty and especially to the other residents!

Jon Hatoun, MD, MPH – PGY2

2012 Social Media Contest Starts Today

If you have made it to this blog post, you may or may not have found the contest question on Twitter. If you have found the question, post your answer in the comment section below. If not, see the contest rules below and Good Luck!

The first person to find the contest question on Twitter, and then post the correct answer in the comment section of the “2012 Social Media Contest Starts Today” post on the Transparent Health blog will be crowned the Pre-Telluride Social Media Scholar.

With that prestigious title also comes your choice of one of the educational documentary films we will discuss during the week in Telluride.

Hashtags are an excellent resource to find information on a specific topic on Twitter! Our meeting hashtag is #TPSER8

2012 Telluride Patient Safety Educational Roundtable Gearing Up

The first of three weeks of Patient Safety Education for medical students and residents kicks off in Telluride, CO with the Resident Patient Safety Summer Camp, Monday, June 11th at the Telluride Science Research Center (TSRC). If you are a speaker or student and have not yet registered, use this link to take you to the TSRC home page.

In its 8th year, the Summer Camp has expanded its reach and will train 60 future patient safety leaders in 2012 thanks to the generous support of The Doctors Company. And this year’s cast of patient safety leaders once again promises to provide top notch leadership from those creating meaningful change in health care ! Paul Levy, former President and CEO of Beth Israel Deaconess, patient advocate, health care social media leader and blogger at Not Running A Hospital, will open the week along with David Mayer MD, founder of the Telluride Summer Camps, and VP of Quality & Safety at MedStar Health System in Washington DC/Maryland who will discuss the educational documentary film series, From Tears to Transparency and lead lively discussions around the value of open, honest communication in health care.

At the end of this first week residents, will be able to:

  1. Give an in-depth presentation based on reasons why open, honest and effective communication between caregivers and patients is critical to patient safety and reducing risk in healthcare.
  2. Apply tools and strategies learned to lead change around reducing patient harm at their own institutions.
  3. Implement, lead and complete a Safety/QI project at their home institution over the coming year.

Alumni, speakers, students, patients, providers along with anyone trying to improve health care, are welcome to join the discussion on Twitter at #TPSER8 starting June 11th, and on the Transparent Health blog throughout the month of June!

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